Management Strategies for Different Levels of Ankle Sprains
The most effective management of ankle sprains should be tailored to the specific grade of injury, with functional rehabilitation including a semi-rigid brace and supervised exercise program being the preferred approach for all grades of lateral ankle sprains. 1
Classification of Ankle Sprains
- Ankle sprains are classified into three grades based on severity 1:
- Grade I (Mild): Stretching of ligaments with minimal tearing, minimal swelling and tenderness, no joint instability
- Grade II (Moderate): Partial ligament tears with moderate pain, swelling, and tenderness, mild to moderate joint instability
- Grade III (Severe): Complete ligament rupture with severe swelling, hemorrhage, tenderness, and joint instability
Diagnosis Approach
- The Ottawa Ankle Rules should be used as the primary tool to rule out fractures and determine if radiography is needed 1
- Delayed physical examination (4-5 days post-injury) provides optimal sensitivity (84%) and specificity (96%) for assessing ligament damage using the anterior drawer test 1
- MRI is only indicated for suspected high-grade ligament injuries, osteochondral defects, syndesmotic injuries, or occult fractures that don't respond to initial treatment 1
Management by Grade
Grade I Sprains
- Initial Treatment: PRICE protocol (Protection, Rest, Ice, Compression, Elevation) for the first 24-48 hours 1
- Functional Support: Elastic bandage or athletic tape for comfort 1
- Rehabilitation: Early range of motion exercises and weight-bearing as tolerated 1
- Medication: NSAIDs may be used for pain and swelling but should be used cautiously as they may suppress the natural healing process 1
- Return to Activity: Usually within 1-2 weeks 2
Grade II Sprains
- Initial Treatment: PRICE protocol for 48-72 hours 1
- Functional Support: Semi-rigid ankle brace preferred over elastic bandages 1, 3
- Rehabilitation: Supervised exercise-based program focusing on proprioception, strength, and coordination 1, 3
- Medication: Short-term NSAIDs for pain management if not contraindicated 3
- Return to Activity: Usually within 2-4 weeks for normal activities; 4-6 weeks for sports 2
Grade III Sprains
- Initial Treatment: PRICE protocol with possible short-term immobilization (3-5 days) to control pain and swelling 1
- Functional Support: Semi-rigid ankle brace for 3-6 weeks during weight-bearing activities 3
- Rehabilitation: Comprehensive supervised exercise program with progressive balance, proprioception, and strengthening exercises 1, 3
- Surgical Consideration: Surgery should be reserved only for cases that do not respond to thorough and comprehensive exercise-based treatment 1
- Return to Activity: Usually within 6-8 weeks for normal activities; 8-12 weeks for sports 3, 2
Exercise Therapy Protocol
Phase 1 (Acute - first week):
Phase 2 (Subacute - weeks 2-4):
Phase 3 (Functional - weeks 4+):
Prevention of Recurrence
- Ankle braces should be considered for preventing recurrent lateral ankle sprains 1, 4
- Supervised balance and coordination training has shown significant protective effects against recurrent sprains (RR 0.62,95% CI 0.51 to 0.76) 3
- Functional support through taping or bracing has demonstrated effectiveness in preventing recurrent sprains (RR 0.30,95% CI 0.21 to 0.43) 4, 3
Common Pitfalls to Avoid
- Complete immobilization should be avoided as it shows no benefits and delays recovery 3
- Elastic bandages like Tubigrip provide insufficient support for moderate to severe sprains 3
- Relying solely on passive modalities without implementing an active exercise program 1, 3
- Returning to sports too early without adequate rehabilitation, which increases risk of recurrence 2
- Failing to address proprioceptive deficits, which are critical for preventing chronic ankle instability 3, 5