What is the recommended treatment for a pregnant patient with an ankle sprain?

Treatment of Ankle Sprains in Pregnant Patients

For pregnant patients with ankle sprains, the PRICE (Protection, Rest, Ice, Compression, Elevation) protocol is recommended as the primary treatment approach, with careful consideration of medication safety and diagnostic imaging limitations during pregnancy. 1

Initial Assessment and Diagnosis

• The Ottawa Ankle and Foot Rules should be used to determine the need for radiological evaluation, helping to minimize unnecessary radiation exposure during pregnancy 2
• When imaging is necessary, ultrasound should be considered as the first-line imaging modality for pregnant patients with ankle sprains, as it involves no radiation 2
• MRI can be used safely during pregnancy when more detailed imaging is required for diagnosis 2
• X-rays should be limited and used only when absolutely necessary, with appropriate shielding of the abdomen 2

Treatment Protocol

Immediate Management (First 24-72 Hours)

• Implement the PRICE protocol:
  • Protection: Use appropriate ankle support to prevent further injury 1
  • Rest: Limit weight-bearing for up to 72 hours to allow ligaments to heal 1
  • Ice: Apply cryotherapy to reduce edema and decrease pain 1
  • Compression: Use compressive devices to minimize swelling 1
  • Elevation: Keep the ankle elevated to reduce swelling 1

Pain Management

• CAUTION: NSAIDs (including ibuprofen) should be avoided during pregnancy, particularly after 20 weeks gestation, due to risks of:
  • Premature closure of the fetal ductus arteriosus
  • Oligohydramnios and potential neonatal renal impairment 3
• Acetaminophen may be used as a safer alternative for pain management during pregnancy 3

Functional Rehabilitation

• Begin functional rehabilitation within 48-72 hours after injury when pain and swelling have improved 1
• Functional treatment is superior to immobilization, helping patients return to normal activities more quickly 1
• The rehabilitation program should include:
  • Range of motion exercises
  • Strengthening exercises
  • Proprioception training 4

Support Devices

• Lace-up or semirigid ankle supports are more effective than tape or elastic bandages 1
• Semirigid ankle supports result in:
  • Shorter time to return to normal activities
  • Less ankle instability 1
• Avoid elastic tubular bandages (Tubigrip) as they may not provide adequate support and could increase the need for pain medication 5

Special Considerations for Pregnant Patients

• Pregnancy causes increased joint laxity due to hormonal changes, which may affect recovery and increase the risk of re-injury 6
• Weight gain and changes in body mass distribution during pregnancy can alter gait patterns and place additional stress on the healing ankle 6
• Functional exercises may need modification to accommodate the pregnant patient's changing center of gravity 6
• Regular reassessment is important as pregnancy progresses to adjust treatment as needed 2

Follow-up Care

• Re-examination 3-5 days after injury, when pain and swelling have improved, helps with accurate diagnosis and treatment planning 1
• Supervised exercises focusing on proprioception, strength, coordination, and function are strongly recommended for optimal recovery 4
• Patient education about proper ankle support and injury prevention is essential, particularly given the increased risk of falls during pregnancy 4

Common Pitfalls to Avoid

• Inadequate treatment can lead to chronic problems such as decreased range of motion, pain, and joint instability 1
• Prolonged immobilization should be avoided as it shows no benefits compared to functional treatment 4
• Heat application is not recommended for acute ankle injuries 1
• Using NSAIDs after 20 weeks of pregnancy can cause serious fetal complications 3