Ankle Sprain Diagnosis and Treatment
For diagnosing ankle sprains, the Ottawa Ankle Rules should be used as the primary tool to rule out fractures, followed by delayed physical examination 4-5 days post-injury for optimal assessment of ligament damage. 1, 2
Diagnostic Steps
Initial Assessment
- Apply the Ottawa Ankle Rules to rule out fractures with high sensitivity (86-99%) and determine if radiography is needed 1
- Ottawa Ankle Rules criteria include:
- Pain on the dorsal side of one or both malleoli
- Palpation pain at the base of the fifth metatarsal bone
- Palpation pain of the navicular bone
- Inability to walk at least four steps 1
Physical Examination
- Delay comprehensive ligament assessment by 4-5 days post-injury for optimal sensitivity (84%) and specificity (96%) 1
- Look for presence of haematoma, pain on palpation around distal fibula, and positive anterior drawer test to identify lateral ligament rupture 1
- Classify ankle sprains into three grades 1:
- Grade I: Mild sprain
- Grade II: Moderate sprain with microligament lesions
- Grade III: Severe sprain with full ligament lesion
Advanced Imaging
- MRI should be considered only for suspected high-grade ligament injuries, osteochondral defects, syndesmotic injuries, or occult fractures (sensitivity 93-96%, specificity 100%) 1
- Ultrasonography has good sensitivity (92%) but lacks specificity (64%) compared to delayed physical examination 1
- Stress radiographs and arthrography are not recommended due to limited diagnostic value and invasiveness 1
Treatment Protocol
Immediate Care (0-72 hours)
- RICE (Rest, Ice, Compression, Elevation) may be used initially, though evidence for efficacy is limited 1
- Cryotherapy combined with exercise therapy is more effective for reducing swelling than heat application 1
- NSAIDs may reduce pain and swelling but could potentially suppress the natural healing process 1
Functional Treatment (Days 3-14)
- Use tape or a brace for functional support rather than immobilization 1, 2
- Semi-rigid ankle braces are preferred over elastic bandages for Grade II sprains 2
- Begin supervised exercise-based rehabilitation focusing on:
- Range of motion exercises
- Isometric strengthening
- Non-weight bearing balance exercises 2
Rehabilitation (Week 2 onward)
- Progress to supervised exercise program focusing on proprioception, strength, and coordination 2
- Functional rehabilitation is superior to immobilization for recovery 3
- Surgery should be reserved only for cases that do not respond to comprehensive exercise-based treatment 1, 2
Prevention of Recurrence
- Ankle braces should be used for preventing recurrent lateral ankle sprains 2
- Supervised balance and coordination training significantly reduces risk of recurrent sprains 2
- Address negative prognostic factors early, including:
- Current level of pain
- Workload demands
- Level of sports participation 1
Common Pitfalls to Avoid
- Complete immobilization delays recovery and shows no benefits 2
- Relying solely on passive modalities without implementing active exercise program 2
- Using MRI in acute settings when delayed physical examination is sufficient 1
- Failing to address risk factors for chronic ankle instability, which develops in approximately 20% of acute ankle sprains 4