What is the recommended treatment and care for a patient with a high ankle sprain?

Management of High Ankle Sprain

Functional treatment with early exercise therapy and appropriate ankle support is the recommended approach for high ankle sprains, as it leads to faster recovery, earlier return to work, and better outcomes compared to immobilization.

Initial Management (First 24-48 Hours)

• Implement the PRICE protocol (Protection, Rest, Ice, Compression, Elevation) immediately after injury to minimize pain and swelling 1
• Apply cold therapy (ice wrapped in a damp cloth) for 20-30 minutes per application, avoiding direct skin contact to prevent cold injury 1
• Use compression wraps for comfort, ensuring circulation is not compromised 1
• Avoid activities that cause pain 1
• Note that while RICE/PRICE is traditionally recommended, evidence suggests it has limited effectiveness when used alone 2

Support and Weight Bearing

• Use a semi-rigid brace or lace-up ankle support rather than tape or elastic bandages, as these provide better stability and lead to:
  • Shorter time to return to sports 3
  • Earlier return to work 3
  • Less ankle instability 3
• Begin weight bearing as tolerated with appropriate support, as functional treatment shows better outcomes than immobilization 3
• Functional treatment helps patients return to work 7.1 days sooner than immobilization 3

Rehabilitation Protocol (48-72 Hours Onward)

Phase 1: Early Rehabilitation (Days 2-7)

• Begin exercise therapy within 48-72 hours after injury 3, 1
• Start with gentle range of motion exercises to prevent stiffness 1
• Include early proprioceptive exercises 1, 2
• Continue using compression and elevation to manage swelling 1

Phase 2: Progressive Rehabilitation

• Gradually increase exercise intensity focusing on:
  • Proprioception training 1, 2
  • Strength exercises, particularly for the peroneal muscles 1, 2
  • Coordination exercises 1, 2
  • Functional movements 1, 2
• Manual mobilization may be beneficial when combined with exercise therapy 1, 2

Phase 3: Advanced Rehabilitation

• Incorporate sport-specific drills and endurance training 3
• Include balance training and ankle disk exercises to reduce risk of recurrent sprains 3
• Use perturbation training and agility drills for athletes 4
• Gradually increase activity intensity based on pain and functional improvement 2

Special Considerations for High Ankle Sprains

• High ankle sprains involve the syndesmosis between tibia and fibula and can be detected using the crossed-leg test (pain when pressure is applied to the medial side of the knee) 3, 2
• These injuries typically require longer recovery time than lateral ankle sprains 2
• More intensive rehabilitation is needed due to the complexity of the injury 2
• Re-examination 3-5 days after injury helps with accurate diagnosis when swelling has decreased 1, 2

Prevention of Recurrence

• External ankle supports (braces) provide a 47% relative reduction in ankle sprains during high-risk activities 3
• This protective effect is greatest for those with a history of recurrent sprains 3
• Ankle disk training exercises help reduce the risk of recurrent ankle sprains 3
• Exercise therapy should be incorporated into regular training activities for those with previous sprains 2

Common Pitfalls to Avoid

• Prolonged immobilization delays recovery and shows no benefits 3, 5
• Inadequate rehabilitation can lead to chronic problems including decreased range of motion, pain, and joint instability 1
• Heat application is not recommended for acute ankle injuries 1
• Therapeutic ultrasound appears to have no value in treatment of acute ankle sprains 3
• Delaying exercise therapy beyond 72 hours may prolong recovery time 1

Medication Considerations

• NSAIDs may be used to reduce pain and swelling in the acute phase 2
• Consider the patient's risk for adverse events, particularly gastrointestinal effects 5