Is a walking boot the best initial treatment for an ankle injury?

Walking Boot for Ankle Injuries: Evidence-Based Recommendations

A walking boot is not the best initial treatment for most acute ankle injuries; functional treatment with a lace-up or semi-rigid ankle brace is superior for improving outcomes and faster return to work and activities. 1

Initial Assessment and Treatment Selection

• For acute ankle sprains, functional treatment is superior to immobilization, with patients returning to work 7.1 days sooner and experiencing better outcomes 1
• The PRICE protocol (Protection, Rest, Ice, Compression, Elevation) should be initiated within 24 hours of injury to minimize pain and swelling 1
• After initial PRICE protocol, functional support with a brace is preferred over complete immobilization for 4-6 weeks 1

Evidence for Ankle Support Options

Recommended Support Types:

• Lace-up or semi-rigid ankle supports show superior outcomes compared to elastic bandages or tape 1:
  • Less persistent swelling at short-term follow-up 1
  • Shorter time to return to work and sports 1
  • Less ankle instability 1

Walking Boot Considerations:

• Short-term immobilization (≤10 days) with a rigid support or walking boot may be beneficial only for:
  • Severe ankle sprains with significant pain and swelling 1
  • Cases where pain control is the primary concern 1
• Longer immobilization (>4 weeks) leads to worse outcomes than functional treatment 1

Treatment Algorithm

1. Mild to moderate ankle sprains:

   • Implement PRICE protocol for first 24-48 hours 1
   • Progress to functional treatment with lace-up or semi-rigid ankle brace 1
   • Begin exercises to restore motion and strength within 48-72 hours of injury 1

2. Severe ankle sprains:

   • Short period (<10 days) of immobilization with a walking boot may help reduce pain and swelling 1
   • After initial immobilization period, transition to functional support and begin rehabilitation 1
   • For partial or total ligament ruptures, expect 3-6 weeks before return to light work 1

Rehabilitation Protocol

• Begin exercises to restore motion and strength within 48-72 hours of injury 1
• Progress to endurance training, sport-specific drills, and balance training as healing advances 1
• Exercise therapy significantly reduces the risk of recurrent ankle sprains (RR 0.62,95% CI 0.51 to 0.76) 1

Common Pitfalls to Avoid

• Prolonged immobilization: Avoid immobilization longer than 10 days as it delays recovery and return to work/activities 1
• Inadequate support: Elastic bandages are less effective than lace-up or semi-rigid braces 1, 2
• Delayed rehabilitation: Failing to start early motion exercises within 48-72 hours can prolong recovery 1
• Inappropriate imaging: Follow Ottawa Ankle Rules to determine need for X-rays 3

Return to Work and Activities Timeline

• Mild sprains (distortion): Return to light work in approximately 2 weeks, full work in 3-4 weeks 1
• Moderate to severe sprains (partial or total ligament rupture): Return to light work in 3-6 weeks, full work in 6-8 weeks 1
• Post-surgical cases: Weight bearing as tolerated at 3-6 weeks, return to physically demanding jobs at 12-16 weeks 1