What is the recommended treatment and management plan for an ankle sprain?

Ankle Sprain Management

For acute ankle sprains, implement functional treatment with 3-5 days of rest, ice, compression, and elevation (RICE), followed immediately by early weight-bearing and supervised exercise therapy focusing on proprioception, strength, coordination, and function, combined with a semirigid ankle brace for optimal recovery and return to activities. 1

Initial Assessment and Diagnosis

Rule Out Fractures First

• Apply the Ottawa Ankle Rules to determine if radiography is needed—this has high sensitivity and specificity for detecting fractures 1
• Order X-rays only if there is pain in the malleolar or midfoot zone AND either bone tenderness over the lateral malleolus, medial malleolus, base of fifth metatarsal, or navicular bone, OR inability to bear weight for four steps 2
• Using the Ottawa Ankle Rules reduces unnecessary radiographs by approximately 60% and saves €7-31 per patient 1

Timing of Physical Examination

• Reexamine patients 4-5 days post-injury when swelling has decreased—this optimizes clinical assessment of ligament damage and distinguishes partial tears from complete ruptures 1, 3
• Initial examination within 48 hours may be limited by excessive swelling and pain 1

Acute Treatment Protocol (First 3-7 Days)

RICE Protocol with Important Caveats

• Apply rest, ice, compression, and elevation for 3-5 days 1
• Critical caveat: RICE alone has no positive influence on pain, swelling, or patient function—it must be combined with early mobilization and exercise 3
• Cryotherapy should be applied for 15 minutes, 1-3 times daily, ideally started within 36 hours of injury for maximum effectiveness 4
• Cryotherapy combined with exercise therapy shows greater effect on reducing swelling compared to heat application 3

Pain Management

• NSAIDs are recommended to reduce swelling and pain in the acute phase and may decrease time to return to usual activities 1, 3
• Options include NSAIDs, acetaminophen, or mild opioids for pain control 2

Functional Support (Critical Component)

• Apply a semirigid ankle brace immediately—this is the most cost-effective option and superior to taping 1
• Alternative options include lace-up ankle supports or air stirrup braces combined with elastic compression wrap 1, 2
• Avoid prolonged immobilization—it shows no benefits compared to functional treatment and delays recovery 1, 3
• Short-term immobilization (if used at all) may only help diminish pain and swelling initially but should be brief 1

Early Mobilization and Exercise Therapy

Start Exercise Immediately After Initial RICE Period

• Begin supervised exercise therapy as soon as possible after the 3-5 day RICE period—this is the treatment with the strongest evidence (level 1) 1, 3
• Early functional treatment helps patients return to sports 4.6 days sooner and return to work 7.1 days sooner than immobilization 3

Comprehensive Exercise Program Components

Supervised exercises must include: 1, 3

• Proprioception training (e.g., ankle disk training)
• Strength exercises to address muscle deficits
• Coordination exercises
• Range of motion exercises
• Sport-specific functional exercises

Supervision Matters

• Supervised exercise provides better outcomes than non-supervised training—this is a key finding from recent evidence 1
• Exercise therapy should address proprioception, muscle response time, and muscle strength to enable early return to sport participation 1

Additional Treatment Considerations

Manual Therapy

• Manual mobilization should only be used in combination with exercise therapy, not as standalone treatment 1, 3
• If range of motion restriction persists, mobilization therapy combined with exercise is advised 1

Surgery

• Reserve surgery only for refractory cases with complete lateral ligament ruptures to avoid unnecessary invasive treatment and risk of complications 1
• The vast majority of ankle sprains should be treated conservatively 5

Prevention of Recurrent Sprains

For Patients Returning to Activities

• Continue wearing a semirigid ankle brace—bracing is superior to taping and neuromuscular training for preventing recurrent sprains (level 1 evidence) 1
• Implement neuromuscular training programs including proprioceptive exercises—these have proven beneficial for preventing recurrent sprains 1
• Incorporate graded exercise regimens with proprioceptive elements into regular training activities 1, 2

Risk Factor Awareness

• History of previous ankle sprain is the greatest risk factor for recurrent injury 1, 2
• Preventive efforts show high cost benefits, mainly through reduced indirect costs 1

Common Pitfalls to Avoid

Critical Mistakes in Ankle Sprain Management

• Excessive imaging without applying Ottawa Ankle Rules 5
• Unwarranted non-weight-bearing—early weight-bearing is essential 5
• Unjustified immobilization—functional treatment is superior 1, 3, 5
• Delay in functional movements—early mobilization speeds healing 5, 2
• Inadequate rehabilitation—supervised comprehensive exercise is essential to prevent chronic problems 1, 5

Long-Term Consequences of Poor Treatment

• Inadequate treatment leads to chronic problems including decreased range of motion, persistent pain, joint instability, and increased risk of recurrent sprains 1, 3
• Patients are at risk of developing chronic conditions that lead to subsequent costs and disability 1

Return to Work and Sport

Timeline Expectations

• With proper functional treatment, expect return to work approximately 7 days sooner than with immobilization 3
• Functional approach leads to fastest resumption of work and daily life activities 1

Return to Sport Decision

• Base return-to-sport decisions on self-reported variables, manual stability tests, and functional performance testing 5
• Supervised exercises focusing on proprioception, strength, coordination, and function are strongly recommended for sport resumption 3