What is the initial management and treatment for an ankle sprain?

Initial Management and Treatment of Ankle Sprains

For acute ankle sprains, immediately implement functional treatment consisting of 3-5 days of RICE (rest, ice, compression, elevation) with early weight-bearing, followed by supervised exercise therapy starting as soon as possible, combined with a semirigid ankle brace—this approach gets patients back to work 7.1 days sooner and back to sports 4.6 days sooner than immobilization. 1, 2

Immediate Assessment and Fracture Exclusion

• Apply the Ottawa Ankle Rules to determine if radiography is needed—this clinical decision tool has high sensitivity and specificity for detecting fractures and reduces unnecessary X-rays by approximately 60%. 1, 2
• If the Ottawa Ankle Rules are negative, proceed directly to functional treatment without imaging. 1
• Reexamine the ankle 4-5 days post-injury when swelling has decreased for optimal clinical assessment of ligament damage. 1, 2

Acute Phase Treatment (Days 0-5)

RICE Protocol with Critical Modifications

• Implement 3-5 days of rest, ice, compression, and elevation, BUT understand that RICE alone has no positive influence on pain, swelling, or patient function—it simply provides initial symptom control. 1, 2
• Apply ice combined with exercise therapy, as cryotherapy with exercise shows greater effect on reducing swelling than heat application. 2
• Use NSAIDs to reduce pain and swelling in the acute phase—this may decrease time to return to usual activities. 1, 2

Immediate Functional Support

• Apply a semirigid ankle brace immediately—this is superior to elastic bandages or taping and is the most cost-effective option. 1, 2
• Encourage early weight-bearing as tolerated during the RICE period. 1, 3
• Avoid immobilization entirely—it shows no benefits compared to functional treatment and delays recovery. 1, 2

Active Rehabilitation Phase (Starting Day 3-5)

Supervised Exercise Therapy

• Begin supervised exercise therapy as soon as possible after the initial RICE period—this has the strongest evidence (level 1) for effectiveness in ankle sprain rehabilitation. 1, 2
• Supervised exercises must include:
  • Proprioception training (balance and position sense exercises) 1, 2
  • Strength exercises targeting ankle and lower leg muscles 1, 2
  • Coordination exercises 1, 2
  • Functional activities specific to the patient's work or sport demands 1, 2
• Supervised exercise provides better outcomes than home exercise programs alone—manual therapy combined with supervised exercise leads to better recovery than home programs. 2, 4

Manual Therapy Adjunct

• Consider manual mobilization of the ankle and surrounding joints, but only in combination with exercise therapy to enhance treatment effect—never as standalone treatment. 1, 2

Return to Activity

• Implement immediate functional treatment with a return-to-work schedule to minimize work absenteeism—functional treatment leads to the fastest resumption of work and daily life activities. 1, 2
• Expect return to work approximately 7.1 days sooner with functional treatment compared to immobilization. 2
• For athletes, expect return to sports 4.6 days sooner with functional treatment. 2

Prevention of Recurrent Sprains

• Continue wearing a semirigid ankle brace for prevention—bracing is superior to taping and neuromuscular training for preventing recurrent sprains (level 1 evidence). 1, 2
• Implement neuromuscular training programs including proprioceptive exercises for long-term prevention. 1, 2
• Both neuromuscular training and ankle braces have proven beneficial as preventive investments due to lower societal costs. 1

Critical Pitfalls to Avoid

• Never immobilize the ankle—this is the single most important pitfall, as immobilization delays recovery and provides no benefit. 1, 2
• Do not rely on RICE alone—current evidence shows RICE without exercise therapy has no positive influence on outcomes. 1, 2
• Do not use elastic bandages instead of semirigid braces—treatment with semirigid supports is superior. 1
• Warn patients that inadequate treatment leads to chronic problems—more than 70% of people who sprain their ankles continue to have problems, and up to 80% will sprain their ankles again without proper rehabilitation. 1, 4
• Do not provide unsupervised home exercise programs as the primary treatment—supervised exercise therapy is essential for optimal outcomes. 2, 4