What are the diagnosis and treatment options for an ankle sprain?

Ankle Sprain Diagnosis and Treatment

Diagnosis

For suspected fractures, apply the Ottawa Ankle Rules immediately—they have high sensitivity and specificity and reduce unnecessary radiographs by 60%. 1

Clinical Assessment Steps

• Exclude fractures first using the Ottawa Ankle Rules: obtain radiographs only if there is bone tenderness at the posterior edge or tip of either malleolus (within 6 cm), at the base of the fifth metatarsal, at the navicular bone, or if the patient cannot bear weight for four steps immediately after injury and in the emergency department 1

• Delay ligament assessment for 4-5 days post-injury when evaluating anterior talofibular ligament damage—the anterior drawer test achieves optimal sensitivity (84%) and specificity (96%) after swelling subsides, making it superior to immediate examination or ultrasonography 1

• Grade the sprain clinically: Grade I (mild stretch without instability), Grade II (partial tear with moderate instability), Grade III (complete rupture with significant instability) 1

• Consider MRI only for persistent symptoms beyond 4-6 weeks or when suspecting osteochondral defects, syndesmotic injuries, or occult fractures—not needed for routine uncomplicated lateral ligament ruptures 1, 2

Acute Treatment Protocol

Implement functional treatment with a semirigid ankle brace for 4-6 weeks combined with supervised exercise therapy starting within 48-72 hours—this approach returns patients to work 7.1 days sooner and to sports 4.6 days sooner than immobilization. 1, 3, 4

First 3-5 Days: Modified RICE

• Apply ice for 15-20 minutes several times daily for the first 48-72 hours, but recognize that RICE alone has no proven benefit on pain, swelling, or function—ice only helps when combined with exercise therapy 1, 3, 4

• Use compression and elevation for comfort, but understand these are adjuncts, not primary treatments 3

• Allow early weight-bearing as tolerated—complete rest beyond 3-5 days delays recovery 1, 3

Functional Support (Start Immediately)

• Apply a semirigid ankle brace for 4-6 weeks—this is the most cost-effective option and superior to tape, elastic bandages, or immobilization 1, 3, 4

• Never use cast immobilization as it leads to muscle atrophy, joint stiffness, delayed recovery, and worse outcomes than functional treatment 1

Medication

• Prescribe NSAIDs for short-term use (<14 days) to reduce pain and swelling—either oral or topical formulations are effective 1, 3

• Consider diclofenac over ibuprofen for the first 48 hours as it shows superior pain reduction, though standard ibuprofen dosing (400-600mg three times daily) is acceptable 3

• Weigh gastrointestinal risks before prescribing NSAIDs, particularly in older patients or those with GI history 4

Exercise Therapy (Level 1 Evidence)

Begin supervised exercise therapy within 48-72 hours after injury—this has the strongest evidence of all interventions and leads to faster return to sport. 1, 3, 4

Exercise Progression

• Days 1-3: Gentle range of motion exercises (ankle circles, alphabet writing) as pain allows while continuing ice and elevation 3, 4

• Days 3-7: Progress to weight-bearing exercises including heel raises, toe raises, and progressive ambulation 3

• Days 7-14: Add proprioceptive training with balance exercises on stable surfaces, then progress to unstable surfaces (wobble boards, foam pads) 1, 3, 4

• Weeks 2-6: Incorporate strength training for peroneal muscles, coordination drills, and sport-specific functional movements 1, 3

Supervision Matters

• Ensure exercises are supervised—supervised programs produce significantly better outcomes than home exercise alone, addressing proprioception deficits, delayed peroneal muscle response time, and strength deficits that originate from central nervous system disturbances 1, 3

• Add manual mobilization only as an adjunct to exercise therapy to enhance treatment effects, never as standalone treatment 1

Return to Activity Timeline

• Mild sprains (Grade I): Return to normal activities by days 14-21 3

• Moderate to severe sprains (Grade II-III): Complete the full 4-6 week brace protocol and supervised rehabilitation before returning to sport 3

• High ankle sprains (syndesmotic injury): Expect longer recovery times and more intensive rehabilitation—these injuries involve the tibia-fibula syndesmosis and can be detected by the crossed-leg test (pain at syndesmosis when pressure applied to medial knee) 5, 4

Surgery Indications

Reserve surgery only for professional athletes requiring rapid recovery or patients with persistent symptoms after 4-6 weeks of optimal conservative treatment—avoid unnecessary invasive procedures. 1

• Surgery carries complication risks that conservative treatment does not, and most patients recover fully without it 1

Prevention of Recurrent Sprains

Continue wearing a semirigid ankle brace during high-risk activities—bracing provides 47% relative risk reduction and is superior to both taping and neuromuscular training alone for prevention. 1, 5, 4

• Incorporate proprioceptive exercises into regular training permanently for those with previous sprains—exercise therapy has proven preventive effects for recurrent injuries 1, 5

Critical Pitfalls to Avoid

• Never immobilize beyond 3-5 days—prolonged immobilization causes muscle atrophy, joint stiffness, and significantly delays recovery compared to functional treatment 1, 3

• Do not rely on RICE alone—it has no proven benefit without exercise therapy 1, 3, 5

• Avoid premature return to full activity—this leads to re-injury and chronic instability 3

• Do not ignore symptoms persisting beyond 4-6 weeks—this indicates incomplete healing, possible osteochondral lesions, peroneal tendon injury, syndesmotic injury, or chronic instability requiring further evaluation 3, 2

• Never skip supervised rehabilitation—passive treatments without active exercise lead to suboptimal outcomes 3