What is the best course of treatment for a patient with bilateral ankle sprains and difficulty walking, currently taking over-the-counter (OTC) Ibuprofen (nonsteroidal anti-inflammatory drug (NSAID)) for pain management, with concerns about excessive NSAID use?

Treatment of Bilateral Ankle Sprains with NSAID Use

Continue ibuprofen at an appropriate dose (400mg three times daily, maximum 1200mg/day for short-term use) for pain control, initiate functional treatment with an ankle brace immediately, and begin supervised exercise therapy within 48-72 hours rather than prolonged rest. 1

Immediate Pain Management with NSAIDs

Your patient's concern about "too many NSAIDs" is valid but should not prevent appropriate short-term use for acute injury. The evidence strongly supports NSAID use for bilateral ankle sprains:

• Oral NSAIDs provide superior pain relief and improved function compared to placebo in the short term (<14 days) without significantly increasing adverse event risk in young, healthy patients. 1, 2
• Ibuprofen 400mg three times daily (1200mg/day total) is effective and well-tolerated for ankle sprains. 1
• Treatment duration should be limited to 7-10 days to minimize any theoretical concerns about delayed healing, as NSAIDs may suppress inflammation needed for tissue recovery. 1, 2

NSAID Safety Considerations for This Patient

For a patient with bilateral ankle sprains taking OTC ibuprofen, the key safety points are:

• Maximum daily dose should not exceed 3200mg for prescription use, but 1200mg/day is the standard therapeutic dose for ankle sprains. 1
• Avoid use if the patient has history of peptic ulcer disease, significant alcohol use (≥2 drinks/day), cardiovascular disease, renal impairment, or is over 60 years old. 1, 3
• Do not use NSAIDs if the patient has had recent MI, is post-CABG surgery, or has severe heart failure. 3
• Monitor for gastrointestinal symptoms (nausea, abdominal pain, black stools), cardiovascular symptoms (chest pain, shortness of breath), or signs of renal dysfunction. 3

Alternative to Ibuprofen if Contraindicated

If NSAIDs are contraindicated or the patient remains concerned, acetaminophen (paracetamol) 1300mg three times daily is equally effective for pain, swelling, and range of motion in ankle sprains. 1, 2, 4

Topical NSAIDs (diclofenac gel with or without menthol) are first-line alternatives with fewer systemic side effects and similar efficacy to oral NSAIDs. 2

Functional Treatment Protocol (Critical - Not Just Rest)

The outdated RICE (Rest, Ice, Compression, Elevation) protocol alone is NOT recommended as it provides no proven benefit for recovery. 1

What Actually Works

Functional treatment with early mobilization is superior to immobilization and returns patients to work 7.1 days sooner and to sports 4.6 days sooner. 1

The evidence-based three-phase approach:

1. Phase 1 (First 24-48 hours): Protection with ankle brace (NOT immobilization), elevation, and pain control with NSAIDs 1

2. Phase 2 (48-72 hours post-injury): Begin supervised exercise therapy to restore range of motion and strength - this is when most patients mistakenly continue resting 1

3. Phase 3 (Ongoing): Progress to proprioception training, balance exercises, and sport-specific drills 1

Ankle Support Device Selection

Use a lace-up or semi-rigid ankle brace for 4-6 weeks, which is more effective than elastic bandages or tape for returning to activity and preventing instability. 1, 2

Critical Pitfalls to Avoid

Common mistakes that lead to chronic ankle instability (occurs in >70% of inadequately treated sprains):

• Prolonged rest beyond 72 hours delays recovery and increases risk of chronic instability. 1, 5
• Using elastic bandages instead of proper ankle braces results in slower recovery. 1
• Failing to initiate supervised exercise therapy within 48-72 hours leads to persistent weakness and reinjury. 1
• Immobilization with casting (unless fracture present) worsens outcomes compared to functional treatment. 1

When to Obtain Imaging

Apply Ottawa Ankle Rules to determine if radiographs are needed (sensitivity 86-99% for excluding fracture): 1

• Pain in malleolar zone PLUS inability to bear weight (take 4 steps) immediately after injury and in the emergency department 1
• Bone tenderness at posterior edge or tip of lateral malleolus 1
• Bone tenderness at posterior edge or tip of medial malleolus 1
• Bone tenderness at base of 5th metatarsal or navicular bone 1

If Ottawa rules are negative, no radiographs are needed. 1

Specific Instructions for This Patient

For bilateral ankle sprains with difficulty walking:

• Continue ibuprofen 400mg three times daily with food for 7-10 days maximum 1, 2
• Obtain bilateral ankle braces (lace-up or semi-rigid) and wear continuously for 4-6 weeks 1, 2
• Begin weight-bearing as tolerated immediately - walking aids (crutches) only if needed for severe pain 1
• Start supervised physical therapy within 48-72 hours focusing on range of motion and strengthening exercises 1
• Avoid complete immobilization or prolonged rest beyond initial 24-48 hours 1

Red flags requiring urgent re-evaluation:

• Severe, uncontrolled pain despite NSAIDs 1
• Inability to bear any weight after 48 hours 1
• Numbness or tingling in foot 6
• Signs of compartment syndrome (severe pain with passive stretch, tense swelling) 6