What is the management of acute ankle sprain?

Management of Acute Ankle Sprain

Immediate Treatment: PRICE Protocol

Implement the PRICE protocol (Protection, Rest, Ice, Compression, Elevation) immediately for all acute ankle sprains, combined with semirigid bracing rather than elastic bandages or tape. 1

PRICE Components:

• Protection: Apply a semirigid ankle brace or lace-up support immediately—this is superior to elastic bandages or tape and provides the most cost-effective treatment 1, 2
• Rest: Limit weight-bearing for 3-5 days only, avoiding activities that cause pain 1, 3
• Ice: Apply cold (ice and water surrounded by damp cloth) for 20-30 minutes per session without direct skin contact to prevent cold injury 1
• Compression: Use compression wraps for comfort while ensuring circulation is not compromised 1
• Elevation: Keep ankle above heart level 3

Pain Management:

• NSAIDs (piroxicam, celecoxib, or naproxen) should be used to reduce pain and swelling, which accelerates return to activity 4, 3
• Heat application is contraindicated in acute ankle injuries 1, 3

Early Mobilization: 48-72 Hours Post-Injury

Begin supervised exercise therapy within 48-72 hours after injury—this has Level 1 evidence as the most effective treatment for ankle sprain rehabilitation. 1, 2

Exercise Protocol Must Include:

• Range of motion exercises 1
• Progressive strengthening exercises 1, 3
• Proprioception training (balance exercises) 1, 2
• Coordination exercises 2
• Sport-specific functional exercises as recovery progresses 5

Supervised exercises are superior to non-supervised training and should focus on proprioception, strength, coordination, and function. 2

Avoid Prolonged Immobilization

Functional treatment with bracing is strongly preferred over immobilization or casting. 1, 2

Evidence for Functional Treatment:

• Returns patients to sports 4.6 days sooner than immobilization 1, 2
• Returns patients to work 7.1 days sooner than immobilization 1, 2
• Immobilization shows no benefits compared to functional treatment 1, 2

Follow-Up Assessment

Re-examine the patient 3-5 days after injury when pain and swelling have improved for accurate diagnosis and treatment planning. 1, 2

• Clinical assessment of ligament damage is optimized at 4-5 days post-injury when swelling has decreased 1, 2
• Use Ottawa Ankle Rules to determine if radiography is needed—this reduces unnecessary X-rays by approximately 60% 2

Prevention of Recurrent Sprains

Continue wearing a semirigid ankle brace throughout rehabilitation and upon return to sport—this has Level 1 evidence for preventing recurrent sprains. 3, 2

• Bracing is superior to taping and neuromuscular training alone for preventing recurrence 2
• Incorporate proprioceptive exercises into regular training activities for patients with history of recurrent sprains 1, 2

Special Consideration: High Ankle Sprains

High ankle (syndesmotic) sprains require more intensive rehabilitation and significantly longer recovery time than lateral ankle sprains. 1, 3

Diagnosis:

• Mechanism: dorsiflexion with external rotation or eversion with internal rotation 3
• Pain location: syndesmosis area between tibia and fibula, above typical lateral ligament injury site 3
• Use crossed-leg test (squeeze test): pressure on medial knee with legs crossed produces syndesmosis pain 1, 3

Treatment:

• Same PRICE protocol with semirigid bracing 3
• More intensive supervised rehabilitation 3
• Continue bracing throughout recovery and return to sport 3

Critical Pitfalls to Avoid

• Excessive imaging: Use Ottawa Ankle Rules to guide radiography decisions 2, 5
• Unwarranted non-weight-bearing beyond 3-5 days: Early mobilization is essential 5
• Unjustified immobilization: Functional treatment is superior 5
• Delay in functional movements: Exercise should begin within 48-72 hours 1, 5
• Inadequate rehabilitation: This leads to chronic pain, decreased range of motion, and joint instability 1, 2