Twisted Ankle Management
Implement the PRICE protocol immediately (Protection, Rest, Ice, Compression, Elevation) combined with a semirigid ankle brace, NSAIDs for pain control, and begin supervised exercise therapy within 48-72 hours—avoid prolonged immobilization as it delays recovery and worsens outcomes. 1, 2
Immediate First Aid (First 3-5 Days)
PRICE Protocol Components:
- Protection: Apply a semirigid ankle brace immediately—this is superior to tape or elastic bandages and has the strongest evidence for preventing recurrent sprains 1, 3
- Rest: Limit weight-bearing for 3-5 days, avoiding activities that cause pain 1, 2
- Ice: Apply cold (ice and water surrounded by damp cloth) for 20-30 minutes per session, never directly on skin to prevent cold injury 1, 2
- Compression: Use a compression wrap for comfort, ensuring circulation is not compromised 1
- Elevation: Keep ankle above heart level 2
Pain Management:
- Start NSAIDs (piroxicam, celecoxib, or naproxen) immediately to reduce pain and swelling, which accelerates return to activity 1, 2, 3
Critical Pitfall to Avoid
Never use prolonged immobilization—functional treatment with bracing returns patients to work 7.1 days sooner and to sports 4.6 days sooner than immobilization 1, 3. Immobilization shows no benefits and leads to decreased range of motion, chronic pain, and joint instability 1, 3.
Early Mobilization Phase (48-72 Hours Post-Injury)
Begin supervised exercise therapy within 48-72 hours—this has Level 1 evidence as the most effective treatment for ankle sprains 1, 3. The British Journal of Sports Medicine notes that RICE alone has no positive influence on pain, swelling, or patient function without exercise 3.
Exercise Program Must Include:
- Range of motion exercises 1, 3
- Progressive strengthening exercises 1, 2
- Proprioception training (balance exercises)—critical for preventing re-injury 1, 3
- Coordination exercises 1, 3
- Sport-specific exercises as recovery progresses 1
Supervised exercises are superior to home exercises alone and should focus on proprioception, strength, coordination, and function 3.
Bracing Strategy
Lace-up or semirigid ankle supports are more effective than tape or elastic bandages 1. Continue semirigid bracing throughout rehabilitation and upon return to sport—this has Level 1 evidence for preventing recurrent sprains 2, 3.
Special Consideration: High Ankle Sprains
If pain is located in the syndesmosis area (between tibia and fibula, above typical lateral ligament site), suspect a high ankle sprain 2, 3:
- Crossed-leg test: Apply pressure to medial knee while patient sits with legs crossed; pain in syndesmosis area confirms diagnosis 1, 2, 3
- High ankle sprains require more intensive rehabilitation and significantly longer recovery time 2, 3
- Same PRICE protocol applies, but expect extended timeline 2
Follow-Up Timing
Re-examine at 3-5 days post-injury for accurate diagnosis and treatment planning 1. Clinical assessment of ligament damage is optimized at 4-5 days when swelling has decreased 1, 3.
What NOT to Do
- Never apply heat to acute ankle injuries—contraindicated in the acute phase 1, 2
- Never delay exercise therapy beyond 72 hours without medical justification 1, 3
- Never allow prolonged non-weight-bearing unless fracture is present 4
- Never rely on RICE alone without exercise therapy—it provides no functional benefit 3
Imaging Decisions
Apply Ottawa Ankle Rules to determine if radiography is needed—this reduces unnecessary X-rays by 60% and has high sensitivity for detecting fractures 3.
Return to Activity
With proper functional treatment, patients return to work approximately 7.1 days sooner than with immobilization 1, 3. Continue wearing the semirigid brace during sports participation to prevent recurrent injury 2, 3.