What is the best management approach for a foot or ankle sprain?

Optimal Management of Foot or Ankle Sprains

Functional support with an ankle brace for 4-6 weeks combined with early exercise therapy (starting within 48-72 hours) is the gold standard treatment for ankle sprains, while avoiding prolonged immobilization and abandoning the traditional RICE protocol. 1

Immediate Management (First 10 Days)

Functional Support - NOT Immobilization

• Apply a semirigid ankle brace immediately as the preferred functional support device, which shows superior outcomes compared to tape, elastic bandages, or immobilization 1
• Lace-up or semirigid ankle supports are more effective than tape or elastic bandages for reducing pain and accelerating recovery 2
• If severe pain or swelling requires short-term immobilization, limit this to maximum 10 days only, then immediately transition to functional support 1
• Continue brace use for the full 4-6 week period, as this reduces recurrent injury risk and speeds return to activity by 4.6 days compared to immobilization 1, 2

Pain and Swelling Management

• NSAIDs are recommended to reduce pain and swelling, with diclofenac showing superior results at days 1-2 compared to other NSAIDs for pain during motion 1
• Paracetamol (acetaminophen) is equally effective as NSAIDs for pain and swelling if NSAIDs are contraindicated, with fewer side effects 1
• Avoid opioid analgesics as they provide equal pain relief to NSAIDs but cause significantly more side effects 1
• Apply cold (ice and water surrounded by damp cloth) for 20-30 minutes per application, avoiding direct skin contact to prevent cold injury 2
• Intermittent ice application may provide better pain relief than continuous 20-minute protocols 3

What NOT to Do

• Do not use the RICE protocol - there is no evidence supporting its effectiveness as a standalone treatment 1, 4
• Avoid prolonged immobilization (>10 days) as it results in 7.1 days longer return to work and delayed functional recovery 1, 2
• Do not apply heat to acute ankle injuries 2, 5
• Avoid unnecessary imaging unless Ottawa ankle rules criteria are met 6

Exercise Therapy Protocol (Start Within 48-72 Hours)

Early Phase (Days 2-14)

• Begin supervised exercise therapy within 48-72 hours of injury, as this has Level 1 evidence for effectiveness 1, 2
• Start with range of motion exercises to restore joint mobility 2, 5
• Progress to gentle strengthening exercises as tolerated 2
• Early mobilization combined with functional support reduces recurrent injury prevalence and functional ankle instability 1

Progressive Rehabilitation (Weeks 2-6)

• Implement comprehensive neuromuscular and proprioceptive exercises, which reduce recurrent injuries (10 RCTs, n=1284) and functional ankle instability (3 RCTs, n=174) 1
• Include progressive strengthening exercises targeting ankle stabilizers 2, 5
• Add coordination and sport-specific functional exercises 2, 5
• Continue exercises until full recovery, maintaining brace use throughout rehabilitation 2, 5

Evidence Strength

Exercise therapy initiated early has Level 1 evidence for quicker recovery, enhanced outcomes, and prevention of recurrent injuries 1

Special Considerations for High Ankle Sprains

Diagnosis

• Suspect high ankle sprain if mechanism involves dorsiflexion with external rotation or eversion with internal rotation 5
• Pain localizes to the syndesmosis area between tibia and fibula, above typical lateral ligament injury site 5
• Perform crossed-leg test (squeeze test): apply pressure to medial knee while patient sits with legs crossed; positive if produces syndesmosis pain 2, 5

Modified Treatment

• High ankle sprains require more intensive rehabilitation and significantly longer recovery time than lateral ankle sprains 2, 5
• Use same functional support approach with semirigid bracing, but expect extended recovery period 5
• Limit weight-bearing for 3-5 days initially, longer than typical lateral sprains 5
• Continue semirigid bracing throughout rehabilitation and upon return to sport, as it has Level 1 evidence for preventing recurrent sprains 5

Follow-Up and Re-Assessment

• Re-examine at 4-5 days post-injury when swelling has decreased, allowing optimal clinical assessment of ligament damage 2, 4
• This delayed examination provides more accurate diagnosis and treatment planning than immediate assessment 2
• Monitor for signs of inadequate healing: persistent pain, decreased range of motion, or joint instability 1, 2

Interventions to Avoid

• Do not use platelet-rich plasma injections, hyaluronic acid injections, or Traumeel - none show superiority over standard treatment 1
• Manual mobilization should only be used in combination with other modalities, not as standalone treatment 1, 4
• Surgery is reserved only for professional athletes requiring rapid recovery or patients with persistent symptoms after failed conservative treatment 1

Prevention of Recurrent Sprains

• Continue brace use during sports activities after recovery, particularly for those with history of ankle sprains 1, 2
• Incorporate proprioceptive and neuromuscular exercises into regular training activities for recurrent sprain prevention 1, 2
• Both tape and brace may be used for prevention, with choice based on patient preference 1

Critical Pitfall to Avoid

The most common error is prolonged immobilization beyond 10 days, which delays recovery, increases risk of chronic instability, and prolongs return to work/sport by over a week compared to functional treatment 1, 2. Even severe sprains benefit from early functional support and exercise over extended immobilization.