What is the treatment for lateral ankle pain with external rotation, swelling, and bruising with a negative X-ray (radiograph)?

Treatment of Lateral Ankle Sprain with Negative X-ray

Functional bracing with an ankle brace for 4-6 weeks combined with early exercise therapy is the optimal treatment for lateral ankle sprains with negative radiographs. 1

Immediate Management (First 10 Days)

• Apply a functional ankle brace (preferred over tape, elastic bandage, or rigid immobilization) as it shows the greatest treatment effects and reduces swelling, pain, and edema more effectively 1
• Short-term immobilization (maximum 10 days) with a rigid support or plaster cast may be used initially if pain and swelling are severe, but must transition to functional treatment after this period 1
• NSAIDs for pain control: Ibuprofen 400 mg every 4-6 hours as needed (do not exceed 3200 mg daily) 2
• Allow protected weight-bearing as tolerated—functional supports permit loading of damaged tissues in a controlled manner, which is superior to complete immobilization 1

Weeks 2-6: Functional Treatment Phase

• Continue ankle brace use for the full 4-6 week period 1
• Initiate exercise therapy immediately (within first 1-2 weeks), focusing on neuromuscular and proprioceptive exercises, as this reduces recurrent injury risk (RR 0.37) and prevents functional ankle instability 1
• Manual joint mobilization combined with exercise therapy provides better outcomes than exercise alone, improving dorsiflexion range of motion and decreasing pain 1
• Home exercise programs are effective and should be prescribed for patient independence 1

Clinical Pitfalls and Re-evaluation

• Do not rely on physical examination in the first 48 hours to distinguish between simple distortion and complete ligament rupture due to excessive swelling and pain 3
• Re-examine the patient at 4-5 days post-injury when the anterior drawer test has optimized sensitivity (84%) and specificity (96%) 3
• Four findings indicate likely complete lateral ligament rupture: hematoma, pain on palpation, positive anterior drawer test, and significant swelling 3

When to Consider Advanced Imaging

• If pain persists beyond 1-3 weeks despite appropriate treatment, order MRI without contrast to evaluate for occult fractures, osteochondral lesions, bone marrow edema, peroneal tendon injury, or syndesmosis injury 1, 4, 5
• Lateral talar process fractures (snowboarder's fracture) are missed on initial radiographs 40-50% of the time and may present as persistent lateral ankle pain with swelling inferior to the lateral malleolus 1, 3

Treatments to Avoid

• Do not use prolonged immobilization (>10 days) as it results in worse outcomes compared to functional treatment 1
• Do not use ultrasound, laser therapy, electrotherapy, or short-wave therapy as they have no proven benefit 1
• Do not use compression stockings beyond the acute phase as they are not helpful 1
• Avoid elastic bandages or tubigrip as sole treatment—they are inferior to proper ankle braces 1

Expected Recovery Timeline

• Return to light work: 2 weeks for distortion injuries, 3-6 weeks for partial/complete ligament ruptures (with restrictions: mostly sitting work, no lifting >10 kg, limited standing/walking on uneven surfaces) 1
• Full return to former work: 3-4 weeks for distortion, 6-8 weeks for ligament ruptures depending on physiotherapy response 1
• Therapeutic response is typically seen within 2 weeks of functional treatment 1

Surgical Consideration

• Surgery is NOT indicated acutely for lateral ankle sprains, even with complete ligament rupture, as conservative treatment provides equal long-term outcomes 1, 6
• Reserve surgery for chronic instability (>6 months) that has failed comprehensive exercise-based physiotherapy, as surgery has longer recovery times, higher rates of ankle stiffness, and more complications 1