What is the initial treatment for an ankle sprain in a pediatric patient?

Initial Treatment for Ankle Sprain in a 9-Year-Old Male

For a pediatric ankle sprain, immediately initiate functional treatment with a semirigid ankle brace (not elastic bandage), start supervised exercise therapy within 48-72 hours, and use NSAIDs or acetaminophen for pain control—avoid prolonged rest or immobilization beyond 10 days. 1

Immediate Management (First 24-48 Hours)

Pain and Swelling Control

• Use NSAIDs (ibuprofen or naproxen) or acetaminophen for pain relief, as both are equally effective for reducing pain and swelling in pediatric patients 1
• Apply ice/cryotherapy only when combined with exercise therapy—cryotherapy alone without exercise has no proven benefit 1
• Elevate the ankle to reduce swelling 1, 2
• Do not rely on RICE protocol alone, as there is no evidence that RICE by itself improves outcomes 1

Critical Pitfall to Avoid

• Never immobilize the ankle beyond 10 days maximum—prolonged immobilization leads to worse functional outcomes, delayed return to activity, and increased risk of chronic instability 1
• If immobilization is used at all for severe pain control, limit it to less than 10 days, then immediately transition to functional treatment 1

Functional Support (Start Immediately)

Ankle Bracing

• Apply a semirigid ankle brace (not tape or elastic bandage) for 4-6 weeks, as braces are superior to all other support methods for pediatric ankle sprains 1
• Semirigid braces allow protected weight-bearing while preventing excessive inversion, promoting faster recovery than elastic bandages 1
• Continue brace use during sports activities for prevention of recurrent sprains, especially in children with previous ankle injuries 2, 3

Exercise Therapy (Start Within 48-72 Hours)

Early Mobilization Protocol

• Begin supervised exercise therapy within 48-72 hours of injury—this is the single most important intervention for preventing chronic ankle instability 1, 2
• Focus on three phases: (1) early range of motion exercises, (2) progressive strengthening, and (3) proprioceptive/balance training 1
• Supervised exercise therapy reduces recurrent ankle sprains by 50% and prevents functional ankle instability 1

Specific Exercise Components

• Start with gentle range-of-motion exercises (ankle circles, alphabet writing with toes) within 48 hours 1
• Progress to resistance band exercises for strengthening all ankle movements by day 5-7 1
• Add proprioceptive training (single-leg balance, wobble board exercises) as pain allows, typically by week 2 1, 2
• Advance to sport-specific drills and agility training once strength and balance are restored 1

What NOT to Do

Avoid These Common Errors

• Do not prescribe rest beyond 3-5 days—prolonged rest delays return to activity by 7.1 days compared to functional treatment 1
• Do not use elastic bandages or compression stockings as the primary support—they are inferior to semirigid braces 1
• Do not apply heat in the acute phase—heat is contraindicated for acute ankle injuries 1
• Do not use opioid analgesics—they provide no better pain relief than NSAIDs but cause significantly more side effects 1

Return to Activity Timeline

Expected Recovery

• With functional treatment, children typically return to sports 4.6 days sooner than with immobilization 1
• Return to full activity when the child can: hop on the injured ankle without pain, perform single-leg balance for 30 seconds, and complete sport-specific movements without apprehension 1, 3
• Continue wearing the ankle brace during sports for at least 6 months to prevent recurrent sprains 2, 3, 4

When to Refer

Red Flags Requiring Urgent Evaluation

• Inability to bear weight after 48 hours suggests possible fracture—apply Ottawa Ankle Rules to determine need for radiography 1, 2
• Severe night pain that wakes the child may indicate infection, inflammatory arthropathy, or neurologic causes requiring urgent evaluation 2, 5
• Systemic symptoms, fever, or rapid progression of swelling suggest septic arthritis needing immediate joint aspiration 2, 5
• Persistent pain beyond 6 weeks despite appropriate treatment warrants orthopedic referral for evaluation of occult injuries 3, 6

Prevention of Recurrent Injury

Long-Term Strategy

• Continue proprioceptive exercises as part of regular training even after full recovery—this is the most effective prevention strategy 1, 4
• Maintain brace use during high-risk activities for 6-12 months, as previous ankle sprain is the strongest risk factor for recurrent injury 1, 2, 3
• Address any identified risk factors such as limited ankle flexibility or muscle weakness through ongoing exercise 1, 3