What is the approach to managing unilateral ankle pain and swelling?

Approach to Unilateral Ankle Pain and Swelling

Begin functional treatment immediately with a semirigid or lace-up ankle brace combined with early weight-bearing as tolerated and supervised exercise therapy within 48-72 hours—avoid immobilization beyond initial pain control as it delays recovery without improving outcomes. 1, 2

Initial Assessment and Diagnosis

History and Physical Examination

• Mechanism of injury determines the type of sprain: inversion injuries cause lateral ligament damage (most common), while dorsiflexion with external rotation or eversion with internal rotation suggests high ankle (syndesmotic) sprain 1, 3
• Timing matters: Re-examine at 3-5 days post-injury when swelling decreases for optimal assessment of ligament damage, as initial swelling can obscure findings 1, 2
• Key physical findings for grade III sprains include all four: swelling, hematoma, pain on palpation, and positive anterior drawer test—96% of patients with all four have lateral ligament rupture 1
• High ankle sprain detection: Use the crossed-leg test where pressure on the medial knee produces syndesmotic pain 1, 3

Imaging Decision

• Apply Ottawa Ankle Rules to determine need for radiography—these correctly rule out fracture in 299 of 300 patients (99.7% sensitivity) 1
• Order ankle radiographs only if: pain in malleolar zone AND either inability to bear weight immediately and in emergency department OR bone tenderness at posterior edge or tip of lateral or medial malleolus 1

Immediate Management (First 48-72 Hours)

PRICE Protocol Components

The RICE protocol alone is NOT effective and should not be used as standalone treatment 1, 2. However, individual components can be strategically applied:

• Protection: Apply semirigid or lace-up ankle brace immediately—this is superior to elastic bandages or tape 1, 2
• Ice: Apply for 20-30 minutes per session using ice and water surrounded by damp cloth, avoiding direct skin contact 2. Intermittent application (not continuous 20 minutes) provides better pain relief 4
• Compression: Use compression wrap for comfort, ensuring circulation is not compromised 2
• Elevation: Keep ankle above heart level 2
• Weight-bearing: Begin immediately as tolerated—do NOT enforce strict rest beyond avoiding activities that cause pain 2

Pain Management

NSAIDs are effective for short-term pain control (<14 days) and accelerate return to activity 1:

• First-line options: Ibuprofen, naproxen, diclofenac, or celecoxib—all equally effective 1
• Alternative: Acetaminophen is equally effective as NSAIDs for pain, swelling, and range of motion if NSAIDs are contraindicated 1, 2
• Avoid opioids: They provide no superior pain relief but cause significantly more side effects 1, 2
• Caution: NSAIDs may delay natural healing by suppressing necessary inflammatory responses 1

Functional Treatment (Primary Approach)

Bracing Protocol

Use semirigid or lace-up ankle brace for 4-6 weeks—this shows greatest effects compared to other support types 1, 2:

• Patients return to sports 4.6 days sooner than with immobilization 1, 2
• Patients return to work 7.1 days sooner than with immobilization 1, 2
• Continue bracing during high-risk activities even after recovery to prevent recurrence 2

Exercise Therapy (Level 1 Evidence)

Begin supervised exercise therapy within 48-72 hours after injury—this has the strongest evidence for effectiveness 1, 2:

Phase 1 (48-72 hours post-injury):

• Range of motion exercises 2
• Gentle ankle circles and alphabet writing 2

Phase 2 (Days 3-14):

• Progressive strengthening exercises (resistance bands, toe raises) 2
• Proprioception training (single-leg balance, wobble board)—critical for preventing recurrent sprains 1, 2

Phase 3 (Weeks 2-6):

• Coordination and functional exercises 2
• Sport-specific drills when phase 2 is well underway 1
• Endurance training 1

Manual Therapy

• Manual mobilization can be added to enhance treatment effects but should never be used alone 1, 2

Special Considerations for High Ankle Sprains

High ankle sprains require more intensive rehabilitation and significantly longer recovery time 2, 3:

• Use same functional treatment approach with semirigid bracing 3
• Expect delayed return to sports compared to lateral ankle sprains 3
• May require limited weight-bearing for 3-5 days initially 3
• Ligamentous strength may not fully return for months even with optimal treatment 3

Return to Activity Timeline

Mild Sprains:

• Return to sedentary work: 2 weeks 2
• Full return to work and sports: 3-4 weeks depending on demands 2

Moderate to Severe Sprains:

• Return to sedentary work: 3-4 weeks 2
• Full return to work and sports: 6-8 weeks depending on physiotherapy results 2

Critical Pitfalls to Avoid

Do NOT immobilize beyond 3-5 days for initial pain control 1, 2:

• Immobilization shows no benefits compared to functional treatment 1
• Prolonged immobilization leads to decreased range of motion, chronic pain, and joint instability 2
• Inadequate treatment causes long-term problems including decreased ROM, pain, and joint instability 2

Do NOT apply heat to acute ankle injuries 1, 2

Do NOT use RICE protocol alone without exercise therapy—it has no evidence for effectiveness 1, 2

Prevention of Recurrent Sprains

• Continue proprioception exercises incorporated into regular training activities 2
• Use ankle bracing during high-risk activities (Level 1 evidence for prevention) 2
• Patients with history of two or more sprains require ongoing proprioception training 2