What are the recommended medications and treatments for ankle pain?

Ankle Pain Medication and Treatment

For acute ankle pain from sprains, use NSAIDs (ibuprofen 400mg every 4-6 hours, naproxen, or diclofenac) combined with immediate functional bracing (lace-up or semi-rigid ankle brace for 4-6 weeks) and supervised exercise therapy starting within 48-72 hours—avoid immobilization beyond initial pain control and do not rely on RICE protocol alone. 1, 2

Medication Management

First-Line Analgesics

• NSAIDs are the preferred medication for reducing pain and swelling in acute ankle injuries, with evidence showing they accelerate return to activity without significantly increasing adverse events compared to placebo (26 RCTs, n=4225). 1
• Ibuprofen 400mg every 4-6 hours is the standard dosing—doses greater than 400mg showed no additional benefit in controlled trials. 3
• Alternative NSAIDs include naproxen, diclofenac, or celecoxib (200mg twice daily), all showing similar efficacy. 1
• Diclofenac demonstrated superior pain reduction at days 1-2 compared to piroxicam and ibuprofen for mild-to-severe sprains. 1

Alternative Pain Management

• Acetaminophen (paracetamol) is equally effective as NSAIDs for pain, swelling, and range of motion if NSAIDs are contraindicated (3 RCTs, n=450). 1, 2
• Avoid opioid analgesics—they provide equal pain relief but cause significantly more side effects (2 RCTs, n=869). 1, 2

Important Medication Caveat

• NSAIDs may delay natural healing by suppressing inflammation, which is necessary for tissue recovery—use the lowest effective dose for the shortest duration. 1
• Consider this trade-off: short-term symptom relief versus potential impact on long-term healing. 1

Functional Support (Critical Component)

Bracing Protocol

• Apply a lace-up or semi-rigid ankle brace within 48 hours and continue for 4-6 weeks—this is superior to immobilization and leads to return to sports 4.6 days sooner and return to work 7.1 days sooner. 1, 2
• Ankle braces show the greatest effects compared to other types of functional support (tape, elastic bandages). 1
• Semi-rigid or lace-up supports are more effective than tape or elastic bandages. 1, 2

What NOT to Do

• Avoid immobilization beyond 3-5 days for initial pain control—prolonged casting (≥4 weeks) results in less optimal outcomes compared to functional support. 1, 2
• Short-period immobilization (<10 days) with plaster cast may have added value for decreasing pain and edema in severe injuries, but transition quickly to functional support. 1

Exercise Therapy (Essential for Recovery)

Timing and Supervision

• Begin supervised exercise therapy within 48-72 hours after injury—this has Level 1 evidence for effectiveness and reduces recurrent injury prevalence (10 RCTs, n=1284). 1, 2
• Supervised exercises are superior to home exercises alone—patients should work with a physical therapist. 2

Exercise Components

• Comprehensive program must include:
  • Range of motion exercises 2
  • Proprioception training (critical for preventing recurrent sprains) 1, 2
  • Strengthening exercises 2
  • Coordination and functional exercises 2
• Neuromuscular and proprioceptive exercises reduce prevalence of functional ankle instability (3 RCTs, n=174). 1

Adjunctive Treatments

PRICE Protocol Components

• The traditional RICE protocol alone has no evidence for effectiveness—individual components can be used strategically but not as standalone treatment. 2, 4
• Cold application (ice) for 20-30 minutes per application may provide comfort but has limited evidence when used alone. 2
• Compression wraps may be applied for comfort, ensuring circulation is not compromised. 2
• Elevation can be used as part of comprehensive treatment. 2

Treatments to Avoid

• Venotonic drugs showed no enhanced outcomes compared to acetaminophen. 1
• Platelet-rich plasma injections were not superior to placebo (1 RCT, n=37). 1
• Topical Traumeel was not superior to diclofenac gel. 1
• Periarticular hyaluronic acid injections showed no positive effect on pain or return to sport. 1

Return to Activity Timeline

Mild Sprains (Grade I)

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

Moderate to Severe Sprains (Grade II-III)

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

Follow-Up and Prevention

Monitoring

• Re-examine patients 3-5 days after injury—this helps distinguish partial tears from complete ruptures, as excessive swelling and pain can limit initial examination. 1, 2
• Clinical assessment of ligament damage is optimized when delayed 4-5 days post-injury after swelling decreases. 2

Preventing Recurrence

• Incorporate ongoing ankle exercises into regular training activities after recovery—this has high cost-benefit ratios due to reduced recurrence rates. 2
• Continue ankle bracing during high-risk activities even after recovery, especially for patients with history of recurrent sprains. 1, 2
• History of previous ankle sprain is the strongest risk factor for future injury. 1

Critical Pitfalls to Avoid

• Do not immobilize beyond what's needed for initial pain control—this leads to decreased range of motion, chronic pain, and joint instability without demonstrated benefits. 2, 5
• Do not delay exercise therapy—early movement promotes better healing and functional outcomes. 1, 2
• Do not rely on RICE protocol alone—it has insufficient evidence as standalone treatment. 2, 4
• Do not apply heat in the acute phase—only cold application is appropriate initially. 2
• Inadequate treatment leads to chronic problems in up to 40% of patients including pain, instability, and recurrent sprains. 1, 6