What treatment is recommended for a patient with a 2-week-old ankle sprain, experiencing weight-bearing pain and pain on the dorsal (top) aspect of the foot?

Management of 2-Week-Old Ankle Sprain with Persistent Weight-Bearing Pain

This patient requires immediate radiographic evaluation using the Ottawa Ankle Rules to exclude a fracture, particularly given the dorsal foot pain and inability to bear weight at 2 weeks post-injury, followed by functional bracing and exercise therapy if no fracture is present. 1

Immediate Diagnostic Evaluation

The persistence of weight-bearing pain at 2 weeks is concerning and mandates fracture exclusion:

• Apply the Ottawa Ankle Rules immediately to determine if radiographs are needed—any patient with pain over the malleoli or inability to bear weight requires imaging to rule out fracture 1
• Dorsal foot pain specifically raises concern for midfoot fractures or occult injuries that may have been missed initially 1
• Standard three-view ankle radiographs (anteroposterior, lateral, and mortise views) should be obtained if Ottawa criteria are met 2
• If initial radiographs are negative but symptoms persist beyond 2-3 weeks, consider MRI or CT to detect occult fractures, osteochondral lesions, or soft tissue pathology not visible on plain films 3, 4

Treatment Algorithm Based on Imaging Results

If Fracture is Identified:

• Unstable fractures require orthopedic consultation for surgical fixation to prevent chronic pain, instability, and post-traumatic arthritis 2
• Apply a well-padded posterior splint, elevate the extremity, and provide adequate analgesia with NSAIDs while awaiting orthopedic evaluation 2

If No Fracture (Confirmed Sprain):

The 2-week timeframe with persistent symptoms indicates inadequate initial management and requires aggressive functional rehabilitation:

• Functional bracing is mandatory—use a semi-rigid or lace-up ankle brace for 4-6 weeks, which is superior to elastic bandages, tape, or immobilization 5, 3
• Avoid any further immobilization, as this delays return to function and worsens outcomes 5
• Begin immediate exercise therapy focusing on neuromuscular and proprioceptive exercises, as early exercise therapy reduces recurrent injuries and functional instability 3, 6

Comprehensive Exercise Protocol

The exercise program must be progressive and include:

• Range of motion exercises to restore joint mobility 6
• Proprioceptive training using ankle disk exercises or balance boards 3, 6
• Strengthening exercises targeting ankle stabilizers and peroneal muscles 6
• Sport-specific functional exercises if the patient is an athlete 6
• Combine exercises with functional bracing for optimal outcomes 5

Pain Management

• NSAIDs (ibuprofen 400 mg every 4-6 hours) are first-line for pain control and inflammation reduction 7, 3
• Use the lowest effective dose for the shortest duration to minimize gastrointestinal and cardiovascular risks 7
• Acetaminophen is an equally effective alternative if NSAIDs are contraindicated 3
• Note that NSAIDs may theoretically delay natural healing by suppressing necessary inflammatory responses, but short-term use is acceptable 3

Critical Red Flags at 2 Weeks

The persistence of symptoms at 2 weeks raises several concerning possibilities:

• Up to 40% of patients develop chronic ankle instability (CAI) despite initial treatment, indicating that current management has been inadequate 1
• Pain persisting beyond 2 weeks may indicate: anterior impingement (present in 25% of patients), osteochondral lesions, peroneal tendon injury, or syndesmosis injury 1, 4
• Inability to complete jumping and landing within 2 weeks is a negative prognostic factor for developing CAI 1
• Higher physical workload increases risk of recurrent sprains and instability 1

Follow-Up and Monitoring

• Re-examine within 1-2 weeks to assess healing progress and exercise compliance 3
• If symptoms persist beyond 3-4 weeks total (1-2 more weeks from now) despite appropriate functional treatment, advanced imaging with MRI is indicated 3, 4
• Monitor for signs of complications: excessive swelling, inability to progress with exercises, or development of instability 5
• Continue exercises until full recovery, focusing on proprioception, strength, and functional performance 5

Common Pitfalls to Avoid

• Do not continue immobilization or rest—this is the most common error and delays recovery 5, 6
• Do not rely on RICE protocol alone—there is no evidence supporting its effectiveness as standalone treatment 5
• Do not delay functional rehabilitation—inadequate rehabilitation is the primary cause of persistent symptoms at this stage 6, 4
• Do not ignore persistent dorsal foot pain—this may indicate midfoot injury or occult fracture requiring different management 1, 3