What is the treatment for ankle pain?

Treatment for Ankle Pain

For acute ankle sprains causing ankle pain, immediately apply a lace-up or semi-rigid ankle brace (within 48 hours) and continue for 4-6 weeks, combined with supervised exercise therapy starting within 48-72 hours, while using NSAIDs for pain control and avoiding prolonged immobilization. 1, 2

Immediate Management (First 48-72 Hours)

PRICE Protocol Components

• Apply cold therapy (ice and water surrounded by damp cloth) for 20-30 minutes per application without direct skin contact to prevent cold injury 2
• Use compression wraps for comfort while ensuring circulation is not compromised 2
• Elevate the ankle above heart level to reduce swelling 3
• Protect the ankle and avoid activities that cause pain while seeking medical attention 2

Critical caveat: The RICE protocol alone has no evidence for effectiveness when used in isolation, but individual components can be strategically applied 2. Do not rely on RICE as your sole treatment approach 2.

Functional Support (Most Important Intervention)

• Apply a lace-up or semi-rigid ankle brace within the first 48 hours and continue for 4-6 weeks 1, 2
• This approach is superior to immobilization and leads to return to sports 4.6 days sooner and return to work 7.1 days sooner compared to immobilization 2
• Lace-up or semi-rigid ankle supports are more effective than tape or elastic bandages 2

Exercise Therapy (Level 1 Evidence)

Timing and Supervision

• Begin supervised exercise therapy within 48-72 hours after injury 1, 2
• Supervised exercises are superior to non-supervised home exercises—patients should work with a physical therapist rather than performing exercises alone 2

Exercise Components

• Range of motion exercises to restore ankle mobility 2
• Progressive strengthening exercises targeting ankle musculature 2, 3
• Proprioception training (critical for preventing recurrent sprains, especially after two previous sprains) 2
• Coordination and functional exercises to prepare for return to activity 2

Pain Management

First-Line: NSAIDs

• Use NSAIDs such as ibuprofen, naproxen, diclofenac, or celecoxib for short-term pain control (<14 days) 1, 2
• NSAIDs reduce pain and swelling without significantly increasing adverse events in relatively young, healthy patients 1
• Diclofenac showed superior results at days 1-2 compared to piroxicam and ibuprofen for reducing pain during motion 1
• Celecoxib (200 mg twice daily) is non-inferior to non-selective NSAIDs with equal adverse event rates 1

Alternative: Acetaminophen

• Acetaminophen is equally effective as NSAIDs for pain, swelling, and range of motion if NSAIDs are contraindicated 1, 2

Avoid Opioids

• Opioids should be avoided as they cause significantly more side effects without superior pain relief 1, 2

Important consideration: NSAIDs may delay natural healing by suppressing inflammation necessary for tissue recovery, though clinical significance remains debated 1.

Immobilization Guidelines

Short-Term Immobilization (If Needed)

• A short period of immobilization (<10 days) with plaster cast or rigid support can decrease pain and edema in severe acute injuries 1
• Use immobilization only for initial pain control (3-5 days maximum) 2

Avoid Prolonged Immobilization

• Do not immobilize beyond 10 days as this leads to decreased range of motion, chronic pain, and joint instability without demonstrated benefits 1, 2
• Minimum 4 weeks in a lower leg cast results in less optimal outcomes compared to functional support 1

Return to Activity Timeline

Mild Sprains

• Return to mostly sitting work at 2 weeks 2
• Full return to work and sports at 3-4 weeks depending on task requirements 2

Moderate to Severe Sprains

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

Prevention of Recurrent Sprains

• Incorporate ongoing ankle exercises into regular training activities after recovery 2
• Continue ankle bracing during high-risk activities even after full recovery 2
• Neuromuscular training and ankle braces have Level 2 evidence for preventing recurrent sprains through reduced societal costs 2

Special Consideration: High Ankle Sprains

Diagnosis

• Pain located in the syndesmosis area between tibia and fibula (above typical lateral ligament injury site) 3
• Use the crossed-leg test (squeeze test): applying pressure to medial knee while patient sits with legs crossed produces syndesmosis pain 3

Treatment Differences

• High ankle sprains require more intensive rehabilitation and significantly longer recovery time than lateral ankle sprains 3
• Follow same functional treatment principles but expect extended timeline 3
• Continue semi-rigid bracing throughout rehabilitation and upon return to sport 3

Common Pitfalls to Avoid

• Never immobilize beyond 3-5 days unless absolutely necessary for severe pain control 2
• Do not apply heat to acute ankle injuries—this is contraindicated 2, 3
• Inadequate treatment leads to chronic problems including decreased range of motion, pain, and joint instability 2
• Do not use manual mobilization alone—it should only be added to enhance other treatment effects 2
• Re-examine patients 3-5 days after injury for accurate diagnosis and treatment planning, as clinical assessment of ligament damage is optimized when swelling has decreased 2