What is the best treatment approach for an ankle sprain with contractures?

Ankle Sprain with Contractures: Treatment Approach

For an ankle sprain with contractures, immediately initiate functional treatment with a lace-up or semi-rigid ankle brace for 4-6 weeks combined with aggressive supervised exercise therapy starting within 48-72 hours, focusing specifically on range of motion exercises to address the contractures while avoiding prolonged immobilization which will worsen the contracture. 1

Immediate Management (First 48 Hours)

• Apply the PRICE protocol with cold application for 20-30 minutes per session and compression wrap, while avoiding activities that cause pain 1
• Do NOT immobilize beyond what is needed for initial pain control (3-5 days maximum), as prolonged immobilization will significantly worsen contractures and lead to decreased range of motion, chronic pain, and joint instability 1, 2
• Apply a lace-up or semi-rigid ankle brace within the first 48 hours, which is superior to immobilization and prevents contracture development 1, 2
• Begin weight-bearing as tolerated immediately, avoiding only activities that cause pain 1

Critical Contracture Management (48-72 Hours Post-Injury)

The presence of contractures makes early aggressive range of motion exercises absolutely essential—this is your priority intervention. 1

• Start supervised exercise therapy within 48-72 hours after injury (Level 1 evidence for effectiveness) 1, 2
• Range of motion exercises must be initiated immediately and performed multiple times daily to prevent contracture progression 1, 2
• Supervised exercises are superior to home exercises alone—patients should work with a physical therapist rather than performing unsupervised training 1
• Manual mobilization can be added to enhance treatment effects for contractures, but should not be used alone 1, 2

Comprehensive Rehabilitation Protocol

Your exercise program must include all of the following components 1, 2:

• Range of motion exercises (most critical for contractures) - performed multiple times daily
• Progressive strengthening exercises targeting ankle musculature
• Proprioception training to prevent recurrent sprains
• Coordination and functional exercises
• Sport-specific exercises as recovery progresses

Pain Management

• Use NSAIDs (ibuprofen, naproxen, diclofenac, celecoxib, or piroxicam) for pain and swelling reduction in the short term (<14 days) 1, 3
• Acetaminophen is equally effective if NSAIDs are contraindicated 1
• Avoid opioids as they cause significantly more side effects without superior pain relief 1
• Never apply heat to acute ankle injuries—use cryotherapy combined with exercise therapy instead 3, 2

Bracing Strategy

• Continue the lace-up or semi-rigid ankle brace for the full 4-6 weeks 1, 2
• This approach leads to return to sports 4.6 days sooner and return to work 7.1 days sooner compared to immobilization 1, 3
• Continue ankle bracing during high-risk activities even after recovery to prevent recurrence 1

Special Considerations for High Ankle Sprains

If you suspect a high ankle sprain (syndesmotic injury) 3, 2:

• Perform the crossed-leg test (squeeze test): apply pressure to the medial side of the knee while patient sits with legs crossed—pain in the syndesmosis area is positive 3, 2
• High ankle sprains require more intensive rehabilitation and significantly longer recovery time 3, 2
• The same principles apply but expect extended timelines for full recovery 3, 2

Return to Activity Timeline

For mild sprains with contractures 1:

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

For moderate to severe sprains with contractures 1:

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

Critical Pitfalls to Avoid

• Do NOT immobilize beyond 3-5 days—this is the most common mistake and will dramatically worsen contractures 1, 2
• Do NOT delay exercise therapy—waiting beyond 72 hours significantly compromises outcomes, especially with contractures present 1, 2
• Do NOT use elastic bandages or tape instead of semi-rigid bracing—they are inferior 1
• Do NOT allow unsupervised home exercises only—supervised therapy is essential 1
• Inadequate treatment leads to chronic decreased range of motion, pain, and joint instability—the contractures you're already dealing with will become permanent 1, 2

Follow-Up Protocol

• Re-examine at 3-5 days post-injury for accurate diagnosis and treatment planning 1
• Clinical assessment of ligament damage is optimized at 4-5 days post-injury when swelling has decreased 1
• Monitor contracture resolution closely—if range of motion is not improving by 2 weeks with aggressive therapy, consider additional manual therapy techniques 1, 2

Long-Term Prevention

• Incorporate ongoing ankle exercises into regular training activities after recovery 1, 2
• Continue proprioception training, which is critical to prevent recurrent sprains (especially after two or more previous sprains) 1
• Maintain ankle bracing during high-risk activities indefinitely 1