What is the management approach for an inverted ankle sprain?

Management of Inverted Ankle Sprains

Begin functional treatment immediately with a lace-up or semi-rigid ankle brace for 4-6 weeks combined with supervised exercise therapy starting within 48-72 hours, while avoiding immobilization beyond initial pain control. 1

Immediate Management (First 48-72 Hours)

Apply the PRICE protocol strategically rather than relying on it as standalone treatment, as RICE alone has no evidence for effectiveness on pain, swelling, or function 1. However, individual components remain useful:

• Protection and compression: Apply a lace-up or semi-rigid ankle brace within the first 48 hours and continue for 4-6 weeks—this is superior to elastic bandages or tape and leads to faster return to sports (4.6 days sooner) and work (7.1 days sooner) compared to immobilization 1, 2
• Ice application: Apply cold (ice and water surrounded by damp cloth) for 20-30 minutes without direct skin contact to avoid cold injury 1
• Elevation and rest: Limit to 3-5 days maximum, then transition to early weight-bearing as tolerated 1, 3

Critical pitfall to avoid: Do not immobilize beyond what is needed for initial pain control (3-5 days maximum), as prolonged immobilization delays recovery, decreases range of motion, and causes chronic pain and instability without any demonstrated benefits 1, 4

Pain Management

Use NSAIDs as first-line for pain control in the short term (<14 days):

• Options include ibuprofen, naproxen, diclofenac, piroxicam, or celecoxib 1
• Acetaminophen is equally effective if NSAIDs are contraindicated 1
• Avoid opioids—they cause significantly more side effects without superior pain relief 1
• Limit analgesic therapy to 2-7 days post-trauma 5

Exercise Therapy (The Most Critical Component)

Begin supervised exercise therapy within 48-72 hours after injury—this has Level 1 evidence for effectiveness and is the treatment with the strongest evidence base 1, 4:

• Supervised exercises are superior to home exercises alone—patients should work with a physical therapist rather than performing unsupervised training 1
• Include all four components: range of motion exercises, proprioception training, strengthening exercises (especially peroneal muscles), and coordination/functional exercises 1, 4
• Proprioception training is critical to prevent recurrent sprains, especially in patients who have already sustained two sprains 1

Manual mobilization (anteroposterior glide on the talus) can be added to enhance treatment effects and achieve pain-free dorsiflexion faster, but should not be used alone—always combine with other modalities 1, 6

Weight-Bearing Protocol

Allow immediate weight-bearing as tolerated, avoiding only activities that cause pain 1:

• For mild sprains: Return to mostly sitting work at 2 weeks, full return to work and sports at 3-4 weeks 1
• For moderate to severe sprains: Return to sedentary work at 3-4 weeks, full return to work and sports at 6-8 weeks depending on physiotherapy results 1

Follow-Up and Re-Assessment

Re-examine at 4-5 days post-injury when swelling has decreased—this is the optimal time for clinical assessment of ligament damage and accurate diagnosis 1, 4, 5

Prevention of Recurrent Sprains

Long-term consequences are common—63% of patients have persistent symptoms (pain, swelling, giving way, or weakness) at 2+ years follow-up, with only 26% recovering fully 7. To prevent this:

• Continue ankle bracing during high-risk activities even after recovery—bracing has Level 2 evidence for preventing recurrent sprains 1
• Incorporate ongoing ankle exercises into regular training activities—neuromuscular training has high cost-benefit ratios due to reduced recurrence rates 1, 4
• Maintain proprioception training as part of regular athletic conditioning 1

Special Consideration: High Ankle Sprains (Syndesmotic Injury)

Use the crossed-leg test to detect syndesmotic involvement: pressure applied to the medial side of the knee produces pain in the syndesmosis area 1, 4:

• These injuries require more intensive rehabilitation and longer recovery time 1
• Same principles apply (functional treatment, early exercise therapy, bracing) but expect extended timelines 4

What NOT to Do

• Never immobilize for more than 3-5 days unless fracture is present 1, 4
• Do not use heat application for acute ankle injuries 1
• Avoid elastic bandages or tape as primary support—semi-rigid braces are more effective and cost-effective 1, 3
• Do not delay exercise therapy—waiting beyond 72 hours compromises outcomes 1