What is the recommended treatment for an ankle sprain?

Recommended Treatment for Ankle Sprain

Apply a lace-up or semi-rigid ankle brace immediately and continue for 4-6 weeks, combined with supervised exercise therapy starting within 48-72 hours—avoid prolonged immobilization beyond initial pain control as it delays recovery without improving outcomes. 1

Initial Management (First 48 Hours)

PRICE Protocol Components

• Apply ice (wrapped in damp cloth to avoid direct skin contact) for 20-30 minutes per application to reduce pain and swelling 1
• Use compression wraps for comfort while ensuring circulation is not compromised 1
• Elevate the injured ankle 1
• Protect the ankle from further injury but avoid complete rest beyond 3-5 days 1

Important caveat: The RICE protocol alone has no evidence for effectiveness when used in isolation, but individual components can be used strategically as part of a comprehensive functional treatment approach 1

Bracing (Most Critical Intervention)

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

Weight-Bearing

• Begin weight-bearing as tolerated immediately after injury 1
• Avoid only activities that cause pain 1
• Do not immobilize beyond what is needed for initial pain control (maximum 3-5 days) 1

Pain Management

NSAIDs (First-Line)

• Use NSAIDs such as ibuprofen, naproxen, diclofenac, piroxicam, or celecoxib to reduce pain and swelling in the short term (<14 days) 1
• NSAIDs accelerate return to activity 1
• Acetaminophen is equally effective if NSAIDs are contraindicated 1

Avoid Opioids

• Opioids cause significantly more side effects without superior pain relief 1

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 alone 1
• Work with a physical therapist rather than performing exercises independently 1

Exercise Components (All Required)

• Range of motion exercises to restore ankle mobility 1
• Strengthening exercises targeting ankle musculature 1
• Proprioception training (critical to prevent recurrent sprains, especially after two previous sprains) 1
• Coordination and functional exercises specific to the patient's activity demands 1

Manual Therapy

• Manual mobilization can be added to enhance treatment effects but should never be used alone 1, 2

Follow-Up Care

Re-examination Timing

• Schedule re-examination 3-5 days after 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

Return to Activity Timeline

For Mild Sprains:

• Return to sedentary work at 2 weeks 1
• Full return to work and sports at 3-4 weeks depending on task requirements 1

For Moderate to Severe Sprains:

• Return to sedentary work at 3-4 weeks 1
• Full return to work and sports at 6-8 weeks depending on physiotherapy results 1

Special Considerations for High Ankle Sprains

Identification

• Use the crossed-leg test: pressure applied to the medial side of the knee produces pain in the syndesmosis area 1, 2
• High ankle sprains involve injury to the syndesmosis between tibia and fibula 1, 2

Treatment Differences

• Require more intensive rehabilitation and longer recovery time 1
• Same principles apply: functional support with bracing, early supervised exercise therapy, and avoidance of prolonged immobilization 2

Prevention of Recurrent Sprains

Ongoing Exercise

• Incorporate ankle exercises into regular training activities even after recovery 1
• This has high cost-benefit ratios due to reduced recurrence rates 1

Continued Bracing

• Continue ankle bracing during high-risk activities even after recovery 1
• Neuromuscular training and ankle braces have Level 2 evidence for preventing recurrent sprains 1

Critical Pitfalls to Avoid

Do Not Immobilize Beyond 3-5 Days

• Prolonged immobilization leads to decreased range of motion, chronic pain, and joint instability without any demonstrated benefits 1
• Immobilization shows no advantages compared to functional treatment 1

Do Not Apply Heat

• Heat application is not recommended for acute ankle injuries 1
• Cryotherapy combined with exercise therapy is more effective for reducing swelling 2

Do Not Delay Exercise Therapy

• Inadequate treatment leads to chronic problems including decreased range of motion, pain, and joint instability 1
• Starting supervised exercises within 48-72 hours is essential for optimal recovery 1