What is the best initial therapy for a patient with a right ankle inversion injury, significant swelling, and tiredness, but no fracture, who can walk with a limp?

Best Initial Therapy for Acute Ankle Inversion Sprain

Apply the PRICE protocol (Protection, Rest, Ice, Compression, Elevation) immediately, combined with a semirigid ankle brace within the first 48 hours, and begin supervised exercise therapy within 48-72 hours after injury. 1

Immediate Management (First 48 Hours)

PRICE Protocol Implementation

• Apply ice for 20-30 minutes every 4 hours using ice and water surrounded by a damp cloth, avoiding direct skin contact to prevent cold injury 1
• Apply a compression wrap to promote comfort while ensuring circulation is not compromised 1
• Elevate the ankle and rest for 3-5 days to control pain and swelling 2, 3
• Protect the ankle immediately with a semirigid or lace-up ankle brace within the first 48 hours and continue for 4-6 weeks, as this is superior to elastic bandages and the most cost-effective option 3, 1

Pain Management

• Use NSAIDs (ibuprofen, naproxen, diclofenac, or celecoxib) for the first 2-7 days to reduce pain and swelling, which accelerates return to activity 1
• Acetaminophen is equally effective if NSAIDs are contraindicated 1
• Avoid opioids as they cause significantly more side effects without superior pain relief 1

Early Mobilization (48-72 Hours Post-Injury)

Weight-Bearing and Activity

• Begin weight-bearing as tolerated immediately after the initial 3-5 day RICE period, avoiding only activities that cause pain 1
• The patient can walk with a limp as tolerated, which is appropriate and encouraged 1
• Avoid prolonged immobilization beyond 3-5 days, as this delays recovery without improving outcomes and can lead to decreased range of motion, chronic pain, and joint instability 1, 4

Supervised Exercise Therapy

• Start supervised exercise therapy within 48-72 hours after injury (this has Level 1 evidence for effectiveness) 1
• Exercises must include:
  • Range of motion exercises 1
  • Proprioception training 1
  • Strengthening exercises 1
  • Coordination and functional exercises 1
• Supervised exercises are superior to home exercises alone, so referral to physical therapy is strongly recommended 1

Critical Pitfalls to Avoid

• Do not use RICE protocol alone beyond the initial 3-5 days, as it has no evidence for long-term effectiveness when used in isolation 1
• Do not immobilize the ankle beyond what is needed for initial pain control (3-5 days maximum), as functional treatment leads to return to sports 4.6 days sooner and return to work 7.1 days sooner than immobilization 1
• Do not use elastic bandages alone for support, as semirigid braces or lace-up supports are significantly more effective 2, 1
• Do not delay exercise therapy, as inadequate treatment can lead to chronic problems in 74% of patients, including persistent pain, swelling, giving way, and weakness for years 5

Follow-Up Timing

• Re-examine the patient at 4-5 days post-injury when pain and swelling have improved, as this is the optimal time for accurate clinical assessment of ligament damage 2, 1
• This delayed examination has good interobserver agreement and helps determine if there is a lateral ligament rupture versus simple distortion 6

Expected Recovery Timeline

• For this patient with significant swelling who can walk with a limp (suggesting a moderate sprain), expect return to sedentary work at 3-4 weeks and full return to work and sports at 6-8 weeks depending on physiotherapy results 1
• Functional treatment with bracing and supervised exercise therapy will optimize this timeline 1