Treatment for High Ankle Sprain
High ankle sprains require functional treatment with immediate PRICE protocol, lace-up or semirigid ankle bracing for 4-6 weeks, and supervised exercise therapy beginning within 48-72 hours—avoiding prolonged immobilization which delays recovery without any demonstrated benefit. 1
Initial Management (First 24-48 Hours)
Implement the PRICE protocol immediately:
- Protection: Apply a lace-up or semirigid ankle brace within the first 48 hours 1
- Rest: Avoid activities that cause pain, but do not enforce complete non-weight-bearing 1
- Ice: Apply cold (ice and water surrounded by damp cloth) for 20-30 minutes per application, avoiding direct skin contact 1
- Compression: Use compression wraps for comfort while ensuring circulation is not compromised 1
- Elevation: Elevate the injured ankle to minimize swelling 1
Critical distinction: High ankle sprains involve the syndesmosis between the tibia and fibula, detected by the crossed-leg test where pressure on the medial knee produces pain in the syndesmosis area 2, 1. These injuries typically require more intensive rehabilitation and longer recovery time than standard lateral ankle sprains 1.
Ankle Support (Continue for 4-6 Weeks)
Use lace-up or semirigid ankle supports rather than elastic bandages or tape 2, 1. This approach is superior because:
- Patients return to sports 4.6 days sooner compared to immobilization 1
- Patients return to work 7.1 days sooner than with immobilization 2, 1
- Results in less ankle instability and shorter recovery time 2
Avoid prolonged immobilization beyond initial pain control (3-5 days maximum), as it leads to decreased range of motion, chronic pain, and joint instability without any demonstrated benefits 1.
Supervised Exercise Therapy (Begin 48-72 Hours Post-Injury)
Start supervised exercise therapy within 48-72 hours—this has Level 1 evidence for effectiveness 1. The rehabilitation should include:
Phase 1 (Days 2-14): Range of motion exercises and gentle strengthening while maintaining brace support 2, 1
Phase 2 (Weeks 2-6): Progressive strengthening, proprioception training (critical for preventing recurrent sprains), coordination exercises, and functional exercises 2, 1
Phase 3 (Weeks 6+): Sport-specific drills, agility training, plyometrics, and perturbation training on unstable surfaces 2, 3
Important caveat: 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 but should not be used alone 1.
Pain Management
Use NSAIDs for short-term pain control (<14 days): Options include ibuprofen, naproxen, diclofenac, or celecoxib 2, 1. These medications reduce pain and swelling, accelerating return to activity 2.
Avoid opioids as they cause significantly more side effects without superior pain relief 1.
Acetaminophen is equally effective if NSAIDs are contraindicated 1.
Weight-Bearing Protocol
Begin weight-bearing as tolerated immediately after injury 1. Avoid only activities that cause pain, but do not enforce strict non-weight-bearing restrictions 1. Early mobilization allows earlier return to work and may be more comfortable for patients 4.
Follow-Up and Re-Examination
Re-examine the patient 3-5 days after injury when swelling has decreased 1. This delayed examination is critical because:
- Initial examination cannot distinguish partial tears from complete ruptures 1
- Clinical assessment of ligament damage is optimized when swelling has subsided 1
- Helps with accurate diagnosis and treatment planning 1
Return to Activity Timeline
For high ankle sprains specifically (which require longer recovery than standard sprains):
- Return to sedentary work: 3-4 weeks 1
- Full return to work and sports: 6-8 weeks depending on physiotherapy results 1
- Continue ankle bracing during high-risk activities even after recovery 1
Prevention of Recurrent Injury
Incorporate ongoing ankle exercises into regular training activities with high cost-benefit ratios due to reduced recurrence rates 1. Proprioception training is critical, especially after the initial injury 1.
Continue ankle bracing during high-risk activities as this shows a 47% relative reduction in ankle sprains, with greatest benefit for those with history of recurrent sprains 2, 1.
Common Pitfalls to Avoid
Do not immobilize beyond 3-5 days: Prolonged immobilization shows no benefits compared to functional treatment and delays recovery 2, 1
Do not use therapeutic ultrasonography: It has no demonstrated value in treating acute ankle sprains 2
Do not apply heat to acute injuries: Heat application is not recommended for acute ankle injuries 1
Do not skip the delayed physical examination: Inadequate initial assessment can lead to chronic problems including decreased range of motion, pain, and joint instability 1