What is the best course of action for a patient with lateral right ankle pain, superficial abrasion, and able to bear weight after a motorcycle fell on their ankle, with a negative X-ray for fracture?

Management of Lateral Ankle Injury with Negative X-ray

This patient has a lateral ankle sprain and should receive functional treatment with a lace-up or semi-rigid ankle brace for 4-6 weeks combined with supervised exercise therapy starting within 48-72 hours, NSAIDs for pain control, and wound care for the abrasion. 1

Immediate Wound Management

• Clean the superficial abrasion thoroughly with large volumes of warm or room temperature potable water with or without soap until no foreign matter remains in the wound. 1
• Apply antibiotic ointment or cream to the abrasion (if no known allergies) and cover with a clean occlusive dressing, as wounds heal better with less infection when covered. 1

Functional Support and Immobilization

• Apply a lace-up or semi-rigid ankle brace within the first 48 hours and continue for 4-6 weeks, as this approach is superior to immobilization and leads to return to sports 4.6 days sooner and return to work 7.1 days sooner. 1, 2
• Avoid immobilization beyond what is needed for initial pain control (maximum 3-5 days), as prolonged immobilization delays recovery, decreases range of motion, and causes chronic pain and joint instability without any demonstrated benefits. 1, 2
• Lace-up or semi-rigid ankle supports are more effective than tape or elastic bandages. 2

Exercise Therapy Protocol

• Begin supervised exercise therapy within 48-72 hours after injury (Level 1 evidence for effectiveness). 1, 2
• The exercise program should include:
  • Range of motion exercises 1, 2
  • Proprioception training (critical to prevent recurrent sprains) 1, 2
  • Strengthening exercises 1, 2
  • Coordination and functional exercises 1, 2
• Supervised exercises are superior to non-supervised home training, so refer to physical therapy rather than providing home exercises alone. 2
• Manual mobilization can be added to enhance treatment effects but should not be used alone. 1, 2

Pain Management

• Prescribe NSAIDs (ibuprofen, naproxen, diclofenac, or celecoxib) for short-term use (<14 days) to reduce pain and swelling, which accelerates return to activity. 1, 2
• Acetaminophen is equally effective if NSAIDs are contraindicated. 2
• Avoid opioids, as they cause significantly more side effects without superior pain relief. 2

Weight-Bearing Instructions

• Allow immediate weight-bearing as tolerated, avoiding only activities that cause pain. 2
• The patient's ability to bear weight at presentation is a positive prognostic sign and supports conservative management. 1

Follow-up and Re-examination

• Schedule re-examination in 3-5 days when swelling has decreased, as this allows for accurate assessment of ligament damage and helps distinguish between partial tears and complete ruptures. 1, 2
• Clinical assessment of ligament damage is optimized if delayed for 4-5 days post-injury. 2

Expected Return to Activity Timeline

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

Prevention of Recurrent Injury

• Incorporate ongoing ankle exercises into regular training activities after recovery to prevent recurrence (high cost-benefit ratio due to reduced recurrence rates). 2
• Continue ankle bracing during high-risk activities even after recovery. 2
• Proprioception training is especially critical for patients who have already had two sprains. 2

Critical Pitfalls to Avoid

• Do not use the RICE protocol alone, as it has no evidence for effectiveness, though individual components (ice, compression) can be used strategically for comfort. 2
• Do not immobilize the ankle beyond 3-5 days, as this leads to worse outcomes. 1, 2
• Do not skip the delayed physical examination at 3-5 days, as initial examination cannot distinguish partial tears from complete ruptures. 2
• Do not apply ice directly to skin; use cold application (ice and water surrounded by a damp cloth) for 20-30 minutes per application. 1, 2

Additional Imaging Considerations

Since the patient has lateral ankle pain and was able to bear weight with negative X-rays, no additional imaging is needed at this time. 1 However, if pain persists beyond 1-3 weeks despite appropriate treatment, consider MRI or CT to evaluate for occult injuries or ligamentous tears. 1