What is the best course of treatment for a patient with a suspected ankle sprain or fracture, presenting with swelling and bruising, who injured their left ankle while playing basketball a few days ago?

Management of Acute Ankle Sprain with Swelling and Bruising

For this patient presenting several days post-injury with persistent swelling and bruising, immediately apply the Ottawa Ankle Rules to determine if radiographs are needed to exclude fracture, then initiate 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. 1, 2, 3

Immediate Diagnostic Assessment

Rule out fracture first using the Ottawa Ankle Rules, which have 86-99% sensitivity and 97-99% negative predictive value 1, 4:

• Order radiographs if the patient has any of the following 1, 4:

  • Pain on palpation at the posterior edge (6 cm) of the lateral or medial malleolus
  • Pain on palpation at the base of the fifth metatarsal bone
  • Pain on palpation of the navicular bone
  • Inability to bear weight immediately after injury or when examined (inability to walk four steps)

• Critical timing consideration: Since this injury occurred "a few days ago," the patient is still within the 1-week window where Ottawa Ankle Rules remain valid 1

• If Ottawa Ankle Rules are negative, radiographs are unnecessary and you can proceed directly to functional treatment 1, 4

Physical Examination for Severity Grading

Do not attempt definitive ligament assessment yet - physical examination in the first 48-72 hours cannot reliably distinguish between partial and complete ligament ruptures due to excessive swelling and pain 4. However, assess for indicators of severe (Grade III) injury 2:

• Significant swelling (present in this case)
• Hematoma/bruising (present in this case)
• Severe pain on palpation around the distal fibula
• Positive anterior drawer test (though sensitivity is poor in acute phase)

Plan for delayed re-examination at 4-5 days post-injury when the anterior drawer test achieves optimal sensitivity (84%) and specificity (96%) for detecting complete ligament rupture 4. This delayed examination is critical and should not be skipped 3.

Immediate Treatment Protocol

Functional Support (NOT Immobilization)

Apply a lace-up or semi-rigid ankle brace immediately and continue for 4-6 weeks - this is superior to immobilization and leads to return to sports 4.6 days sooner and return to work 7.1 days sooner 3. Avoid immobilization beyond what is needed for initial pain control, as prolonged immobilization delays recovery without improving outcomes 3.

PRICE Protocol Components

While the RICE protocol alone has no evidence for effectiveness as a complete treatment, individual components should be used strategically 3:

• Protection: Lace-up or semi-rigid ankle brace (as above) 2, 3
• Rest: Limit weight-bearing initially but begin weight-bearing as tolerated immediately, avoiding only activities that cause pain 2, 3
• Ice: Apply for 15-20 minutes every 2-3 hours (or 20-30 minutes per application), using ice and water surrounded by a damp cloth to avoid direct skin contact 2, 3
• Compression: Use elastic bandage or wrap, ensuring circulation is not compromised 2, 3
• Elevation: Keep ankle above heart level 2

Pain Management

Prescribe NSAIDs for pain and swelling reduction - options include ibuprofen, naproxen, diclofenac, piroxicam, or celecoxib, which are effective for short-term use (<14 days) and may accelerate return to activity 2, 3. If NSAIDs are contraindicated, acetaminophen is equally effective 3. Avoid opioids - they cause significantly more side effects without superior pain relief 3.

Supervised Exercise Therapy (Critical Component)

Refer to physical therapy immediately and begin supervised exercise therapy within 48-72 hours after injury - this has Level 1 evidence for effectiveness and is superior to home exercises alone 2, 3. The program should include 2, 3:

• Range of motion exercises (begin immediately)
• Proprioception training (critical to prevent recurrent sprains, especially since previous ankle sprain is a significant risk factor)
• Strengthening exercises (progressive loading)
• Coordination and functional exercises (sport-specific as recovery progresses)

Supervised exercises are superior to non-supervised training, so the patient should work with a physical therapist rather than performing home exercises alone 3.

Expected Recovery Timeline

Based on injury severity 3:

• Mild sprains: Return to sedentary work at 2 weeks; full return to work and sports at 3-4 weeks
• 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

Special Considerations and Red Flags

Assess for High Ankle (Syndesmotic) Sprain

Perform the crossed-leg test: Apply pressure to the medial side of the knee while the patient's legs are crossed - pain in the syndesmosis area indicates high ankle sprain, which requires more intensive rehabilitation and longer recovery time 2, 3.

Risk Factors for Chronic Ankle Instability

This patient is at risk for developing chronic ankle instability (CAI), which occurs in up to 40% of individuals after lateral ankle sprain 1. Address these factors early 1:

• Current level of pain
• Sports participation level (basketball is high-risk)
• Workload demands

Unfavorable prognostic factors include inability to complete jumping and landing within 2 weeks, deficiencies in dynamic postural control, and lack of mechanical stability at 8 weeks 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 3
• Do not skip the delayed physical examination at 4-5 days - initial examination cannot distinguish partial tears from complete ruptures 3, 4
• Do not order radiographs without applying Ottawa Ankle Rules - only 15% of patients examined with radiographs actually have fractures 1
• Do not prescribe home exercises alone - supervised therapy is superior 3
• Do not apply heat - not recommended for acute ankle injuries 3

Long-Term Prevention

• Continue ankle bracing during high-risk activities (like basketball) even after recovery 3
• Incorporate ongoing ankle exercises into regular training - this has high cost-benefit ratios due to reduced recurrence rates 3
• Implement proprioceptive training - critical for patients who have already had ankle sprains 3