What is the recommended treatment for a patient with a lateral ankle sprain?

Lateral Ankle Sprain Treatment

For a lateral ankle sprain, immediately 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, while avoiding prolonged immobilization beyond 10 days. 1, 2

Immediate Management (First 48 Hours)

Apply the PRICE protocol strategically (Protection, Rest, Ice, Compression, Elevation), though evidence shows the protocol alone is insufficient—individual components should be used purposefully rather than as a standalone treatment. 2

• Ice application: Apply for 20-30 minutes per session using ice and water surrounded by a damp cloth, avoiding direct skin contact to prevent cold injury. 2
• Compression: Use a compression wrap to promote comfort while ensuring circulation is not compromised. 2
• Elevation: Keep the ankle above heart level. 3
• Weight-bearing: Begin immediately as tolerated, avoiding only activities that cause pain—do not enforce non-weight-bearing. 2

Critical pitfall to avoid: Do not use RICE alone as definitive treatment; it lacks evidence for effectiveness as a standalone intervention. 2

Functional Support (Primary Treatment)

Apply a lace-up or semi-rigid ankle brace within the first 48 hours and continue for 4-6 weeks. This approach is superior to immobilization and results in return to sports 4.6 days sooner and return to work 7.1 days sooner. 1, 2

• Brace selection: Lace-up or semi-rigid ankle supports are more effective than tape or elastic bandages. 2
• Duration: Continue bracing for the full 4-6 weeks, then during high-risk activities even after recovery to prevent recurrence. 2

If immobilization is necessary for severe pain or edema control, limit it to a maximum of 10 days, then immediately transition to functional treatment. 1 Prolonged immobilization beyond this period leads to decreased range of motion, chronic pain, and joint instability without any demonstrated benefits. 2

Exercise Therapy (Essential Component)

Begin supervised exercise therapy within 48-72 hours after injury—this has Level 1 evidence for effectiveness and is critical for preventing recurrent injuries and functional ankle instability. 1, 2

The exercise program should be comprehensive and progressive, including:

• Range of motion exercises: Start immediately to restore normal ankle mobility. 2
• Proprioception training: Critical for preventing recurrent sprains, especially after the first 3-4 weeks; use tilt board exercises. 2, 4
• Strengthening exercises: Progressive loading of ankle musculature. 2
• Coordination and functional exercises: Sport-specific movements as recovery progresses. 2

Supervised exercises are superior to home exercises alone—patients should work with a physical therapist rather than performing unsupervised training. 2 This approach reduces the prevalence of recurrent injuries (Level 2 evidence from 10 RCTs with 1,284 patients) and functional ankle instability (Level 2 evidence from 3 RCTs with 174 patients). 1

Pain Management

Use NSAIDs for short-term pain and swelling control (<14 days), as they are effective for reducing symptoms and accelerating return to activity. 1, 2 Options include:

• Ibuprofen
• Naproxen
• Diclofenac
• Celecoxib
• Piroxicam 2

Acetaminophen is equally effective as NSAIDs for pain, swelling, and range of motion (Level 1 evidence from 3 RCTs with 450 patients), making it an appropriate alternative if NSAIDs are contraindicated. 1

Avoid opioids—they provide no superior pain relief compared to other analgesics but cause significantly more side effects (Level 2 evidence from 2 RCTs with 869 patients). 1, 2

Important caveat: NSAIDs may theoretically delay natural healing by suppressing inflammation necessary for tissue recovery, though clinical significance remains unclear. 1

Manual Therapy

Manual joint mobilization can be added to enhance treatment effects, providing short-term increases in ankle dorsiflexion range of motion and decreased pain (Level 1 evidence from 12 RCTs with 427 patients). 1 However, it should only be used in combination with other treatment modalities, never as standalone therapy. 2

Return to Activity Timeline

For mild sprains (Grade I-II):

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

For moderate to severe sprains (Grade III):

• Return to sedentary work: 3-4 weeks
• Full return to work and sports: 6-8 weeks depending on physiotherapy results 2

Re-examination at 3-5 days post-injury is critical for accurate diagnosis and treatment planning, as initial examination cannot distinguish partial tears from complete ruptures when swelling is maximal. 2

Prevention of Recurrent Sprains

Incorporate ongoing ankle exercises into regular training activities after recovery—this has high cost-benefit ratios due to reduced recurrence rates. 2 Continue ankle bracing during high-risk activities even after full recovery, as this has Level 1 evidence for preventing recurrent sprains. 3

Interventions to Avoid

• Platelet-rich plasma injections: Not superior to placebo for pain and functional outcomes (Level 3 evidence). 1
• Hyaluronic acid injections: No positive effect on pain, return to sport timing, or recurrent sprain prevalence (Level 2 evidence). 1
• Venotonic drugs: No enhanced outcomes compared to acetaminophen and RICE (Level 2 evidence). 1
• Prolonged immobilization: Results in less optimal outcomes compared to functional support (Level 1 evidence from 22 RCTs with 2,304 patients). 1