What management is recommended for a 21-year-old male with improved ankle pain 3 weeks after a motor vehicle collision (MVC), who has been weight-bearing in a boot?

Management at 3 Weeks Post-Injury with Improved Pain

For a 21-year-old male with improved ankle pain at 3 weeks after MVC who has been weight-bearing in a boot, transition to a lace-up or semi-rigid ankle brace and advance supervised exercise therapy while gradually increasing functional activities toward return to work and sports. 1

Transition from Boot to Functional Support

• Remove the walking boot and transition to a lace-up or semi-rigid ankle brace, which should be continued for a total of 4-6 weeks from the initial injury 1
• The brace provides adequate support while allowing progressive functional rehabilitation, which is superior to prolonged immobilization 1
• Continue the brace during all weight-bearing activities and sports participation until the 6-week mark from injury 1

Advance Exercise Therapy Program

• Intensify supervised exercise therapy focusing on proprioception training, strengthening exercises, coordination drills, and sport-specific functional activities 1
• Supervised exercises are superior to home exercise programs alone and should be performed with a physical therapist rather than independently 1
• Proprioception training is particularly critical at this stage to prevent recurrent sprains, especially since any previous ankle sprain increases future injury risk 1
• Progress strengthening exercises beyond basic range of motion to include resistance training and dynamic movements 1

Return to Activity Timeline

• For mild sprains with improved pain at 3 weeks, plan for full return to work and sports at 3-4 weeks depending on job requirements and physiotherapy progress 1
• If the injury was moderate to severe (which seems less likely given the improvement), full return may extend to 6-8 weeks 1
• Begin weight-bearing activities as tolerated, avoiding only those that reproduce significant pain 1

Pain Management Adjustments

• Discontinue or reduce NSAIDs if pain has significantly improved, as they are primarily indicated for short-term use (<14 days) 1
• Options if continued pain control is needed include ibuprofen, naproxen, diclofenac, or celecoxib 1
• Avoid opioids as they cause more side effects without superior pain relief 1

Critical Monitoring Points

• Reassess for any signs of incomplete rehabilitation including persistent pain, workload limitations, or difficulty with sports-specific movements, as these negatively influence recovery and increase reinjury risk 2
• Following acute ankle injury, 5-46% of patients report long-term pain at 1-4 years, and up to 40% develop chronic ankle instability despite initial treatment 2
• Pain that persists beyond 6 weeks may indicate inadequate rehabilitation, impingement, occult osteochondral lesions, peroneal tendon injury, or lateral instability requiring further evaluation 3

Prevention of Recurrent Injury

• Incorporate ongoing ankle exercises into regular training activities even after symptoms resolve, as this has high cost-benefit ratios due to reduced recurrence rates 1
• Continue ankle bracing during high-risk activities even after recovery is complete 1
• Address any extrinsic risk factors including sport type, playing surface, and training load modifications 2

Common Pitfalls to Avoid

• Do not continue immobilization in the boot beyond what is needed, as prolonged immobilization beyond 3-5 days leads to decreased range of motion, chronic pain, and joint instability without demonstrated benefits 1
• Do not skip the transition to functional bracing, as adequate support during the 4-6 week period is essential for optimal healing 1
• Do not allow the patient to return to full sports participation without completing supervised rehabilitation, as inadequate rehabilitation is a primary cause of persistent symptoms 3