What is the best course of treatment for a patient with an acute sprain?

Acute Sprain Management

For a patient with an acute 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 initial pain control. 1

Immediate First-Line Treatment (First 48 Hours)

• Apply the PRICE protocol (Protection, Rest, Ice, Compression, Elevation) as initial management, though recognize that RICE alone has limited evidence and should not be the sole treatment strategy 1
• Cold application should be limited to 20-30 minutes per session using ice and water surrounded by a damp cloth, avoiding direct skin contact to prevent cold injury 1
• Apply compression wraps for comfort while ensuring circulation is not compromised 1
• Avoid activities that cause pain but do not enforce complete rest, as prolonged immobilization delays recovery 1

Important caveat: While RICE/PRICE is widely recommended, research shows insufficient evidence for its effectiveness as a standalone treatment, and one study found no difference in outcomes between cold compress versus no cold compress 2, 3. The individual components should be used strategically rather than as a complete protocol 1.

Functional Support: The Critical Intervention

• 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 elastic bandages 1
• Functional bracing leads to return to sports 4.6 days sooner and return to work 7.1 days sooner compared to immobilization 1
• Avoid immobilization beyond 3-5 days, as prolonged immobilization causes decreased range of motion, chronic pain, and joint instability without any demonstrated benefits 1

Exercise Therapy: Level 1 Evidence

• Begin supervised exercise therapy within 48-72 hours after injury, which has the strongest evidence (Level 1) for effectiveness 1
• Supervised exercises are superior to home exercises alone, so patients should work with a physical therapist rather than performing unsupervised training 1
• Exercise protocol should include:
  • Range of motion exercises 1
  • Proprioception training (critical for preventing recurrent sprains, especially after two previous sprains) 1
  • Strengthening exercises 1
  • Coordination and functional exercises 1

Weight-Bearing Protocol

• Allow immediate weight-bearing as tolerated, avoiding only activities that cause pain 1
• Do not enforce non-weight-bearing status, as early mobilization with functional support is the evidence-based approach 1

Pain Management

• NSAIDs are first-line for pain control, with options including ibuprofen, naproxen, diclofenac, piroxicam, or celecoxib for short-term use (<14 days) 1
• Acetaminophen is equally effective if NSAIDs are contraindicated 1
• Avoid opioids, as they cause significantly more side effects without superior pain relief 1

Return to Activity Timeline

• For mild sprains: Return to sedentary work at 2 weeks, full return to work and sports at 3-4 weeks depending on task requirements 1
• For 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 1

Critical Follow-Up

• Re-examine the patient at 3-5 days post-injury when swelling has decreased, as this allows for accurate assessment of ligament damage and distinction between partial tears and complete ruptures 1
• Clinical assessment is optimized if delayed for 4-5 days post-injury, as initial examination cannot reliably distinguish injury severity 1

Special Considerations

• Screen for high ankle sprains using the crossed-leg test (pressure on medial knee producing syndesmotic pain), as these require more intensive rehabilitation and longer recovery 1
• Apply Ottawa Ankle Rules to determine if radiography is needed (inability to bear weight or point tenderness over malleoli) 1

Prevention of Recurrence

• Incorporate ongoing ankle exercises into regular training activities after recovery, as this has high cost-benefit ratios due to reduced recurrence rates 1
• Continue ankle bracing during high-risk activities even after recovery 1
• Address the fact that 5-46% of patients report long-term pain at 1-4 years, and up to 40% develop chronic ankle instability despite initial treatment, making proper rehabilitation essential 1

Common Pitfalls to Avoid

• Never immobilize beyond what is needed for initial pain control (maximum 3-5 days), as this is the most common error leading to chronic problems 1
• Do not skip the delayed physical examination at 3-5 days, as accurate diagnosis requires reassessment when swelling subsides 1
• Do not use heat application for acute ankle injuries 1
• Do not use manual mobilization alone; it should only be combined with other treatment modalities 1