Treatment of Medial Ankle Injury
For an acute medial ankle sprain in a healthy individual, 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—avoid prolonged immobilization beyond initial pain control as it delays recovery without improving outcomes. 1
Immediate Management (First 48 Hours)
- Apply the PRICE protocol (Protection, Rest, Ice, Compression, Elevation) with cold application for 20-30 minutes using ice and water surrounded by a damp cloth, avoiding direct skin contact to prevent cold injury 1
- Begin weight-bearing as tolerated immediately, avoiding only activities that cause pain 1
- Apply a lace-up or semi-rigid ankle brace within the first 48 hours—this is superior to elastic bandages or tape and leads to faster return to sports (4.6 days sooner) and work (7.1 days sooner) compared to immobilization 1
- Start NSAIDs such as ibuprofen, naproxen, diclofenac, or celecoxib for pain and swelling reduction in the short term (<14 days); acetaminophen is equally effective if NSAIDs are contraindicated 1
- Avoid opioids as they cause significantly more side effects without superior pain relief 1
Early Rehabilitation Phase (48-72 Hours to 4 Weeks)
The critical window for preventing chronic problems is early supervised exercise therapy—this has Level 1 evidence for effectiveness and significantly improves ankle function compared to standard care alone. 1, 2
- Begin supervised exercise therapy within 48-72 hours after injury, focusing on:
- Supervised exercises are superior to home exercises alone—patients should work with a physical therapist rather than performing unsupervised training 1
- Continue the lace-up or semi-rigid ankle brace for the full 4-6 weeks 1
- Manual mobilization can be added to enhance treatment effects but should not be used alone 1
Follow-Up and Assessment
- Re-examine the patient 3-5 days after injury when swelling has decreased—this is critical for accurate diagnosis and distinguishing between partial tears and complete ligament ruptures 1
- For medial ankle injuries specifically, assess for potential deltoid ligament involvement or high ankle sprain using the crossed-leg test (pressure applied to the medial side of the knee produces pain in the syndesmosis area) 1
- Monitor for signs of incomplete rehabilitation including persistent pain, workload limitations, or difficulty with sports-specific movements, as these increase reinjury risk 1
Return to Activity Timeline
- 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 1
- 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 1
Critical Pitfalls to Avoid
- Do not immobilize beyond 3-5 days—prolonged immobilization leads to decreased range of motion, chronic pain, joint instability, and loss of proprioception without any demonstrated benefits 1, 3
- Do not use the RICE protocol alone without functional support and exercise therapy, as it has no evidence for effectiveness as a standalone treatment 1
- Do not apply heat to acute ankle injuries 1
- Do not skip the delayed physical examination at 3-5 days, as initial examination cannot distinguish partial tears from complete ruptures 1
- Inadequate treatment leads to chronic problems in 5-46% of patients who report long-term pain at 1-4 years, and up to 40% develop chronic ankle instability 1
Long-Term Prevention
- Incorporate ongoing ankle exercises into regular training activities after recovery—this has high cost-benefit ratios due to reduced recurrence rates 1
- Continue ankle bracing during high-risk activities even after recovery, as neuromuscular training and ankle braces have Level 2 evidence for preventing recurrent sprains 1
- Address extrinsic risk factors including sport type, playing surface, and training load modifications to reduce recurrence rates 1