What is the recommended NSAID (Non-Steroidal Anti-Inflammatory Drug) protocol, specifically with Celecoxib, for a 47-year-old female patient with an acute lateral ankle sprain and possible Achilles tendon strain or paratenonitis?

Celecoxib Protocol for Acute Lateral Ankle Sprain

For this 47-year-old female with acute lateral ankle sprain, initiate celecoxib 400 mg loading dose immediately, followed by 200 mg twice daily for up to 14 days, combined with functional bracing and supervised exercise therapy starting within 48-72 hours. 1, 2, 3

Celecoxib Dosing Regimen

Loading dose strategy: Administer celecoxib 400 mg as a single loading dose on day 1, then continue with 200 mg twice daily for the treatment duration. 3, 4 This loading dose approach achieves faster pain relief compared to standard dosing without the loading phase.

Treatment duration: Continue celecoxib for short-term use only (maximum 14 days), as NSAIDs are most effective in the acute phase and prolonged use may theoretically delay natural tissue healing by suppressing necessary inflammatory responses. 1, 2

Efficacy evidence: Celecoxib 200 mg twice daily is non-inferior to non-selective NSAIDs (ibuprofen 2400 mg/day, naproxen 1000 mg/day) for pain relief in acute ankle sprains, with mean VAS pain scores decreasing from 73 mm at baseline to 29 mm by day 3. 2, 3, 4

Comparative Advantages of Celecoxib

Gastrointestinal safety: Celecoxib causes significantly less dyspepsia (3%) compared to naproxen (12%, P=0.032) and has markedly fewer GI adverse events than non-selective NSAIDs while maintaining equivalent analgesic efficacy. 2, 4

Cardiovascular considerations: The PRECISION trial demonstrated that celecoxib 100 mg twice daily met all prespecified non-inferiority criteria for cardiovascular safety compared to ibuprofen and naproxen (HR 0.86 vs ibuprofen, 0.93 vs naproxen), though this trial primarily studied the 100 mg twice daily dose in chronic arthritis patients. 5 For acute ankle sprain, the 200 mg twice daily dose for 7-14 days carries minimal CV risk given the short treatment duration.

Return to function: Patients treated with celecoxib returned to normal function after 5 days versus 8 days with placebo, representing a clinically meaningful acceleration of recovery. 6

Comprehensive Multimodal Protocol

Immediate Phase (Days 0-2)

• PRICE protocol implementation: Apply Protection (functional brace), avoid Rest beyond initial pain control, apply Ice (20-30 minutes, 3-4 times daily with damp cloth barrier), use Compression wrap ensuring circulation not compromised, and maintain Elevation. 7, 1

• Functional bracing: Apply lace-up or semi-rigid ankle brace within first 48 hours and continue for 4-6 weeks, which is superior to immobilization and leads to return to sports 4.6 days sooner and return to work 7.1 days sooner. 1

• Weight-bearing: Begin weight-bearing as tolerated immediately, avoiding only activities that cause pain. 1

Early Rehabilitation Phase (Days 2-14)

• Supervised exercise therapy: Initiate within 48-72 hours after injury with physical therapist supervision (Level 1 evidence), focusing on range of motion, proprioception training, strengthening, and coordination exercises. 1 Supervised exercises are superior to home exercise programs alone.

• Avoid immobilization: Do not immobilize beyond 3-5 days, as prolonged immobilization delays recovery without improving outcomes and leads to decreased range of motion, chronic pain, and joint instability. 1

Ongoing Phase (Weeks 2-6)

• Continue functional bracing: Maintain brace use for full 4-6 weeks even as pain improves. 1

• Progress exercise intensity: Advance proprioceptive training, which is critical for preventing recurrent sprains, especially given that 5-46% of patients report long-term pain at 1-4 years and up to 40% develop chronic ankle instability. 1

Alternative NSAID Options

If celecoxib unavailable or contraindicated:

• Topical diclofenac gel: First-line alternative, apply to affected area 3-4 times daily, providing equivalent pain relief to oral NSAIDs with significantly fewer systemic side effects (OR 6.39 for symptom relief vs placebo). 2 Particularly valuable for patients ≥75 years or those with renal/cardiovascular risk factors.

• Oral diclofenac: Shows superior pain relief at days 1-2 compared to piroxicam and ibuprofen for acute ankle sprains. 2

• Acetaminophen: Equally effective as NSAIDs for pain, swelling, and range of motion in acute ankle sprains (three RCTs, n=450), suitable if NSAIDs contraindicated. 1, 2

Critical Safety Considerations

Contraindications and cautions:

• Avoid in patients with aspirin-sensitive asthma, active peptic ulcer disease, or severe renal impairment. 5
• Use caution in elderly patients (≥75 years), those with cardiovascular disease, heart failure, or renal insufficiency—consider topical NSAIDs preferentially in these populations. 2
• Concomitant low-dose aspirin may negate GI safety advantages of celecoxib over non-selective NSAIDs. 8

Avoid opioids: Opioids provide similar pain relief to NSAIDs but cause significantly more side effects and should be avoided for ankle sprains. 1, 2

Follow-Up Assessment

Re-examination timing: Schedule follow-up at 3-5 days post-injury when swelling has decreased, as this timing optimizes clinical assessment of ligament damage and allows accurate distinction between partial tears and complete ruptures. 7, 1

Red flags requiring reassessment: Persistent pain beyond expected timeline, inability to bear weight, signs of incomplete rehabilitation including workload limitations or difficulty with sports-specific movements, as these increase reinjury risk. 1

Prevention of Recurrent Injury

Long-term strategies: Continue ankle exercises incorporated into regular training activities after recovery, and maintain ankle bracing during high-risk activities, as exercise therapy and bracing have Level 2 evidence for preventing recurrent sprains. 1