What is the best course of treatment for a 33-year-old active duty female with a 7-day history of hyperinversion injury to her left ankle, presenting with ongoing pain and swelling, likely diagnosed with an Anterior Talofibular Ligament (ATFL) sprain?

Treatment Plan for 7-Day ATFL Sprain in Active Duty Female

Your Current Plan Needs Modification: Non-Weight-Bearing is Incorrect

Your plan to provide crutches for non-weight-bearing is not evidence-based and will delay recovery—immediate weight-bearing as tolerated is the standard of care for ankle sprains. 1 The British Journal of Sports Medicine guidelines explicitly recommend beginning weight-bearing as tolerated immediately after injury, avoiding only activities that cause pain. 1

Correct Initial Management Approach

Weight-Bearing Status

• Allow immediate weight-bearing as tolerated rather than non-weight-bearing restriction. 1
• Instruct the patient to avoid only activities that cause pain, but encourage normal walking as pain permits. 1
• Non-weight-bearing with crutches is contraindicated as it delays recovery without improving outcomes. 2, 1

Functional Support (Critical Component You're Missing)

• Apply a lace-up or semi-rigid ankle brace immediately and continue for 4-6 weeks—this is superior to simple wrapping and shows the greatest treatment effects. 2, 1
• The brace should be applied within the first 48 hours and is more effective than compression bandages or elastic wraps alone. 2, 1
• This approach leads to return to sports 4.6 days sooner and return to work 7.1 days sooner compared to immobilization. 1
• Simple ankle wrapping (compression bandage) is considered "less adequate support" and inferior to bracing. 2

Pain Management

• Naproxen 500mg is appropriate for short-term use (<14 days) to reduce pain and swelling. 2, 1
• Fixed dosing (500mg twice daily) versus as-needed dosing shows no difference in effectiveness. 2
• Acetaminophen is equally effective if NSAIDs are contraindicated. 2, 1
• Limit analgesic therapy to 2-7 days post-trauma when possible. 3
• Important caveat: NSAIDs may theoretically delay natural healing by suppressing inflammation necessary for tissue recovery, though clinical significance remains debated. 2

Supervised Exercise Therapy (Essential Missing Component)

At 7 days post-injury, this patient should already be in supervised exercise therapy—this is Level 1 evidence and the most critical intervention you're not providing. 2, 1

Exercise Protocol

• Begin supervised exercise therapy immediately (should have started within 48-72 hours of injury). 2, 1
• Supervised exercises are superior to home exercises alone—refer to physical therapy rather than just providing instructions. 1
• Exercise program should include:
  • Range of motion exercises 2, 1
  • Proprioception training (critical for preventing recurrence) 2, 1
  • Strengthening exercises 2, 1
  • Coordination and functional exercises 2, 1
• Proprioception training on a tilt board should begin after 3-4 weeks. 4

Evidence for Exercise Therapy

• Reduces prevalence of recurrent injuries (10 RCTs, n=1284, Level 2 evidence). 2
• Reduces prevalence of functional ankle instability (3 RCTs, n=174, Level 2 evidence). 2
• Associated with quicker time to recovery and enhanced outcomes (Level 1 evidence). 2

Imaging Considerations

Your X-ray Plan

• Weight-bearing ankle X-rays are appropriate to rule out avulsion fractures, particularly given the 7-day history with persistent symptoms. 2
• Ottawa Ankle Rules would guide this decision: X-rays indicated if unable to bear weight (take four steps) or pain on palpation of posterior malleolus. 3, 5

Consider Advanced Imaging

• MRI without contrast is the reference standard for ligamentous injury assessment and is routine in active duty/professional athletes. 2, 6
• MRI is most sensitive for occult fractures with bone marrow edema and determines grade of ligament injury (1,2, or 3), which is critical for treatment planning and return-to-duty assessment in military personnel. 2
• 15% of ligamentous injuries show no fracture on radiography but demonstrate significant injury on MRI. 2
• Given her active duty status and 7-day persistent symptoms, MRI should be strongly considered for accurate diagnosis and treatment planning. 2, 6

Immobilization Concerns

What to Avoid

• Do not immobilize beyond 10 days maximum—prolonged immobilization leads to worse outcomes including decreased range of motion, chronic pain, and joint instability. 2, 1
• If immobilization was used initially for pain control, it should have been discontinued by now (at 7 days). 2
• Cast immobilization for 4+ weeks results in less optimal outcomes compared to functional support. 2

Follow-Up and Monitoring

Delayed Physical Examination

• Re-examine at day 4-5 post-injury (which would be now for this patient) when swelling has decreased—this provides more accurate diagnosis and can distinguish between simple sprain and complete ligament rupture. 1, 6, 5
• Initial examination within 48 hours cannot reliably distinguish between distortion and lateral ligament rupture. 5

Expected Recovery Timeline

• For moderate sprains: return to sedentary work at 3-4 weeks, full return to work and sports at 6-8 weeks depending on physiotherapy results. 1
• At 7 days with persistent pain and swelling, this suggests at least a grade II sprain requiring the full 4-6 week brace protocol. 1

Warning Signs

• 5-46% of patients report long-term pain at 1-4 years despite initial treatment. 1
• Up to 40% develop chronic ankle instability if rehabilitation is incomplete. 1
• Reassess for persistent pain, workload limitations, or difficulty with duty-specific movements, as these increase reinjury risk. 1

Prevention of Recurrent Injury

• Continue ankle bracing during high-risk activities even after recovery. 1
• Incorporate ongoing ankle exercises into regular training activities. 1
• Neuromuscular training has Level 2 evidence for preventing recurrent sprains. 1
• History of ankle sprain is a moderate risk factor for future injury, making prevention strategies essential. 1

Critical Pitfalls in Your Current Plan

1. Non-weight-bearing is contraindicated—this will delay her return to duty without any benefit. 1
2. Simple wrapping is inadequate—she needs a lace-up or semi-rigid brace for 4-6 weeks. 2, 1
3. No exercise therapy referral—this is the most important intervention with Level 1 evidence that you're omitting. 2, 1
4. No plan for supervised rehabilitation—home exercises alone are inferior to supervised therapy. 1