What are the treatment guidelines for an adult patient with an ankle strain who has not responded to ibuprofen (Nonsteroidal Anti-Inflammatory Drug, NSAID) and has no significant underlying medical conditions?

Treatment of Ankle Strain After Ibuprofen Failure

When ibuprofen fails to adequately control pain and swelling in an ankle sprain, switch to a different NSAID (diclofenac or naproxen) or consider celecoxib, while immediately initiating functional bracing for 4-6 weeks combined with supervised exercise therapy starting within 48-72 hours. 1

Alternative NSAID Options

First-Line Alternatives to Ibuprofen

• Diclofenac shows superior pain relief compared to ibuprofen at days 1 and 2 for reducing pain during motion in mild-to-severe ankle sprains, with equal adverse event rates 1

• Celecoxib 200 mg twice daily is non-inferior to non-selective NSAIDs (including ibuprofen, naproxen, or diclofenac) for pain control and may offer faster return to function (5 days vs 6 days with ibuprofen) 1, 2

• Naproxen is equally effective as other NSAIDs and can be used as a fixed dose (500 mg twice daily) or as-needed without significant difference in outcomes 1

• Acetaminophen (paracetamol) is equally effective as NSAIDs for pain, swelling, and range of motion if NSAIDs are contraindicated or have failed, and may actually result in less acute edema than diclofenac 1, 3

Critical Caveat on NSAIDs

• NSAIDs may delay natural healing by suppressing inflammation necessary for tissue recovery, so use should be limited to short-term pain control (<14 days) 1

• Avoid opioids as they provide no superior pain relief compared to NSAIDs but cause significantly more side effects 1, 4

Mandatory Functional Treatment (The Core Intervention)

Functional Bracing (Most Important)

• Apply a lace-up or semi-rigid ankle brace immediately 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, 5

• Lace-up or semi-rigid ankle supports are more effective than tape or elastic bandages 5

• Avoid immobilization beyond 10 days maximum (and preferably no more than 3-5 days for initial pain control), as prolonged immobilization leads to worse outcomes including decreased range of motion, chronic pain, and joint instability 1

Supervised 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, 5

• Exercise programs should include:

  • Range of motion exercises 5
  • Proprioception training (critical to prevent recurrent sprains) 5
  • Strengthening exercises 5
  • Coordination and functional exercises 5

• Supervised exercises are superior to home exercise programs alone, so patients should work with a physical therapist rather than performing unsupervised home exercises 6, 5

• Exercise therapy reduces recurrent injuries (10 RCTs, n=1284) and functional ankle instability (3 RCTs, n=174), and is associated with quicker recovery 1

Manual Mobilization (Adjunctive)

• Manual joint mobilization should be added to exercise therapy (not used alone) to enhance treatment effects, as it provides short-term increases in ankle dorsiflexion range of motion and decreases pain 1

Weight-Bearing and Activity Modification

• Begin weight-bearing as tolerated immediately, avoiding only activities that cause pain 5

• For mild sprains: return to mostly sitting work at 2 weeks, full return to work and sports at 3-4 weeks 5

• 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 5

Follow-Up and Reassessment

• Re-examine the patient in 3-5 days when swelling subsides to accurately assess ligament damage severity and distinguish between partial tears and complete ruptures 1, 5

• Late physical examination (4-5 days post-injury) is advised to reach conclusions on the severity of ligament damage 1

• Monitor for signs of incomplete rehabilitation including persistent pain, workload limitations, or difficulty with sports-specific movements, as 5-46% of patients report long-term pain at 1-4 years and up to 40% develop chronic ankle instability 5

Common Pitfalls to Avoid

• Do not use RICE protocol alone as it has no evidence for effectiveness as a complete treatment strategy, though individual components can be used strategically 5

• Do not continue immobilization beyond what is needed for initial pain control, as this delays recovery without improving outcomes 1, 5

• Do not prescribe opioids for ankle sprains, as they cause significantly more side effects without superior pain relief 1

• Do not skip supervised exercise therapy in favor of home exercises alone, as supervised programs have superior outcomes 5, 6