What is the appropriate initial management for a patient presenting with an ankle sprain and bruising of the left lower leg?

Initial Management of Ankle Sprain with Bruising

Begin immediate functional treatment with PRICE protocol (Protection, Rest, Ice, Compression, Elevation), apply a lace-up or semi-rigid ankle brace within 48 hours for 4-6 weeks, and start supervised exercise therapy within 48-72 hours—avoid prolonged immobilization beyond what's needed for initial pain control. 1

Immediate First 48 Hours

PRICE Protocol Implementation

• Apply ice (ice and water in a bag surrounded by a damp cloth) for 20-30 minutes per application to reduce pain and swelling, avoiding direct skin contact to prevent cold injury 1
• Apply a compression wrap to promote comfort, ensuring circulation is not compromised 1
• Elevate the injured leg to reduce swelling 1
• Protect the ankle by avoiding activities that cause pain 1

Functional Support (Critical Decision Point)

• Apply a lace-up or semi-rigid ankle brace within the first 48 hours and continue for 4-6 weeks—this is superior to immobilization and leads to return to sports 4.6 days sooner and return to work 7.1 days sooner 1
• Lace-up or semirigid ankle supports are more effective than tape or elastic bandages 1
• Do NOT immobilize the ankle beyond 3-5 days, as prolonged immobilization leads to decreased range of motion, chronic pain, and joint instability without any demonstrated benefits 1

Pain Management

• Use NSAIDs (ibuprofen, naproxen, diclofenac, or celecoxib) for short-term pain and swelling control (<14 days), as they accelerate return to activity 1
• Acetaminophen is equally effective if NSAIDs are contraindicated 1
• Avoid opioids—they cause significantly more side effects without superior pain relief 1

Early Rehabilitation (48-72 Hours Post-Injury)

Supervised Exercise Therapy (Level 1 Evidence)

• Begin supervised exercise therapy within 48-72 hours after injury—this has Level 1 evidence for effectiveness and is superior to non-supervised home exercises 1
• Include range of motion exercises, proprioception training, strengthening exercises, and coordination/functional exercises 1
• Proprioception training is critical to prevent recurrent sprains, especially after previous ankle injuries 1

Weight-Bearing Protocol

• Begin weight-bearing as tolerated immediately after injury, avoiding only activities that cause pain 1
• The presence of bruising extending to the lower leg does not contraindicate early weight-bearing with appropriate bracing 1

Diagnostic Considerations for Bruising

Rule Out Fracture

• Apply Ottawa Ankle Rules: obtain X-rays if the patient cannot bear weight (4 steps) or has point tenderness over the posterior aspect of the lateral or medial malleolus 1
• The presence of bruising extending to the lower leg may indicate more significant soft tissue injury but does not automatically require imaging 1

Delayed Physical Examination

• Re-examine the patient in 3-5 days when swelling subsides—this is critical for accurately distinguishing between partial tears and complete ligament ruptures and optimizing clinical assessment of ligament damage 1

High Ankle Sprain Assessment

• Perform a crossed-leg test (pressure applied to the medial side of the knee produces pain in the syndesmosis area) to assess for high ankle sprain, which requires more intensive rehabilitation and longer recovery time 1

Return to Activity Timeline

Mild Sprains (Grade I)

• Return to mostly sitting work at 2 weeks 1
• Full return to work and sports at 3-4 weeks depending on task requirements 1

Moderate to Severe Sprains (Grade II-III)

• Return to sedentary work at 3-4 weeks 1
• Full return to work and sports at 6-8 weeks depending on physiotherapy results 1

Critical Pitfalls to Avoid

• Do not use RICE protocol alone as the sole treatment—it has no evidence for effectiveness when used without functional support and exercise therapy 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
• Do not discontinue ankle exercises after recovery—incorporate ongoing ankle exercises into regular training activities to prevent recurrence 1
• Continue ankle bracing during high-risk activities even after recovery 1

Long-Term Monitoring

• Reassess 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 despite initial treatment 1
• Manual mobilization can be added to enhance treatment effects but should not be used alone 1