What are the immediate next steps in managing a 26‑year‑old female with an acute lateral ankle sprain (inversion injury 18 hours ago, lateral malleolar tenderness, limited range of motion, preserved dorsiflexion and plantar reflexes) who is allergic to ibuprofen?

Immediate Management of Acute Lateral Ankle Sprain

Obtain ankle radiographs immediately using the Ottawa Ankle Rules criteria, which this patient clearly meets due to inability to bear weight (arrived in wheelchair), lateral malleolar tenderness, and inability to ambulate. 1

Step 1: Imaging to Rule Out Fracture

Your patient meets all three Ottawa Ankle Rules criteria for mandatory radiography 1:

• Inability to bear weight immediately after injury (arrived in wheelchair) 1
• Point tenderness over the lateral malleolus 1
• Inability to ambulate 4 steps in the emergency department 1

Order three-view ankle radiographs (anteroposterior, lateral, and mortise views) to exclude fracture before proceeding with treatment. 1 The Ottawa Ankle Rules have 92-99% sensitivity for detecting ankle fractures, missing fractures in only 0.3% of cases. 1

Important Caveat

Do not manipulate the ankle prior to obtaining radiographs unless there is neurovascular compromise or critical skin injury, as this may complicate management. 1

Step 2: If Radiographs Are Negative

Immediate Treatment (First 72 Hours)

Initiate PRICE protocol immediately 1, 2:

• Protection: Apply a semi-rigid ankle brace or lace-up brace (NOT elastic bandage alone, which is inferior) 1, 2
• Rest: Limit weight-bearing for 48-72 hours as tolerated 1, 2
• Ice: Apply cryotherapy to reduce edema and pain 1, 2
• Compression: Use the brace for compression 1, 2
• Elevation: Elevate the leg above heart level 1, 2

Pain Management (Critical Given Ibuprofen Allergy)

Prescribe acetaminophen as your first-line analgesic since the patient has an ibuprofen allergy. 1, 2 Limit analgesic use to 2-7 days post-trauma. 3 Alternative NSAIDs (if no class allergy) include naproxen or celecoxib, which improve pain control, decrease swelling, and enable faster return to activity. 1

Functional Support

A lace-up brace is superior to elastic bandages, reducing swelling (RR 5.48) and enabling faster return to work (4.24 days earlier) with fewer complications. 1, 2 Continue brace use for 4-6 weeks during activities. 2

Step 3: Delayed Physical Examination (Days 4-5)

Re-examine the patient in 4-5 days when swelling and pain have subsided, as initial examination within 48 hours cannot reliably distinguish between simple distortion and complete ligament rupture. 1, 4, 3 This delayed examination has good interobserver agreement and provides accurate diagnosis. 4, 3

At the delayed examination, perform:

• Anterior drawer test to detect anterior talofibular ligament (ATFL) injury—the most commonly injured ligament in inversion injuries 5, 6
• Assess for swelling, hematoma, pain on palpation, and range of motion 1

If Grade II-III Injury Is Confirmed

Consider MRI without IV contrast if there is concern for severe ligamentous injury, osteochondral injury, or if the patient is a professional/high-level athlete requiring precise diagnosis. 1, 7 MRI has 77-92% accuracy for detecting ATFL tears. 5

Step 4: Early Functional Rehabilitation (Starting Day 1-3)

Functional treatment is superior to immobilization, resulting in faster return to work (8.23 days earlier), faster return to sports (1.86 times faster), and higher patient satisfaction. 1

Exercise Protocol (Begin Early)

Start immediately as pain allows 2:

• Active range of motion: Dorsiflexion and plantarflexion exercises, 3 sets of 10 repetitions 2
• Early weight-bearing: As tolerated with brace support 2
• Proprioceptive training: Single-leg stance on stable surface with eyes open, 30 seconds × 3 repetitions 2

Progressive Strengthening (Week 2 Onward)

• Resistance band exercises in all four directions: 3 sets of 10 repetitions 2
• Ankle disk/wobble board training: 3 sets of 1 minute 2
• Advanced proprioception: Single-leg stance on foam pad, 30 seconds × 3 repetitions 2

Exercise therapy reduces recurrence risk by 63% (RR 0.37) at 8-12 months. 1, 2

Critical Pitfalls to Avoid

• Do NOT immobilize for >10 days unless there is a fracture requiring it—prolonged immobilization leads to worse outcomes, ankle stiffness, and delayed recovery. 1, 2
• Do NOT delay exercise therapy—early functional rehabilitation is key to preventing chronic instability, which develops in 20% of patients with inadequate treatment. 2, 6
• Do NOT use elastic bandages alone—they are significantly inferior to semi-rigid braces. 1, 2
• Do NOT stop exercises when pain resolves—complete the full 4-6 week program to prevent recurrent injury. 2
• Do NOT confuse this lateral ankle sprain with a high ankle sprain (syndesmotic injury), which has different management. 5

Expected Recovery Timeline

• Return to light work: 2 weeks for distortion, 3-6 weeks for partial/complete rupture 1
• Full return to former work: 3-4 weeks depending on job requirements 1
• Normal dorsiflexion ROM: Restored within 4 weeks 8