For a healthy adult with a grade III ankle sprain, is a removable walking boot the safest initial management compared with a short‑leg stirrup?

Walking Boot vs Short Leg Stirrup for Grade III Ankle Sprain

For a healthy adult with a grade III ankle sprain, a removable walking boot is NOT the safest initial management—functional treatment with a semi-rigid ankle brace or lace-up support combined with early weight-bearing and exercise therapy provides superior outcomes compared to immobilization or walking boots. 1, 2

Initial Assessment and Imaging

• Apply the Ottawa Ankle Rules to determine if radiography is needed: imaging is required when the patient cannot bear weight immediately after injury, has point tenderness over the lateral malleolus, and cannot walk four steps 2
• Three-view ankle radiographs (anteroposterior, lateral, mortise) should be obtained before therapeutic intervention if Ottawa criteria are met 2
• Critical re-examination at 4-5 days post-injury is essential when swelling has subsided, as early examination (<48 hours) is unreliable for distinguishing partial tears from complete ligament ruptures 3, 2

Why Walking Boots Are Not Optimal

The evidence clearly demonstrates that prolonged immobilization with devices like walking boots leads to worse outcomes:

• Functional treatment results in patients returning to work an average of 8.2 days earlier compared to immobilization 2
• Immobilization beyond 10 days causes increased ankle stiffness, delayed recovery, and poorer functional outcomes 1, 2
• A 2024 guideline on Charcot neuroarthropathy noted that "in patients with severe ankle sprain a TCC [total contact cast] had better overall results than a prefabricated walker," suggesting that when immobilization is needed, rigid casting outperforms walking boots 1
• Early mobilization allows 54% of patients to return to full work by day 10, versus only 13% with immobilization 4

Recommended Treatment Algorithm for Grade III Ankle Sprain

First 72 Hours: PRICE Protocol

• Protection, Rest, Ice, Compression, Elevation to control pain and swelling 2
• NSAIDs or acetaminophen for analgesia (both equally effective), limited to 2-7 days 2

Functional Support (NOT a walking boot)

• Use a semi-rigid or lace-up ankle brace rather than elastic bandages or walking boots 1, 2
• Semi-rigid braces reduce swelling (relative risk ≈ 5.5) and enable return to work approximately 4 days earlier with fewer complications 2
• Continue brace use for 4-6 weeks during activities 2

Early Weight-Bearing and Exercise

• Begin early weight-bearing as tolerated with appropriate brace support 2
• Initiate structured exercise therapy immediately, which reduces risk of recurrent sprain by 63% (relative risk ≈ 0.37) at 8-12 months 2
• Exercise program should include:
  • Active dorsiflexion/plantarflexion: 3 sets of 10 repetitions 2
  • Progressive resistance band exercises in all four directions: 3 sets of 10 repetitions 2
  • Early proprioceptive training: single-leg stance on stable surface, 30 seconds, 3 repetitions 2
  • Progress to wobble board training: 3 sets of 1 minute 2

Advanced Imaging Considerations

• MRI without contrast is indicated for grade II-III injuries in professional athletes or when osteochondral damage is suspected 2
• MRI detects anterior talofibular ligament tears with 77-92% accuracy 2

Common Pitfalls to Avoid

• Do not immobilize in a walking boot for extended periods—this is the single most common error and leads to prolonged recovery 1, 5, 6
• Elastic bandages alone are markedly inferior to semi-rigid braces and should not be used as sole supportive device 2
• Delaying therapeutic exercises increases risk of recurrent injury and chronic instability 2, 6
• Discontinuing exercises once pain subsides increases recurrence risk; complete the full 4-6 week program 2
• Excessive imaging without using Ottawa Ankle Rules leads to unnecessary radiation and costs 6

When Surgery May Be Considered

• Reserve surgical reconstruction for cases that develop chronic functional instability after failed conservative management 7, 8
• Approximately 80% of acute ankle sprains recover fully with conservative management; 20% develop mechanical or functional instability requiring further intervention 8

Expected Recovery Timeline

• Return to light occupational duties: 2 weeks for simple sprains, 3-6 weeks for complete ligament ruptures 2
• Full return to pre-injury work: 3-4 weeks depending on job demands 2
• Return to sport: 1.9-fold faster with functional treatment versus immobilization 2

The evidence overwhelmingly supports functional treatment with bracing over walking boot immobilization for grade III ankle sprains, prioritizing early mobilization and structured exercise to optimize both short-term recovery and long-term outcomes.