What is the recommended initial management for an acute ankle sprain in a 21‑year‑old woman?

Treatment of Acute Ankle Sprain in a 21-Year-Old Female

Implement the PRICE protocol (Protection, Rest, Ice, Compression, Elevation) immediately, apply a lace-up or semi-rigid ankle brace within 48 hours for 4-6 weeks, and begin supervised exercise therapy within 48-72 hours after injury. 1

Immediate Management (First 48 Hours)

PRICE Protocol Implementation

• Apply ice (wrapped in damp cloth) for 20-30 minutes per application to control pain and swelling, avoiding direct skin contact to prevent cold injury 1
• Elevate the ankle above heart level to reduce swelling 2
• Apply compression wrap ensuring circulation is not compromised 1
• Protect the ankle by avoiding activities that cause pain 1
• Use NSAIDs (ibuprofen, naproxen, diclofenac, or celecoxib) for pain control and to accelerate return to activity; acetaminophen is equally effective if NSAIDs are contraindicated 1

Critical Pitfall to Avoid

Do not use heat application for acute ankle injuries 1

Functional Support (Within 48 Hours)

Bracing Strategy

• Apply a lace-up or semi-rigid ankle brace within the first 48 hours and continue for 4-6 weeks 1
• This approach is superior to elastic bandages or tape and results in return to sports 4.6 days sooner and return to work 7.1 days sooner compared to immobilization 1
• Avoid prolonged immobilization beyond what is needed for initial pain control (maximum 3-5 days), as this delays recovery without improving outcomes and can lead to chronic problems including decreased range of motion, pain, and joint instability 1

Exercise Therapy (Begin Within 48-72 Hours)

Supervised Rehabilitation Program

Start supervised exercise therapy within 48-72 hours after injury - this has Level 1 evidence for effectiveness and is critical for preventing recurrent sprains and chronic ankle instability 1

The comprehensive program should include:

• Range of motion exercises to restore ankle mobility 1
• Proprioception training - this is critical to prevent recurrent sprains, especially important given that 20% of acute ankle sprains develop chronic instability 1, 3
• Strengthening exercises targeting ankle stabilizers 1
• Coordination and functional exercises progressing to sport-specific movements 1

Why Supervised Therapy Matters

Supervised exercises are superior to non-supervised home training - patients should work with a physical therapist rather than performing exercises alone 1

Follow-Up Assessment

Re-examination Timing

Re-examine the patient 3-5 days after injury when pain and swelling have improved 2, 1

• This delayed examination is critical for accurate diagnosis and distinguishing between partial tears and complete ligament ruptures 1
• Initial examination cannot reliably differentiate injury severity due to pain and swelling 1

Weight-Bearing Recommendations

Begin weight-bearing as tolerated immediately after injury, avoiding only activities that cause pain 1

• Early weight-bearing with functional support is preferred over non-weight-bearing 1

Return to Activity Timeline

For this 21-year-old patient:

• Mild sprains (Grade I): Return to mostly sitting work at 2 weeks, full return to work and sports at 3-4 weeks 1
• Moderate to severe sprains (Grade II-III): Return to sedentary work at 3-4 weeks, full return to work and sports at 6-8 weeks depending on physiotherapy results 1

Imaging Considerations

Apply Ottawa Ankle Rules to determine if radiography is needed 1

• X-rays are indicated only if the patient cannot bear weight (four steps) or has point tenderness over the posterior aspect of the lateral or medial malleolus 1
• Most ankle sprains do not require imaging 4

Prevention of Recurrent Injury

Incorporate ongoing ankle exercises into regular training activities after recovery 1

• Continue ankle bracing during high-risk activities even after recovery 1
• This is particularly important as a history of previous ankle sprain is a moderate risk factor for future injury 2

Critical Mistakes to Avoid

• Excessive imaging when Ottawa Ankle Rules are not met 4
• Unwarranted non-weight-bearing - early weight-bearing is beneficial 4
• Unjustified immobilization beyond 3-5 days 1, 4
• Delay in functional movements - exercise should begin within 48-72 hours 1, 4
• Inadequate rehabilitation - this leads to chronic instability in up to 40% of patients 1
• Using RICE protocol alone without functional support and exercise therapy, as RICE alone has no evidence for effectiveness 1