How should I manage ankle pain and swelling?

Management of Ankle Pain with Swelling

Begin immediate functional treatment with a lace-up or semi-rigid ankle brace for 4-6 weeks combined with supervised exercise therapy starting within 48-72 hours, while using NSAIDs for short-term pain control (<14 days). 1, 2

Initial Assessment (First 48 Hours)

Determine if imaging is needed:

• Apply Ottawa Ankle Rules: obtain X-rays only if the patient cannot bear weight for 4 steps immediately after injury OR has point tenderness over the posterior edge or inferior tip of the medial or lateral malleolus 2, 3
• This approach correctly rules out fracture in 99.7% of cases 1

Identify the injury mechanism:

• Inversion injuries typically cause lateral ligament damage 1
• Dorsiflexion with external rotation or eversion with internal rotation suggests high ankle sprain, which requires longer recovery 1
• Use the crossed-leg test: apply pressure to the medial knee—if this produces syndesmotic pain, suspect high ankle sprain 1, 2

Immediate Management (0-72 Hours)

Apply functional support immediately:

• Place a lace-up or semi-rigid ankle brace within the first 48 hours and continue for 4-6 weeks 1, 2
• This approach returns patients to sports 4.6 days sooner and to work 7.1 days sooner compared to immobilization 2, 3
• Avoid rigid immobilization beyond 3-5 days—prolonged immobilization leads to decreased range of motion, chronic pain, and joint instability without any demonstrated benefits 1, 2

Control swelling and pain:

• Apply ice (crushed ice and water in a damp cloth) for 20-30 minutes, 3-4 times daily for the first 2-3 days 2, 3
• Never apply ice directly to skin to prevent cold injury 3
• Apply a compression wrap to promote comfort, ensuring it doesn't compromise circulation 2, 3
• Elevate the ankle above heart level during the first 48 hours 2

Begin weight-bearing immediately:

• Allow weight-bearing as tolerated from day one, avoiding only activities that cause pain 1, 2
• Do not enforce strict non-weight-bearing unless there is a fracture 2

Exercise Therapy (Starting 48-72 Hours Post-Injury)

Initiate supervised exercise therapy within 48-72 hours:

• This has Level 1 evidence for effectiveness and is the strongest intervention for preventing recurrent sprains and chronic instability 1, 2
• Supervised exercises are superior to home exercises alone 2

Include these specific exercise components:

• Range of motion exercises 1, 2
• Progressive strengthening exercises 1, 2
• Proprioception training (critical for preventing recurrence, especially after two or more previous sprains) 1, 2
• Coordination and functional exercises 1, 2

Pain Management

Use NSAIDs as first-line for pain control:

• Prescribe ibuprofen, naproxen, diclofenac, or celecoxib for short-term use (<14 days) 1, 2
• NSAIDs reduce pain and swelling while accelerating return to activity 1, 2
• If NSAIDs are contraindicated, use acetaminophen—it is equally effective for pain, swelling, and range of motion 1
• Avoid opioids—they cause significantly more side effects without superior pain relief 2

Critical Follow-Up Timing

Re-examine at 3-5 days post-injury:

• Initial swelling obscures accurate assessment of ligament damage 1, 2
• Delayed examination at 4-5 days has 84% sensitivity and 96% specificity for detecting ligament ruptures 2, 3
• This timing is optimal for distinguishing grade I sprains from grade II-III sprains and planning definitive treatment 1, 2

Return to Activity Timeline

For mild (Grade I) sprains:

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

For moderate to severe (Grade II-III) sprains:

• Return to sedentary work at 3-4 weeks 2
• Full return to work and sports at 6-8 weeks depending on physiotherapy results 2, 3

For high ankle sprains:

• Expect delayed return to sports compared to lateral ankle sprains 1
• Use the same functional treatment approach with semi-rigid bracing 1

Prevention of Recurrent Injury

Continue proprioception exercises long-term:

• Incorporate ankle exercises into regular training activities after recovery 1, 2
• This has high cost-benefit ratios due to reduced recurrence rates 2
• A history of previous ankle sprain is a moderate risk factor for future injury 2, 3

Use ankle bracing during high-risk activities:

• Continue bracing during sports or high-risk activities even after full recovery 1, 2
• Neuromuscular training and ankle braces have Level 2 evidence for preventing recurrent sprains 2

Critical Pitfalls to Avoid

• Never immobilize beyond 3-5 days unless there is a fracture—this is the single most common error that leads to chronic problems 1, 2
• Never use RICE protocol alone without exercise therapy—individual components can be used strategically, but RICE alone has no evidence for effectiveness 2
• Never apply heat to acute ankle injuries 1, 2
• Never skip the 3-5 day follow-up examination—initial examination cannot distinguish partial tears from complete ruptures 2
• Never delay exercise therapy beyond 72 hours—this represents a missed opportunity for optimal recovery 2

Red Flags Requiring Immediate Medical Evaluation

• Inability to bear weight for 4 steps immediately after injury 3
• Point tenderness over the posterior edge or inferior tip of the medial or lateral malleolus 2, 3
• Severe swelling with hematoma suggesting grade III sprain with possible complete ligament rupture 1