What is the appropriate management for a Grade II–III lateral ankle sprain involving the anterior talofibular and calcaneofibular ligaments?

Management of Grade II-III Lateral Ankle Sprain (ATFL and CFL Injury)

For Grade II-III lateral ankle sprains involving both the anterior talofibular and calcaneofibular ligaments, initiate immediate PRICE protocol with NSAIDs, followed by 10-14 days of immobilization in a below-knee cast or removable boot, then transition to functional rehabilitation with a lace-up ankle support or brace. 1, 2

Immediate Management (First 4-5 Days)

Implement the PRICE protocol as your foundation:

• Protection: Use a removable boot or below-knee cast for initial immobilization 1, 3, 2
• Rest: Avoid weight-bearing activities initially, though weight-bearing as tolerated with assistive devices (crutches) is acceptable for comfort 1, 3
• Ice: Apply regularly to reduce swelling and pain 1, 3
• Compression: Use compressive wrapping to control hematoma expansion 1, 3
• Elevation: Keep the leg elevated to minimize swelling 1, 3

Initiate NSAIDs immediately to reduce swelling and pain, which may accelerate return to activities 1, 3

Critical Distinction: Combined ATFL-CFL Injuries Require More Aggressive Treatment

This is a crucial clinical pitfall: Combined ATFL and CFL injuries have significantly worse outcomes with conservative treatment compared to isolated ATFL injuries. Only 30% of combined injuries were asymptomatic at 5-year follow-up versus 88% of isolated ATFL injuries 4. This underscores the need for more structured immobilization and rehabilitation.

Immobilization Phase (Days 1-14)

Immobilize for 10-14 days in a below-knee cast or removable boot 2. This initial immobilization period is beneficial for Grade II-III injuries and reduces the risk of chronic instability 2.

• Weight-bearing status should be as tolerated with assistive devices during this phase 3, 2
• For diabetic patients with neuropathy, consider more protective immobilization with partial weight-bearing 5, 3

Functional Rehabilitation Phase (After Day 14)

Transition to a lace-up ankle support or functional brace, which are recommended as functional treatment for ankle injuries and decrease the risk of recurrent injury 1, 2.

• Semirigid or lace-up ankle supports have Level B evidence for reducing recurrent ankle injury risk, especially in patients with history of recurrent sprains 1
• Continue this support during the rehabilitation period and return to activity 1, 2

Structured Rehabilitation Program

Implement graded exercise regimens with proprioceptive elements:

• Proprioceptive training using ankle disk exercises is specifically recommended to reduce risk of ankle sprain (Level B evidence) 1, 3
• Progressive strengthening of ankle dorsiflexors and surrounding musculature 3
• Gradual return to activity based on pain-free range of motion and strength 3

Critical Reassessment Points

Reexamine at 3-5 days after injury to distinguish partial tears from frank ligament ruptures, as excessive swelling and pain can limit initial examination 1, 3.

Reassess at 2-3 weeks if no improvement or worsening symptoms occur 3:

• Consider MRI without contrast if symptoms persist, as it has 77-92% accuracy for ATFL tears and 88-92% accuracy for CFL tears 1
• MRI has the advantage of evaluating associated injuries like tenosynovitis, tendon injury, and osteochondral lesions that may complicate recovery 1

When to Consider Surgical Intervention

For professional/high-level athletes with Grade III injuries, acute repair of lateral ankle ligaments may give better results than conservative management alone 2.

For patients who fail functional rehabilitation and develop chronic ankle instability (approximately 20% of acute sprains), surgical options include Brostrom-Gould anatomic repair or anatomic reconstruction for those with poor tissue quality 6.

Common Pitfalls to Avoid

• Underestimating combined ATFL-CFL injuries: These require more aggressive immobilization and structured rehabilitation than isolated ATFL injuries 4
• Inadequate immobilization period: Skipping the initial 10-14 day immobilization phase increases risk of chronic instability 2
• Neglecting proprioceptive training: This is essential for preventing recurrent injury and has strong evidence support 1, 3
• Premature return to sport: Ensure full pain-free range of motion and strength before clearance 3, 2