What is the recommended emergency department management of an acute ankle ligament sprain in an adult patient without contraindications to NSAIDs or significant comorbidities?

Emergency Department Management of Acute Ankle Ligament Sprain

For an adult with acute ankle sprain in the ED, apply the Ottawa Ankle Rules to determine imaging needs, initiate the PRICE protocol with NSAIDs for pain control, provide a semi-rigid or lace-up ankle brace (not immobilization), and arrange supervised exercise therapy to begin within 48-72 hours. 1, 2

Initial Assessment and Imaging Decision

Apply Ottawa Ankle Rules to Avoid Unnecessary Radiographs

• Order ankle radiographs (3 views: AP, lateral, mortise) ONLY if the patient meets ANY of these criteria: 1

  • Inability to bear weight immediately after injury AND inability to take 4 steps in the ED 1
  • Point tenderness over the posterior edge or tip of either malleolus 1
  • Point tenderness over the navicular bone or base of 5th metatarsal 1

• The Ottawa Ankle Rules have 92-99% sensitivity and correctly rule out fracture in 299 of 300 patients without radiography 1

• If Ottawa Rules are negative and patient can walk, imaging is NOT indicated 1

Special Clinical Tests to Perform

• Crossed-leg test: Apply pressure to medial knee; pain in the syndesmosis area indicates high ankle sprain requiring more intensive treatment 1, 2

• Anterior drawer test: Assess for excessive anterior displacement of talus, indicating anterior talofibular ligament rupture 1

Immediate ED Treatment (First 72 Hours)

PRICE Protocol Implementation

• Protection: Apply semi-rigid or lace-up ankle brace immediately (NOT elastic bandage or Tubigrip) 1, 2

• Rest: Avoid activities causing pain, but encourage early weight-bearing as tolerated 1, 2

• Ice: Apply cold (ice and water in damp cloth) for 20-30 minutes without direct skin contact to avoid cold injury 1, 2

• Compression: Use the ankle brace for compression; ensure circulation is not compromised 1, 2

• Elevation: Elevate ankle above heart level during first 48 hours to reduce swelling 2

Pain Management

• First-line: NSAIDs (ibuprofen, naproxen, diclofenac, or celecoxib) for pain and swelling reduction, which accelerates return to activity 1, 2

• Alternative if NSAIDs contraindicated: Acetaminophen is equally effective for pain control 1, 2

• Avoid opioids: They cause significantly more side effects without superior pain relief 1

Critical: Functional Support, NOT Immobilization

The Single Most Important ED Decision

Provide a semi-rigid or lace-up ankle brace for 4-6 weeks, NOT a walking boot or cast for routine sprains. 1, 2

Evidence Supporting Functional Treatment

• Patients return to sports 4.6 days sooner with functional bracing versus immobilization 2

• Patients return to work 7.1 days sooner with functional treatment versus immobilization 1, 2

• Lace-up or semi-rigid braces are more effective than tape or elastic bandages 1

Common Pitfall to Avoid

Prolonged immobilization beyond 10 days leads to decreased range of motion, chronic pain, joint instability, and delayed recovery WITHOUT any demonstrated benefits. 1, 2, 3 This is the most common management error in ankle sprains 3

Arrange Early Supervised Exercise Therapy

Timing and Referral

• Arrange physical therapy to begin within 48-72 hours of injury (not weeks later) 1, 2

• Supervised exercise therapy has Level 1 evidence for effectiveness and reduces recurrent sprains by 63% 1, 2, 3

• Supervised exercises are superior to home exercise programs alone 2

Exercise Components to Prescribe

The physical therapy program should include: 1, 2

• Range of motion exercises
• Proprioception training (ankle disk/wobble board)
• Progressive strengthening exercises
• Coordination and functional exercises

Follow-Up Instructions

Critical Re-examination Timing

• Schedule follow-up at 3-5 days post-injury when swelling has subsided for accurate assessment 1, 2

• Initial examination within 48 hours cannot reliably distinguish partial tears from complete ligament ruptures 1, 2

• This delayed examination optimizes clinical assessment of ligament damage severity 1, 2

Expected Recovery Timeline

• Mild sprains (Grade I): Return to sedentary work at 2 weeks; full return to work and sports at 3-4 weeks 2

• Moderate to severe sprains (Grade II-III): Return to sedentary work at 3-4 weeks; full return at 6-8 weeks depending on physiotherapy results 2

Red Flags Requiring Advanced Imaging

Consider MRI without contrast if: 1

• Persistent pain beyond 1-3 weeks despite appropriate treatment
• Suspected syndesmotic injury (positive crossed-leg test)
• Suspected osteochondral injury
• Professional athlete or high-level sports participation

Prevention of Chronic Ankle Instability

Long-Term Risks Without Proper Treatment

• 5-46% of patients report persistent pain at 1-4 years 2
• Up to 40% develop chronic ankle instability despite initial treatment 1, 2
• 3-34% experience recurrent sprains 1

Prevention Strategy

• Continue ankle brace during high-risk activities even after recovery 1, 2
• Incorporate ongoing proprioceptive exercises into regular training to prevent recurrence 1, 2
• Address workload and sports participation level, as these negatively influence recovery 1, 2

Discharge Instructions Summary

Provide written instructions including: 1, 2

• Wear semi-rigid or lace-up brace continuously for 4-6 weeks
• Begin weight-bearing as tolerated immediately
• Apply ice 20-30 minutes every 2-3 hours for first 48 hours
• Take prescribed NSAID or acetaminophen for pain
• Attend physical therapy appointment within 48-72 hours
• Return for re-evaluation in 3-5 days
• Seek immediate care if numbness, coldness, or severe pain develops