Management of Partial-Thickness Ankle Ligament Tear (Grade II Ankle Sprain)
For a grade II ankle sprain, immediately apply a semi-rigid or lace-up ankle brace (not elastic bandage or Tubigrip), begin weight-bearing as tolerated, start supervised exercise therapy within 48-72 hours, and continue functional bracing for 4-6 weeks—avoiding immobilization beyond 10 days as it delays recovery without improving outcomes. 1, 2
Immediate Management (First 48-72 Hours)
PRICE Protocol Components
Protection: Apply a semi-rigid or lace-up ankle brace within the first 48 hours and continue for 4-6 weeks, as this is superior to elastic bandages, tape, or Tubigrip and leads to faster return to sports (4.6 days sooner) and work (7.1 days sooner) compared to immobilization. 1, 2, 3
Rest with Early Weight-Bearing: Encourage weight-bearing as tolerated immediately—avoid only activities that cause pain, but do not enforce strict non-weight-bearing. 2, 4
Ice Application: Apply cold (ice wrapped in a damp cloth) for 20-30 minutes every 2-3 hours during the first 48 hours, avoiding direct skin contact to prevent cold injury. 2
Compression: The brace provides compression; ensure distal circulation remains intact. 2
Elevation: Keep the ankle above heart level during the first 48 hours to reduce swelling. 2
Pain Management
First-line: NSAIDs (ibuprofen, naproxen, diclofenac, or celecoxib) for short-term use (<14 days) to reduce pain and swelling, which accelerates return to activity. 2, 5, 6
Alternative: Acetaminophen provides comparable analgesia if NSAIDs are contraindicated. 2
Avoid: Opioids cause significantly more adverse effects without superior pain relief. 2
Critical Timing: Avoid Prolonged Immobilization
Maximum immobilization: If rigid support (cast or boot) is used for initial pain control, limit to 10 days maximum—prolonged immobilization beyond this produces worse functional outcomes including decreased range of motion, chronic pain, and joint instability without any demonstrated benefit. 1, 2, 5
Transition strategy: If a short period of plaster immobilization (up to 10 days) is used for severe pain/swelling control, transition to a semi-rigid brace and begin supervised exercise therapy. 1
Supervised Exercise Therapy (Level 1 Evidence)
Initiation and Structure
Start within 48-72 hours of injury—this has Level 1 evidence for effectiveness and reduces recurrent sprains by approximately 63% (RR 0.37; 95% CI 0.18-0.74). 1, 2
Supervised programs are superior to home exercises alone—patients should work with a physical therapist rather than performing unsupervised training. 2, 7
Exercise Components (Sequential Progression)
Range of motion exercises (begin immediately within 48-72 hours) 1, 2, 7
Proprioception training (critical to prevent recurrent sprains, especially after previous ankle injuries) 1, 2, 7
Progressive strengthening exercises (advance as pain allows) 1, 2, 7
Coordination and functional exercises (sport-specific movements before return to activity) 1, 2, 7
Manual Mobilization
- Manual mobilization can be added to enhance treatment effects but should not be used alone—it has limited added value as a standalone intervention. 1, 2
Follow-Up Assessment
- Re-examine at 3-5 days post-injury when pain and swelling have subsided—initial examination within 48 hours cannot reliably differentiate partial tears from complete ligament ruptures, and delayed assessment optimizes evaluation of ligament damage severity. 2, 5, 6
Return to Activity Timeline
For Partial Ligament Rupture (Grade II):
Return to light/sedentary work: 3-6 weeks with restrictions (mostly sitting work, no lifting >10 kg, limit standing/walking on uneven surfaces) 1
Full return to work: 6-8 weeks depending on task requirements and physiotherapy results 1
Return to sports: Typically 6-8 weeks with supervised functional progression, not based solely on time but on functional evaluation including proprioception and strength testing 2, 4, 7
Interventions to Avoid
Do NOT use: Ultrasound, laser therapy, electrotherapy, or short-wave therapy—these have no demonstrated effectiveness for acute ankle injuries. 1
Do NOT rely on RICE protocol alone—while individual components can be used strategically, RICE alone has no evidence for effectiveness in improving outcomes. 2
Do NOT use elastic bandages or Tubigrip as primary support—these are inferior to semi-rigid or lace-up braces. 1, 2, 3
Prevention of Chronic Ankle Instability
Up to 40% of patients develop chronic ankle instability and 3-34% experience recurrent sprains despite initial treatment. 2, 8
Long-term strategy: Continue wearing an ankle brace during high-risk activities after recovery and incorporate ongoing proprioceptive exercises into regular training activities—this has high cost-benefit ratios due to reduced recurrence rates. 2, 8
Surgical Consideration
Functional treatment is preferred over surgery for grade II sprains—surgery shows limited evidence for longer recovery times and higher incidences of ankle stiffness, impaired mobility, and complications. 1
Surgery may be considered on an individual basis only for top-professional athletes requiring rapid return to play who have not responded to conservative treatment. 1, 5
Common Pitfalls
Failing to initiate supervised exercise therapy within 48-72 hours represents a missed opportunity for optimal recovery and increased risk of chronic instability. 2, 7
Using immobilization beyond 10 days is the most critical mistake—this delays recovery, increases stiffness, and provides no benefit over functional treatment. 1, 2
Prescribing home exercises without supervision—supervised programs yield significantly better outcomes than unsupervised training. 2
Using NSAIDs beyond 14 days—prolonged use may delay natural healing since inflammation is necessary for tissue recovery. 5