How should a grade II (partial‑thickness) ankle ligament sprain be managed when there is also a nondisplaced distal fibular fracture?

Management of Grade II Ankle Sprain with Nondisplaced Distal Fibular Fracture

A nondisplaced distal fibular fracture accompanying a grade II ankle sprain should be managed with functional treatment—not immobilization—using a semi-rigid or lace-up ankle brace for 4–6 weeks combined with immediate supervised exercise therapy starting within 48–72 hours. 1

Initial Assessment and Imaging Confirmation

• Confirm fracture stability and rule out ankle mortise instability by ensuring the fracture is truly nondisplaced on standard ankle radiographs (AP, lateral, mortise views). 2
• Assess for syndesmotic injury using the crossed-leg test (pressure on the medial knee producing pain over the syndesmosis), as high ankle sprains require more intensive management and longer recovery. 1, 3
• Re-examine the patient at 3–5 days post-injury when swelling has subsided to optimize assessment of ligament damage severity; initial examination cannot reliably distinguish partial from complete ligament tears. 1, 3

The presence of a nondisplaced fibular fracture does not change the fundamental management approach for the grade II ligament injury, as simple minimally displaced fibular fractures without ankle instability respond excellently to conservative treatment. 2

Functional Support—Avoid Prolonged Immobilization

• Apply a semi-rigid or lace-up ankle brace within the first 48 hours and continue for 4–6 weeks; this approach is superior to elastic bandages, tape, or casting and leads to return to work 7.1 days sooner and return to sports 4.6 days sooner than immobilization. 1
• If rigid immobilization (cast or boot) is used for initial pain control, limit it to a maximum of 10 days, then transition immediately to a semi-rigid brace. 1
• Prolonged immobilization beyond 10 days produces worse outcomes—decreased range of motion, chronic pain, joint instability, and delayed recovery—without any demonstrated benefit. 1

The nondisplaced fibular fracture will heal adequately with functional bracing; surgical fixation is not indicated for stable, minimally displaced fractures. 2

Immediate Pain and Swelling Management (PRICE Protocol)

• Protection: Use the semi-rigid or lace-up brace continuously. 1
• Rest: Avoid activities that cause pain but encourage weight-bearing as tolerated from the outset—complete non-weight-bearing is not necessary for nondisplaced fractures. 1
• Ice: Apply cold (ice wrapped in damp cloth) for 20–30 minutes every 2–3 hours during the first 48 hours, avoiding direct skin contact. 1
• Compression: The brace provides compression; ensure distal circulation remains intact. 1
• Elevation: Keep the ankle above heart level during the first 48 hours to reduce swelling. 1

Pharmacological Pain Control

• First-line: NSAIDs (ibuprofen, naproxen, diclofenac, or celecoxib) reduce pain and swelling and accelerate return to activity; use for ≤14 days. 1
• If NSAIDs are contraindicated: Acetaminophen provides comparable analgesia. 1
• Avoid opioids: They produce significantly more adverse effects without superior pain relief. 1

Supervised Exercise Therapy (Level 1 Evidence)

This is the most critical intervention and must not be delayed. 1

• Initiate supervised physical therapy within 48–72 hours of injury—even while wearing the brace and despite the fibular fracture—as this has Level 1 evidence for reducing recurrent sprains by approximately 63% (RR 0.37,95% CI 0.18–0.74). 1
• Supervised therapy is superior to unsupervised home exercises; patients should work with a qualified physical therapist rather than performing exercises alone. 1

Progressive Rehabilitation Components

1. Range-of-motion exercises: Begin immediately (within 48–72 hours) to prevent stiffness. 1
2. Proprioception training: Critical for preventing recurrent sprains, especially after prior ankle injuries; typically started at 3–4 weeks. 1, 4
3. Progressive strengthening: Advanced as pain permits, focusing on ankle stabilizers. 1
4. Coordination and sport-specific functional drills: Implemented before return to full activity. 1

Manual joint mobilization may be added as an adjunct but should never be used as stand-alone treatment. 1

Return-to-Activity Timeline

• Light/sedentary work: 3–6 weeks with activity restrictions (no lifting >10 kg, limited standing on uneven surfaces). 1
• Full work duties: 6–8 weeks, depending on job demands and physiotherapy progress. 1
• Return to sports: Typically 6–8 weeks for grade II sprains with nondisplaced fractures, guided by functional testing and therapist clearance. 1

Interventions to Avoid

• Do not use elastic bandages or Tubigrip as primary support—they are inferior to semi-rigid or lace-up braces. 1
• Avoid therapies with no proven benefit: ultrasound, laser therapy, electrotherapy, and short-wave therapy. 1
• Do not delay supervised exercise therapy beyond 48–72 hours—this forfeits the proven reduction in recurrent sprains. 1
• Do not extend immobilization past 10 days—this leads to delayed recovery and increased stiffness without advantage. 1

Surgical Considerations

Surgery is not indicated for nondisplaced fibular fractures with grade II ankle sprains. 2

• Conservative functional treatment is strongly preferred over surgery for both the fracture and ligament injury; surgery shows limited evidence, longer recovery, higher rates of ankle stiffness, impaired mobility, and complications. 1, 4
• Surgery may be reserved only for elite athletes who require rapid return to play and have failed adequate conservative management, but even in this population, secondary surgical repair years later produces results comparable to primary repair. 4

Prevention of Chronic Ankle Instability

• Up to 40% of patients develop chronic ankle instability despite initial treatment, and 5–46% report long-term pain at 1–4 years. 1, 5
• Continue wearing an ankle brace during high-risk activities even after clinical recovery to reduce re-injury risk. 1
• Incorporate ongoing proprioceptive exercises into regular training activities to prevent recurrence. 1

Critical Pitfalls to Avoid

• Treating the fracture with prolonged immobilization while ignoring the ligament injury leads to chronic instability, persistent pain, and functional limitation. 1
• Failing to initiate supervised exercise therapy within 48–72 hours is the single most common error and results in significantly worse long-term outcomes. 1
• Prescribing unsupervised home-exercise programs produces inferior results compared with therapist-guided protocols. 1
• Assuming the fracture requires surgical fixation—nondisplaced fibular fractures heal excellently with functional treatment and do not require operative intervention. 2