What is the appropriate management for an acute ankle sprain in an otherwise healthy adult?

Acute Ankle Sprain Management

Immediate Treatment: PRICE Protocol with Functional Support

For an acute ankle sprain in a healthy adult, immediately apply a semi-rigid or lace-up ankle brace (not elastic bandages or tape) and begin supervised exercise therapy within 48-72 hours while using NSAIDs for pain control. 1

First 48 Hours – PRICE Components

• Protection: Apply a semi-rigid or lace-up ankle brace within the first 48 hours and continue for 4-6 weeks—this is superior to elastic bandages or tape and leads to return to sports 4.6 days sooner and return to work 7.1 days sooner than immobilization. 1

• Rest: Avoid activities that cause pain, but encourage weight-bearing as tolerated immediately—complete rest is not recommended. 1

• Ice: 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. 1 Intermittent ice application (rather than continuous 20-minute protocols) may provide superior pain relief. 2

• Compression: Use the brace to provide compression while ensuring distal circulation remains intact. 1

• Elevation: Keep the ankle above heart level during the first 48 hours to reduce swelling. 1

Pain Management

• First-line: NSAIDs (ibuprofen, naproxen, diclofenac, celecoxib, or piroxicam) reduce pain and swelling and accelerate return to activity. 1

• Alternative: Acetaminophen provides comparable analgesia if NSAIDs are contraindicated. 1

• Avoid: Opioids cause significantly more side effects without superior pain relief. 1

Critical Early Rehabilitation (48-72 Hours)

Begin supervised exercise therapy within 48-72 hours of injury—this has Level 1 evidence and reduces recurrent sprains by approximately 63%. 1

Exercise Therapy Components (in sequence)

• Range of motion exercises: Start immediately within 48-72 hours. 1

• Proprioception training: Critical for preventing recurrent sprains, especially in patients with prior ankle injuries. 1

• Progressive strengthening: Advance as pain permits. 1

• Coordination and functional exercises: Include sport-specific movements before return to activity. 1

• Manual mobilization: May be added as an adjunct but should never be used alone. 1

Supervised vs. Home Exercise

• Supervised exercises are superior to unsupervised home programs—patients should work with a physical therapist rather than performing exercises alone. 1

What to Avoid: Common Pitfalls

• Never immobilize beyond 10 days: Prolonged immobilization (>10 days) causes decreased range of motion, chronic pain, joint instability, and delayed recovery without any demonstrated benefit. 1

• Do not use elastic bandages or tape as primary support: These are inferior to semi-rigid or lace-up braces. 1

• Do not delay exercise therapy: Waiting beyond 48-72 hours forfeits the proven reduction in recurrent sprains. 1

• Avoid ineffective therapies: Ultrasound, laser therapy, electrotherapy, and short-wave therapy have no proven benefit for acute ankle sprains. 1

• Do not apply heat: Heat application is not recommended for acute ankle injuries. 1

Imaging Decision: Ottawa Ankle Rules

Obtain ankle radiographs (AP, lateral, mortise views) only if the patient cannot bear weight immediately after injury and cannot take four steps in the emergency department, OR has point tenderness over the posterior malleolus, tip of the malleolus, navicular bone, or base of the fifth metatarsal. 1

• The Ottawa Ankle Rules demonstrate 92-99% sensitivity and correctly exclude fracture in 299 of 300 patients when radiographs are omitted. 1

• If Ottawa Rules are negative and the patient can walk, imaging is not indicated. 1

Follow-Up Assessment

• Schedule re-examination at 3-5 days post-injury after swelling subsides for accurate ligament assessment—examination within 48 hours cannot reliably differentiate partial from complete ligament tears. 1

• Clinical assessment of ligament damage is optimized when delayed 4-5 days post-injury. 1

Return to Activity Timeline

• Mild sprains: Return to mostly sitting work at 2 weeks; full return to work and sports at 3-4 weeks depending on task requirements. 1

• Moderate to severe sprains: Return to sedentary work at 3-4 weeks; full return to work and sports at 6-8 weeks depending on physiotherapy results. 1

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

• Continue wearing an ankle brace during high-risk activities after recovery and incorporate ongoing proprioceptive exercises into regular training. 1

• Neuromuscular training and ankle braces have Level 2 evidence for preventing recurrent sprains. 1

Special Consideration: High Ankle Sprains

• Perform a crossed-leg test (medial knee pressure) to assess for syndesmotic injury—pain over the syndesmosis indicates a high ankle sprain requiring more intensive rehabilitation and longer recovery time. 1

Evidence Strength Note

While the RICE protocol is widely recommended by multiple guideline organizations 1, 3, a 2012 systematic review found insufficient evidence from randomized controlled trials to determine the relative effectiveness of RICE therapy as a complete protocol. 4 However, individual components (particularly functional bracing, early mobilization, and exercise therapy) have strong evidence supporting their use. 1, 5 The key is not rigid adherence to RICE alone, but rather combining functional support with early supervised rehabilitation. 1