What is the appropriate outpatient treatment for an acute ankle sprain in an otherwise healthy adult or adolescent without significant comorbidities?

Outpatient Treatment of Acute Ankle Sprain

Apply a semi-rigid or lace-up ankle brace immediately for 4–6 weeks, start supervised physical therapy within 48–72 hours, use topical or oral NSAIDs for pain control, and avoid immobilization beyond 10 days. 1

Immediate Management (First 48–72 Hours)

PRICE Protocol Implementation

• Protection: Apply a semi-rigid or lace-up ankle brace within the first 48 hours—this is superior to elastic bandages, tape, or Tubigrip and leads to return to sports 4.6 days sooner and return to work 7.1 days sooner than immobilization. 1
• Rest with early weight-bearing: Encourage weight-bearing as tolerated immediately; avoid only activities that cause pain. 1
• 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. 1
• 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 Strategy

• First-line therapy: Use topical NSAIDs with or without menthol gel as the initial pharmacologic intervention to reduce pain, improve physical function, and enhance treatment satisfaction. 2
• Second-line oral options: Prescribe oral NSAIDs (ibuprofen, naproxen, diclofenac, celecoxib) to reduce pain and swelling and accelerate return to activity. 2, 1
• If NSAIDs contraindicated: Use oral acetaminophen, which provides comparable analgesia. 2, 1
• Avoid opioids completely: Opioids produce significantly more adverse effects without superior pain relief compared to NSAIDs. 2, 1

Functional Support (4–6 Weeks)

Bracing Protocol

• Continue the semi-rigid or lace-up brace for 4–6 weeks total—this functional support is more effective than tape or elastic bandages and prevents prolonged immobilization complications. 1
• If rigid immobilization is used for severe pain: Limit it to a maximum of 10 days, then transition immediately to a semi-rigid brace. 1
• Critical pitfall to avoid: Prolonged immobilization beyond 10 days results in decreased range of motion, chronic pain, joint instability, and delayed recovery without any demonstrated benefit. 1

Supervised Exercise Therapy (Level 1 Evidence)

Timing and Structure

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

Exercise Progression

• Phase 1 (48–72 hours): Begin range-of-motion exercises immediately. 1
• Phase 2 (ongoing): Add proprioception training, which is critical to prevent recurrent sprains, especially in patients with prior ankle injuries. 1
• Phase 3 (as pain permits): Progress to strengthening exercises. 1
• Phase 4 (pre-return to activity): Incorporate coordination and sport-specific functional drills. 1

Adjunctive Therapies

• Manual joint mobilization: May be added to enhance treatment effects but should not be used as a stand-alone intervention. 1
• Avoid ineffective modalities: Ultrasound, laser therapy, electrotherapy, and short-wave therapy have no proven benefit for acute ankle sprains. 1

Follow-Up Assessment

• Schedule re-examination at 3–5 days post-injury after swelling subsides—this optimizes evaluation of ligament damage severity and distinguishes partial tears from complete ruptures. 1
• Initial examination within 48 hours cannot reliably differentiate injury severity, making delayed assessment essential for accurate diagnosis. 1

Return-to-Activity Timeline

For Mild Sprains (Grade I)

• Return to sedentary work: 2 weeks 1
• Full return to work and sports: 3–4 weeks depending on task requirements 1

For Moderate to Severe Sprains (Grade II–III)

• Return to sedentary work: 3–4 weeks 1
• Full return to work and sports: 6–8 weeks depending on physiotherapy outcomes 1

Imaging Decisions

• Apply Ottawa Ankle Rules: Obtain ankle radiographs (AP, lateral, mortise) 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
• Ottawa Rules demonstrate 92–99% sensitivity for excluding fracture—when negative, imaging is not indicated. 1
• For persistent pain beyond 1–3 weeks despite appropriate treatment: Obtain MRI without contrast to evaluate for occult osteochondral injury, syndesmotic injury, or peroneal tendon pathology. 1

Prevention of Chronic Complications

• Up to 40% of patients develop chronic ankle instability despite initial treatment, and 3–34% experience recurrent sprains. 1
• Long-term prevention strategy: Continue wearing an ankle brace during high-risk activities after recovery and incorporate ongoing proprioceptive exercises into regular training. 1
• For recurrent sprains after completing rehabilitation: Refer to orthopedics for consideration of surgical reconstruction. 1

Special Considerations

High Ankle Sprains (Syndesmotic Injury)

• Perform the crossed-leg test: Apply pressure to the medial side of the knee while the patient sits with legs crossed—pain in the syndesmosis area suggests high ankle sprain. 1, 3
• High ankle sprains require more intensive rehabilitation and significantly longer recovery time than lateral ankle sprains. 3
• Continue semi-rigid bracing throughout rehabilitation and upon return to sport for syndesmotic injuries. 3

Surgical Referral Indications

• Immediate orthopedic referral: Fracture on radiographs, suspected osteochondral injury, failure of early functional treatment after 1–3 weeks, or alignment abnormality/dislocation. 1
• Conservative functional treatment is preferred over surgery—surgery shows limited evidence, longer recovery, higher rates of ankle stiffness, and complications. 1
• Surgery may be reserved for elite athletes requiring rapid return to play who have failed adequate conservative management. 1

Common Pitfalls to Avoid

• Delaying supervised exercise therapy beyond 48–72 hours forfeits the proven reduction in recurrent sprains. 1
• Extending immobilization past 10 days leads to delayed recovery and increased stiffness without any advantage. 1
• Using elastic bandages or Tubigrip as primary support instead of semi-rigid or lace-up braces results in inferior outcomes. 1
• Prescribing unsupervised home-exercise programs produces worse results than therapist-guided protocols. 1
• Applying heat to acute ankle injuries is contraindicated—use ice only. 1