Approach to Ankle Swelling, Pain, and Inability to Weight Bear
Apply the Ottawa Ankle Rules immediately: obtain ankle radiographs (AP, lateral, mortise views) because the patient cannot bear weight, and if imaging is negative, initiate functional treatment with a semi-rigid or lace-up ankle brace for 4–6 weeks combined with supervised exercise therapy starting within 48–72 hours. 1
Step 1: Rule Out Fracture Using Ottawa Ankle Rules
The Ottawa Ankle Rules are your decision tool for imaging—they demonstrate 92–99% sensitivity and correctly exclude fracture in 299 of 300 patients when negative. 1
Order ankle radiographs (AP, lateral, mortise) if ANY of the following are present:
- Inability to bear weight immediately after injury 1
- Inability to take four steps in the emergency department 1
- Point tenderness over the posterior aspect of the lateral or medial malleolus 1
- Point tenderness over the navicular bone 1
- Point tenderness over the base of the fifth metatarsal 1
If radiographs are positive for fracture, refer immediately to orthopedics. 1
If radiographs are negative, proceed with functional treatment below. 1
Step 2: Assess for High Ankle Sprain (Syndesmotic Injury)
Perform the crossed-leg test: apply pressure to the medial side of the knee while the patient sits with the injured leg crossed over the opposite knee. 1
- Pain over the syndesmosis (anterior ankle between tibia and fibula) indicates a high ankle sprain, which requires more intensive rehabilitation and longer recovery time. 1
- High ankle sprains typically need 6–8 weeks for return to full activity versus 3–4 weeks for lateral ankle sprains. 1
Step 3: Immediate Management (First 48–72 Hours) – PRICE Protocol
Protection & Functional Support
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, tape, or walking boots and leads to return to sports 4.6 days sooner and return to work 7.1 days sooner than immobilization. 1
Critical pitfall to avoid: Do NOT immobilize the ankle beyond 10 days—prolonged immobilization causes decreased range of motion, chronic pain, and joint instability without any demonstrated benefit. 1
Rest & 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
The semi-rigid brace provides compression—ensure distal circulation remains intact (check capillary refill, sensation, and warmth). 1
Elevation
Keep the ankle above heart level during the first 48 hours to reduce swelling. 1
Step 4: Pain Management
First-Line: Topical NSAIDs
Apply a topical NSAID (with or without menthol gel) as first-line medication—this reduces pain, improves physical function, and increases treatment satisfaction. 1
Second-Line: Oral NSAIDs
If topical therapy is insufficient, prescribe oral NSAIDs (ibuprofen, naproxen, diclofenac, or celecoxib)—these reduce pain and swelling and accelerate return to activity. 1
If NSAIDs Are Contraindicated
Use acetaminophen—it provides analgesia comparable to NSAIDs for acute ankle sprain. 1
Avoid Opioids
Do NOT prescribe opioids—they cause significantly more adverse effects without superior pain relief compared to NSAIDs. 1
Step 5: Supervised Exercise Therapy (Level 1 Evidence)
Refer to physical therapy for supervised exercise initiation within 48–72 hours of injury—this has Level 1 evidence and reduces recurrent sprains by approximately 63%. 1
Critical pitfall: Unsupervised home exercise programs produce inferior outcomes compared to therapist-guided protocols. 1
Exercise Program Components (Sequential Progression):
- Range-of-motion exercises (start immediately within 48–72 hours) 1
- Proprioception training (critical to prevent recurrence, especially in patients with prior ankle injuries) 1
- Progressive strengthening exercises (advance as pain permits) 1
- Coordination and sport-specific functional drills (before return to activity) 1
Manual joint mobilization may be added as an adjunct but should NOT be used as stand-alone treatment. 1
Step 6: Follow-Up Assessment at 3–5 Days
Schedule re-examination 3–5 days post-injury after swelling subsides—this optimizes diagnostic accuracy for distinguishing partial ligament tears from complete ruptures, which cannot be reliably assessed within the first 48 hours. 1
At the Follow-Up Visit, Assess:
- Anterior drawer test: Excessive anterior talar displacement indicates anterior talofibular ligament rupture 1
- Persistent severe pain or inability to progress with weight-bearing 1
- Signs of incomplete rehabilitation: persistent pain, workload limitations, or difficulty with sports-specific movements 1
Step 7: Advanced Imaging for Persistent Pain (1–3 Weeks)
If pain persists beyond 1–3 weeks despite appropriate functional treatment (brace + supervised exercise), obtain MRI without contrast to evaluate for:
- Radiographically occult fractures 2
- Osteochondral injury 1
- Syndesmotic injury 1
- Peroneal tendon pathology 1
MRI is the preferred advanced imaging modality when radiographs are normal or nondiagnostic—it provides comprehensive evaluation of ligaments, tendons, cartilage, and bone. 1
Do NOT use CT as first-line imaging—it bypasses the evidence-based algorithm and subjects patients to unnecessary radiation without superior diagnostic information compared to plain radiographs. 1
Step 8: 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 with activity restrictions (no lifting >10 kg, limited standing on uneven surfaces) 1
- Full return to work and sports: 6–8 weeks depending on physiotherapy outcomes 1
Step 9: Orthopedic Referral Indications
Immediate Referral:
- Any fracture on radiographs 1
- Suspected osteochondral injury on imaging or clinical examination 1
- Gross malalignment or dislocation 1
Delayed Referral (After Conservative Trial):
- Persistent pain after 1–3 weeks of appropriate functional treatment 1
- Chronic ankle instability (recurrent sprains or functional instability after completing supervised rehabilitation) 1
Note: Up to 40% of patients develop chronic ankle instability despite initial treatment, and 3–34% experience recurrent sprains. 1
Step 10: Prevention of Recurrent Injury
Continue wearing an ankle brace during high-risk activities after recovery and incorporate ongoing proprioceptive exercises into regular training—this has high cost-benefit ratios due to reduced recurrence rates. 1
A history of previous ankle sprain is a moderate risk factor for future ankle injuries. 1
Common Pitfalls to Avoid (Evidence-Based)
- 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, increased stiffness, and offers no advantage 1
- Using elastic bandages or Tubigrip as primary support—these are inferior to semi-rigid or lace-up braces 1
- Prescribing unsupervised home exercise programs—these result in inferior outcomes compared to therapist-guided protocols 1
- Using walking boots or casts for routine sprains—functional bracing is superior 1
- Premature MRI delay—obtain MRI promptly if pain persists beyond 1–3 weeks to detect occult pathology 1
Discharge Instructions (Patient Handout)
- Wear a semi-rigid or lace-up brace continuously for 4–6 weeks 1
- Begin weight-bearing as tolerated immediately 1
- Apply ice for 20–30 minutes every 2–3 hours during the first 48 hours 1
- Take prescribed topical or oral NSAID (or acetaminophen if NSAIDs contraindicated) for pain control 1
- Attend physical therapy appointment within 48–72 hours of injury 1
- Return for re-evaluation in 3–5 days 1
- Seek urgent care if numbness, coldness, or severe pain develops (possible neurovascular compromise) 1