How should I manage a patient with a grade II ankle sprain who still has swelling and limited motion after one week of treatment?

Management of Grade II Ankle Sprain with Persistent Swelling and Limited Motion at One Week

Your patient requires immediate escalation of functional treatment: transition from any rigid immobilization to a semi-rigid or lace-up ankle brace, initiate supervised physical therapy within 48 hours if not already started, and consider switching NSAIDs if pain control is inadequate. 1

Immediate Assessment and Red Flags

At one week post-injury with persistent swelling and limited motion, you must first rule out complications:

• Re-examine now to distinguish partial ligament tears from complete ruptures, as initial examination within 48 hours cannot reliably make this distinction 1, 2
• Obtain ankle radiographs (AP, lateral, mortise views) if not already done and the patient meets Ottawa Ankle Rules: inability to bear weight immediately after injury, inability to take four steps, or point tenderness over posterior malleolus, navicular, or base of fifth metatarsal 3, 1
• Order MRI without contrast if the patient has failed appropriate functional treatment (brace + supervised exercise started within 48-72 hours) to detect occult fractures, osteochondral lesions, syndesmotic injury, or peroneal tendon pathology 1
• Perform crossed-leg test: apply pressure to medial knee; pain over the syndesmosis indicates high ankle sprain requiring more intensive management and possible orthopedic referral 1

Critical Treatment Errors to Correct Immediately

If your patient is still immobilized in a cast or rigid boot beyond 10 days, you are causing harm. 1, 2

• Prolonged immobilization beyond 10 days leads to decreased range of motion, chronic pain, joint instability, and delayed recovery with no demonstrated benefit 1, 2
• Transition immediately to a semi-rigid or lace-up ankle brace for the remaining 3-5 weeks 1, 2

If supervised physical therapy has not started, this is the primary reason for poor progress. 1, 2

• Supervised exercise therapy initiated within 48-72 hours has Level 1 evidence and reduces recurrent sprains by 63% (RR 0.37,95% CI 0.18-0.74) 1, 2
• Home exercises alone produce inferior outcomes compared to therapist-guided protocols 1, 2

Mandatory Functional Treatment Protocol

Mechanical Support (4-6 Weeks Total)

• Apply semi-rigid or lace-up ankle brace continuously for 4-6 weeks from injury 1, 2
• This approach returns patients to sports 4.6 days sooner (95% CI 1.5-7.6) and to work 7.1 days sooner (95% CI 5.6-8.7) compared to immobilization 1
• Lace-up or semi-rigid braces are more effective than elastic bandages or tape 1

Supervised Exercise Therapy (Start Immediately if Not Already Done)

The exercise program must progress sequentially through four phases: 1, 2

1. Range-of-motion exercises (start immediately, even if delayed to week 1)
2. Proprioception training (critical to prevent recurrence, especially with prior ankle injuries)
3. Progressive strengthening (advance as pain permits)
4. Coordination and sport-specific functional drills (before return to activity)

Manual joint mobilization should be added as an adjunct to enhance dorsiflexion range of motion and decrease pain, but never as stand-alone treatment 2

Weight-Bearing Protocol

• Begin weight-bearing as tolerated immediately, avoiding only activities that cause pain 1, 2
• The patient should be walking now at one week post-injury unless pain prohibits it 1

Pharmacologic Management Adjustment

If the patient is still on ibuprofen with inadequate pain control, switch NSAIDs: 2

• First-line alternative: Diclofenac shows superior pain relief compared to ibuprofen at days 1-2 for reducing pain during motion 2
• Alternative: Celecoxib 200 mg twice daily is non-inferior to non-selective NSAIDs and offers faster return to function 2
• Alternative: Naproxen is equally effective as other NSAIDs 2
• If NSAIDs contraindicated: Acetaminophen is equally effective for pain, swelling, and range of motion 2
• Never prescribe opioids: they cause significantly more side effects without superior pain relief 1, 2

Expected Recovery Timeline from This Point

Given that one week has already passed with suboptimal progress:

• Return to sedentary work: 2-3 additional weeks (total 3-4 weeks from injury) with activity restrictions 1
• Full return to work and sports: 5-7 additional weeks (total 6-8 weeks from injury), depending on rehabilitation progress 1, 2

Follow-Up Schedule

• Re-examine in 3-5 days after implementing these changes to assess response 1, 2
• Monitor for signs of incomplete rehabilitation: persistent pain beyond 3 weeks, workload limitations, or difficulty with functional movements 1
• Consider MRI at 2-3 weeks if pain persists despite corrected functional treatment 1

Orthopedic Referral Indications

Refer immediately if: 1

• Fracture identified on radiographs
• Suspected osteochondral injury on imaging or persistent mechanical symptoms
• Failure of appropriate functional treatment after 1-3 weeks (brace + supervised PT started within 48-72 hours)
• Positive crossed-leg test suggesting syndesmotic injury
• Gross malalignment or instability on examination

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. 3, 1 The primary modifiable factor is inadequate rehabilitation—specifically failure to initiate supervised exercise therapy within 48-72 hours and prolonged immobilization. 1, 2

• Continue ankle brace during high-risk activities even after recovery 1
• Incorporate ongoing proprioceptive exercises into regular training activities 1, 2

Common Pitfalls in Your Current Management

Based on persistent symptoms at one week, your patient likely experienced one or more of these errors: 1, 2

• Delayed or absent supervised physical therapy beyond the 48-72 hour window
• Prolonged immobilization in a cast or rigid boot beyond 10 days
• Reliance on home exercises alone instead of therapist-guided protocols
• Inadequate mechanical support (elastic bandage or tape instead of semi-rigid brace)
• Use of RICE protocol alone without functional treatment components