Conservative Management of Acute Ankle Sprains

Although among the most common athletic injuries, ankle sprains often go untreated or undertreated. Reports reveal that up to 50% of people who sustain ankle sprains do not seek medical treatment.¹

It is important to educate not just ourselves but also our patients on the importance of proper ankle sprain treatment to help them prevent recurrent injures, early degenerative joint changes, and chronic ankle instability. Approximately 40% of patients who sustain ankle sprains develop chronic instability.²

Nearly 85% of ankle sprains are lateral ankle sprains.² Deltoid injuries are more frequently in conjunction with a fibular fracture or syndesmosis injury than in isolation. Isolated deltoid sprains account for only about 3–4% of all ankle injuries.³ Syndesmosis sprains/high ankle sprains account for about 12% of ankle injuries but are more common in contact sports and account for approximately 25% of ankle injuries in collision sports.⁴ Focusing on inversion ankle sprains, current research supports that the majority are best treated nonoperatively. While there is still debate on the surgical indications in the literature, about 80–85% (some may argue much higher) of acute inversion sprains can be treated nonoperatively with success.⁵

This article will take an evidence-based look at the conservative management of acute ankle sprains.

A More Thorough Physical Exam Makes for a More Accurate Diagnosis

A thorough and proper history and physical exam is imperative to the proper treatment of ankle sprains, beginning with correct diagnosis and determination of injury severity. While most ankle sprains are simple inversion sprains, it is important that one does not miss other injuries due to an overly problem-focused physical exam. If the exam solely focuses on the lateral ligament complex, one may miss injuries such as high ankle sprains, deltoid injuries, anterior process calcaneal fractures, fifth metatarsal base fractures, bifurcate ligament injuries, and peroneal tendon pathology. It is important to perform all aspects of the lower extremity musculoskeletal exam including range of motion, strength, targeted palpation, and special tests. If the patient is too guarded and anxious immediately post-injury for a comprehensive exam, then I find having them start with PRICE (protection, rest, ice, compression, elevation) and then returning to the clinic in 3–5 days for a delayed physical exam can be helpful in achieving a better clinical diagnosis.  

Targeted and sequential palpation of all structures surrounding the ankle is key to avoiding a missed diagnosis. It is important to consider surface anatomy to specifically palpate structures and landmarks, and not just feel around until encountering pain. This is especially important in ruling out injuries such anterior process calcaneal fractures and bifurcate ligament injuries that are also sustained during an inversion mechanism. In a recent retrospective analysis of anterior process calcaneal fractures by Cibura and colleagues, providers missed 29.3% of these fractures at initial diagnosis, which led to higher complication rates.⁶ Bifurcate ligament injuries are more common than isolated ligament injuries in conjunction with ankle sprains.⁷ After inversion sprains, clinicians should palpate the bifurcate ligament as well as load the midfoot in inversion and adduction on the rearfoot. There are limited studies on evidence-based treatment of concurrent bifurcate ligament sprains, but in a 2020 Journal of Foot and Ankle Surgery study, the authors showed that traditional ankle braces do not sufficiently support and protect the bifurcate ligament after injury, suggesting that these patients may require a longer period of immobilization than an isolated inversion ankle sprain for better outcomes.⁷

Certain special tests are important to diagnosing ankle sprains, including the anterior drawer and talar tilt tests (Figure 1). When performing these tests, it is important to do so bilaterally to help determine if laxity is present. The anterior drawer primarily tests the laxity of the anterior talofibular ligament (ATFL). The inversion talar tilt evaluates the integrity of the calcaneofibular ligament (CFL) while the eversion talar tilt evaluates the medial deltoids. For all three of these tests, the true definition of a positive test is laxity when compared to the contralateral limb, but when documenting, I find it is important to differentiate if they are positive for either or both pain and laxity. Pain without laxity may indicate a ligamentous injury, but without significant tear or attenuation. While there are a number of tests for syndesmotic injury, the 2 I observe the most in the literature are the syndesmotic squeeze test and the forced dorsiflexion-external rotation (DF/ER) test. These tests should be performed after any twisting ankle injury to rule out a high ankle sprain (Figure 1). In a review by McCollum and colleagues, the authors noted that studies have shown that the DF/ER test has the lowest interobserver error and the highest sensitivity and that the positive squeeze test correlates with a prolonged return to sport.⁸ It is imperative to always evaluate the syndesmosis as clinicians miss these injuries on initial diagnosis up to 25% of the time on physical exam.⁸

A Guide to Treatment of Ankle Sprains

In the initial phase after any acute injury, the mainstay of treatment is RICE (rest, ice, compression, elevation) but with ankle sprains it is important to instead consider PRICE, adding protection. In the initial phase, in my experience, it is important to protect patients from the damaging range of motion, such as preventing frontal plane movements after an inversion sprain with either bracing, taping, or cast boot, pending severity.

The intermittent use of ice becomes controversial. While studies on cryotherapy do exist, consensus on parameters is lacking, physiological studies are mostly on animal models, it is difficult to study its effects isolated in treatment in humans, and there are limited randomized controlled trials on the use of ice. There is, however, a growing trend in the literature recommending against the use of ice in the management of soft tissue trauma.⁹ In the initial acute inflammatory phase (about days 0–7) post–soft tissue injury, ice can decrease pain, muscle spasm, edema, hematoma, and minimize inflammation; however, prolonged and sustained ice use can decrease tissue metabolism, limit the release of healing mediators such as IGF-1, cause cold-induced tissue damage, and potentially delay the healing response.^9-11 The current literature, while mixed, appears to suggest that ice is best in the initial acute inflammatory phase, especially when significant pain and swelling may limit recovery, but cautions to not overutilize past the initial first 2–7 days or when there isn’t significant edema reducing recovery.^9-11  

One should not overlook the “C” of PRICE in the acute phase. Prolonged or significant edema around the ankle joint can lead to persistent reduction in ankle and subtalar joint motion, which in turn leads to slower progression through rehabilitation and prolonged return to play. Devices such as Game Ready (Avanos Medical), combine ice and intermittent compression, which athletic trainers often use in the first week post-injury for athletes (Figure 2). Urgent care centers and emergency rooms often dispense stirrup-style braces after ankle sprains; however, this type of brace does not offer any compression. When utilizing stirrup-style braces in the acute phase, one can add compression via a compression sleeve or elastic wrap under the brace. For athletes with more severe injuries requiring immobilization in a controlled ankle motion (CAM) boot, compression in the boot remains important.

How to Treat Isolated Inversion Sprains

Multiple classification systems exist to guide inversion ankle sprain treatment, but what constitutes the grades among these systems in the literature but those systems varies significantly. To help drive treatment decisions, one can focus on differentiating stable versus unstable injuries. One classification somewhat validated in the literature is a “Modified O’Donoghue” system (Figure 3).^12,13 Magnetic resonance imaging (MRI) is most often not necessary following acute inversion sprains to classify injury severity. Recent literature shows that acute MRI is not a good clinical predictor for recovery and that physical exam findings are more reliable for acute and subacute treatment progression.¹³ Polzer and colleagues found a physical exam is sufficient to evaluate and classify acute inversion sprains as stable or unstable and that acute physical exam and delayed physical exam (3–5 days post-injury) have a sensitivity of 96% and specificity of 84%.¹⁴ However, one may consider MRI if there is acute concern for other associated pathology, or if in the subacute phase the patient does not respond to treatment.   

Immobilization vs. Functional Treatment of Inversion Ankle Sprains

Historically, ankle sprain treatment included RICE, immobilization and prolonged non-weight-bearing (NWB). More recent literature no longer recommends prolonged immobilization and strongly supports functional progressive treatment with limited NWB, early protected range of motion (ROM), early protected weight-bearing, limited immobilization (duration based on grade), and early therapeutic exercise with a functional rehabilitation progression.^1,12–16 Immobilization can lead to joint adhesion, contracture, disuse atrophy, and a prolonged treatment course. It is important to note that this early functional progressive treatment does not equal no treatment nor unrestricted rehabilitation. In my experience, in early intervention there should be an emphasis on “protected” weight-bearing and ROM, meaning that you still need to avoid the injurious frontal and transverse plane ROM during the acute and early subacute phase.  

Given the severity/grade of an inversion injury and pain level, a short period of immobilization and NWB may be necessary, with progression to partial weight-bearing and then full weight-bearing as soon as tolerable. Multiple recent studies recommend immobilization no longer than a maximum of 10 days.¹ In relation to injury grade, a number of studies support little to no immobilization/NWB for Grade 1, Grade 2 should be limited to 2–5 days, and with Grade 3 injuries, these patients can benefit from a short period of immobilization of 7–10 days.^1,13 It is important to state that in any injury grade, transitioning directly from NWB and immobilization directly to full activity is never recommended.¹⁵ Avoiding prolonged immobilization is supported in a growing body of literature. For one example, a randomized controlled trial by Ardèvol and colleagues comparing cast immobilization with functional management in an athletic cohort found that patients managed with a functional protocol returned to sporting activity sooner, had fewer symptoms at 3 and 6 months, and exhibited less ligamentous laxity radiographically on stress radiographs.¹⁵

Functional Rehabilitation Following Inversion Ankle Sprains

After a short period of immobilization, patients should transition to tape or an ankle brace for “protected” weight-bearing. There is some debate as to which type of brace is best. There is limited evidence that a lace-up style braces and semirigid braces are preferable.¹ This author prefers the lace or strap up style braces with rigid removable medial and lateral stays (Figure 4).

These provide rigid stability in the acute and subacute phases, but as the patient transitions through their rehab into more functional activities, they can remove the stays for less rigid support. In Grade 1 and 2 injuries, within the first 48–72 hours after an injury, the patient can start easy, passive ROM, but in dorsiflexion and plantarflexion only. It is important to not initiate circumferential ROM exercises in the acute phase, such as the “ABCs,” to protect against inversion/eversion. To perform passive sagittal ROM, one may instruct the patient to use a towel wrapped around the forefoot and gently, with even pressure from both hands, slowly dorsiflex the foot using care to maintain subtalar neutral position and isolate the sagittal plane motion. There is significant research data to show that early initiation of a protected ROM can improve outcomes. A randomized control trial in the British Journal of Sports Medicine found early exercise within the first week post-injury can significantly improve early functional outcomes and can facilitate early return to work requiring low-intensity activity.¹⁶ For Grade 3 injuries, early ROM is often delayed until after the initial immobilization period.  

It is not uncommon for patients to prematurely stop rehabilitation, especially with milder sprains, after the patient becomes pain-free with ROM and basic strengthening. It is crucial to educate patients on the importance of completing a functional rehabilitation program to prevent repetitive sprains, because strength and ROM alone are not the only deficits following injury. Following a musculoskeletal injury, range of motion, joint mobility (considering the role of edema and scarring), flexibility, muscle activation, strength (including both power and endurance), neuromuscular patterns, balance, and proprioception all experience the impact.¹⁷

Initiation of proper exercises in the correct sequence is one of the most vital principles when designing a rehabilitation program. The progression of a functional rehabilitation program can be best thought of as a pyramid (Figure 5). One has to build the pyramid from the ground up in a stepwise fashion, just as one has to have the proper building blocks before they can progress to the next phase of physical therapy to prevent aggravation or reinjury.

Once one achieves full pain-free sagittal ROM, moving up the pyramid, the next step is muscular strength and endurance. Within this step of the pyramid, it is important first to initiate isometric strengthening (contraction without joint motion) before progressing to isotonic exercises to assist with muscle reactivation. As previously discussed, considering injury patterns, certain planes of motion for ROM and strengthening exercises can be initiated before others in the rehabilitation program. When moving up the pyramid, the next step is balance and proprioception. There are many studies that illustrate the importance of proprioceptive training following any joint injury, especially in sport. There have been many studies including RCT and metanalyses that have shown that incorporating balance and proprioception exercises is extremely important to treatment success and can be considered one of the most important components of rehabilitation.¹⁸ An example of a rehabilitation progression in this block of the pyramid is starting with single leg balance on a stable surface, then single leg balance on an unstable surface, then single leg balance while performing a sport-specific activity (such as throwing and catching a ball), then side to side hopping on both feet, and then progressing to single leg hopping (Figure 6).

Finally, the last stage in the pyramid is functional exercise. This includes more dynamic motions in multiple planes and sport-specific activities. High level athletes are not the only ones with functional demands. When treating any patient after an ankle sprain, it is important to consider what types of functional activities that person needs in their job, daily life, and recreation.   

Insights on the Treatment of Deltoid Sprains

There is less robust evidence-based treatment studies regarding deltoid sprains. Since most deltoid sprains are not isolated injuries, the first step to proper management of an inversion injury is palpating the full length of the fibula and evaluating the syndesmosis to rule out other associated injuries.^8,19 One should have a low threshold for ordering X-rays to rule out fibular fracture. Once an isolated deltoid injury is diagnosed, the treatment decision is based on stability.

Anatomically, one categorizes the deltoids as superficial and deep. The majority of isolated deltoid injuries involve only the superficial bands. These injuries are typically stable on exam and treatment is very similar to that for inversion ankle sprains. While rare, if on exam there is excessive valgus of the hindfoot, laxity on the eversion talar tilt, and/or medial translation of the talus in the ankle mortise on imaging due to chronic medial instability, and posterior tibial tendon injury is ruled out, this can indicate complete rupture of both the superficial and deep bands. In the case of acute or chronic medial instability, some authors recommend arthroscopic evaluation and direct surgical correction.¹⁹

A Guide to Treatment of High Ankle Sprains

It is extremely important to differentiate a high ankle sprain from a lateral ankle sprain because there are notable and important differences in their management. While there is not as strong of a research-based consensus on best treatment and return to play, we do see that high ankle sprains have less predictable outcomes, more prolonged recovery, and a delayed return to sport.^8,20 These injuries are also typically classified as grade 1–3 with grade 1 being a stable injury.

Grade 1 is usually defined as an isolated anterior inferior talofibular ligament (AITFL) lesion with no displacement of the ankle mortise and no diastases of the syndesmosis. The typical treatment for these grade 1 injuries is nonoperative, typically including a period of immobilization and NWB followed by PWB in a CAM boot, followed by bracing and physical therapy.²¹ The main difference between inversion and high ankle sprains is the duration of the NWB and immobilization, which is typically longer for syndesmotic injuries—up to 2 weeks.²¹

Grade 2 injuries are typically broken down into 2A and 2B, where in 2A there may be a complete rupture of the AITFL but no frank diastasis and in 2B, one sees dynamic diastasis. Treatment for Grade 2 injuries is more debatable with Grade 2A injuries more likely to be treated nonoperatively and Grade 2B being a more likely operative scenario.

Grade 3 injuries are the most unstable with a rupture of all the syndesmotic ligaments with or without a deltoid injury and significant diastases compared bilaterally. Currently Grade 3 injuries are almost always treated operatively.^8,20

When Can Ankle Sprain Patients Return to Play?

While a thorough review of return to play considerations after an injury is too lengthy for this article, it is a very important aspect in the management of ankle sprains. One of the common reasons for reinjury and the development of chronic ankle instability is returning to play too soon. Return to play criteria are not just for competitive or high-level athletes. Almost everybody who sprains their ankle is going to have an activity they want to get back to that has functional demands hindered by their injury.

A common mistake in determining when a patient is ready to return to sports is putting too much emphasis on the time since injury, pain level, and painful strength and ROM when in NWB. In my experience, more emphasis should be placed on functional outcomes measures. Clinical tests for balance, proprioception, and agility should be completed to help determine readiness. A 2021 consensus statement broke readiness to return to play into 5 categories that each needed to be met before an athlete could return to play: Pain severity, ankle impairments (ROM, strength), athlete perception (perceived stability and psychological readiness), sensorimotor control (balance and proprioception, and sport/functional performance (hopping, agility, sport specific drills).²²   

As athletes return to sport after ankle sprains, it is wise to use support in the form of a brace or taping. A 2019 review in the Journal of Athletic Training regarding evidence-based treatment of ankle sprains established one of their treatment pillars as using ankle support for 1 year during athletic activity post-injury.¹⁸ In comparing bracing to taping, bracing is superior for longer duration use and is more cost-effective. While traditional cloth athletic tape does provide adequate support, it has significant reduction in strength over the course of a game or practice. Elastic tapes such as kinesiology tape have become more popular in recent years, however, while useful in other pathologies, studies show that this type of tape does not offer appropriate ankle support.²³

In Conclusion

Regardless of which treatment plan you choose, surgical vs conservative or traditional immobilization vs. accelerated functional, there are the same 2 key aspects of a proper management—the first being a thorough and proper physical exam and the second being proper timing for return to play/activity. Treating our patients most effectively starts with the proper diagnosis and determining the severity and degree of instability present. We see the degree of instability with a proper physical exam is one of the best drivers of treatment decisions regardless of the type of ankle sprain. When determining when our patients should return to play, we should focus on functional outcome measures and a staged return to activity to help prevent reinjury. When considering recurrent ankle sprains and chronic ankle instability, one of the best ways to prevent is to focus on proper initial conservative management and functional rehabilitation.

Dr. Canzanese is a Fellow of, and Vice President for the American Academy of Podiatric Sports Medicine. She is a Diplomate of the American Board of Podiatric Medicine, a member of the American Association for Women Podiatrists, and a certified athletic trainer. She practices in Glenside, PA.

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