Management and treatment of ankle sprain

Ankle sprains are among the most common musculoskeletal injuries, affecting both athletes and the general population. They often result in pain, swelling, and limited motion, and can lead to long-term complications such as chronic instability, disability, and arthritis. Studies show that approximately 44% of individuals continue to experience symptoms such as pain or instability even a year after an ankle sprain. Interestingly, factors like foot type, joint flexibility, and gender do not appear to increase the risk of developing ankle sprains.

Ankle sprains are a major cause of emergency room visits and sports-related injuries, accounting for millions in healthcare costs each year. In sports such as basketball and soccer, they represent a significant percentage of all injuries, primarily affecting the lateral ligaments of the ankle. Because of their prevalence and impact, several clinical practice guidelines (CPGs) have been developed to standardize the diagnosis and treatment of ankle sprains.

Clinical Practice Guidelines for Ankle Sprains

A systematic review of available CPGs revealed substantial variations in quality and recommendations. The study evaluated evidence-based practices to simplify management for both clinicians and patients and identified 17 key treatment recommendations supported by varying levels of evidence.

Diagnosis and Imaging: The Ottawa Ankle Rules

Accurate diagnosis is essential for appropriate treatment. The Ottawa Ankle Rules are widely recognized guidelines that help determine when imaging (X-rays) is necessary after an ankle injury. They are designed to minimize unnecessary radiographs while ensuring fractures are not missed.

Key criteria include:

• Pain in specific areas – tenderness around the bony prominences of the ankle (medial or lateral malleolus) may indicate a fracture.
• Inability to bear weight – if the patient cannot take four steps without significant pain, imaging is recommended.

These rules are highly sensitive and effective in distinguishing fractures from sprains, making them a first-line tool for evaluation in emergency and outpatient settings.

Acute Management and Conservative Care

Conservative (non-surgical) management remains the standard of care for most ankle sprains. Early intervention focuses on pain control, swelling reduction, and functional recovery.

Cryotherapy (Ice Therapy)

Applying ice within the first 48 hours after injury effectively reduces pain and swelling. Cryotherapy is most beneficial during the acute phase, especially when combined with compression and elevation. Its role diminishes in later recovery phases.

NSAIDs (Nonsteroidal Anti-inflammatory Drugs)

Short-term use of NSAIDs is recommended during the acute phase to alleviate pain and inflammation. They are considered safe when used briefly, but long-term use is discouraged due to potential gastrointestinal and cardiovascular side effects.

Early Weight-Bearing and Functional Treatment

Early mobilization and weight-bearing, as tolerated, are strongly supported by evidence. Walking or light activity soon after injury accelerates recovery, prevents stiffness, and promotes healing of the ligaments. Prolonged immobilization is no longer recommended except in severe cases.

Supportive Devices

Ankle braces or semi-rigid supports are more effective than taping or elastic bandages for providing stability and preventing recurrent sprains. Guidelines recommend wearing an ankle brace for 4 to 6 weeks following injury. Prolonged immobilization or restrictive casting should be avoided except in severe (Grade III) sprains, where short-term immobilization (up to 10 days) may be indicated before beginning rehabilitation.

Manual Therapy

Manual therapy, including joint mobilization, manipulation, and soft-tissue massage, has shown both short- and long-term benefits in recovery. Even a single session can significantly reduce pain and swelling. It also improves range of motion and enhances overall functional recovery.

Exercise and Rehabilitation

Exercise therapy is a cornerstone of ankle sprain management, promoting faster recovery and reducing the risk of recurrence. Rehabilitation focuses on restoring flexibility, balance, strength, and proprioception.

Key components include:

• Therapeutic exercises to enhance joint stability and coordination.
• Balance and proprioceptive training to restore neuromuscular control.
• Strength training for peroneal, calf, and tibial muscles to support the joint.

Although supervised programs may provide more structured recovery, unsupervised home exercise programs are also beneficial and widely encouraged.

Rehabilitation and Return to Sport

Two major guidelines strongly emphasize structured rehabilitation as essential for complete recovery and safe return to sport. Rehabilitation improves ankle strength, coordination, and overall lower limb function, significantly lowering the risk of chronic instability.

Immobilization and Surgery

Immobilization is reserved for severe sprains with significant ligament damage (Grade III). It should not exceed 10 days, after which functional rehabilitation must begin. Surgery is rarely indicated and is typically reserved for chronic instability or elite athletes requiring faster recovery for return to competition. Conservative treatment remains preferred due to its safety, cost-effectiveness, and minimal risk of complications.

Other and Emerging Therapies

• Acupuncture: Considered low-risk and cost-effective, though evidence of its superiority over standard care remains limited.
• Opiates: Have low recommendation levels due to insufficient evidence of benefit and risk of dependence.
• Modalities such as ultrasound, diathermy, electrotherapy, and laser therapy: These show minimal or no proven benefit and are not recommended for ankle sprain management.

Key Evidence-Based Recommendations

Of the 17 evaluated recommendations, six have strong evidence and are highly recommended for ankle sprain management:

1. Ottawa Ankle Rules for accurate diagnosis and imaging decisions.
2. Manual Therapy to reduce pain and improve function.
3. Cryotherapy during the acute phase for pain and swelling control.
4. Supportive Bracing for 4 to 6 weeks to stabilize the ankle.
5. Early Weight-Bearing to encourage healing and prevent stiffness.
6. Structured Rehabilitation to restore strength, balance, and function.

Emerging but less-established interventions, such as acupuncture, electroacupuncture, and pharmacopuncture, show potential but require further high-quality studies to determine their long-term efficacy. In contrast, therapies like diathermy, ultrasound, and laser treatment have insufficient evidence to support their use.

Research Spotlight

A 2025 randomized clinical trial published in Cureus evaluated the effectiveness of adding telerehabilitation to usual care for ankle sprains. Eighty-two patients with grade I or II ankle sprains were divided into two groups—one received standard treatment, and the other added a structured four-week telerehabilitation program using daily guided exercises.

The study found that patients who performed telerehabilitation showed significantly greater improvements in ankle function and faster recovery, especially for moderate (grade II) sprains. They also reported less pain and fewer days of missed work.

The findings suggest that integrating digital rehabilitation tools can enhance outcomes and speed return to activity in patients recovering from ankle sprains. (“Study on adding telerehabilitation to ankle sprain care – see PubMed.”)

Summary and Key Takeaways

Ankle sprains are highly prevalent and can lead to persistent instability or chronic pain if not managed appropriately. Evidence strongly supports early mobilization, use of functional braces, short-term cryotherapy and NSAIDs, manual therapy, and structured rehabilitation as the most effective management strategies. Conservative treatment remains the preferred approach, while surgery is reserved for severe or recurrent cases.

By following these evidence-based guidelines, patients can achieve faster recovery, reduced recurrence rates, and improved ankle stability—enabling a quicker and safer return to daily activities or athletic participation.

References / Citations (Optional)

Stiell IG, McKnight RD, Greenberg GH, et al. “Implementation of the Ottawa Ankle Rules.” Orthobullets.
American College of Foot and Ankle Surgeons. “Ankle Sprain Management Guidelines.” FootHealthFacts.org.
van der Wees PJ et al. “Clinical Practice Guidelines for the Treatment of Acute Ankle Sprain: A Systematic Review.” British Journal of Sports Medicine. Updated October 2025.