eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions
Ankle Sprain: Treatment & Medication
Updated: Jun 20, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Rehabilitation Program
Physical Therapy
Physicians frequently recommend physical therapy for patients who have suffered moderate to severe ankle sprains, especially persons who have chronic instability and recurring symptoms.7 Following the acute injury, the physical therapist may provide therapeutic modalities (eg, cryotherapy,10 electric muscle stimulation) to speed the reduction of pain and swelling. As the patient progresses and is able to tolerate further therapy, the goals should be aimed at regaining the full range of motion (ROM), strength, and stability of the ankle joint. (See Further Outpatient Care.)11,12
The physical therapist also completes patient education throughout the rehabilitation process and establishes an appropriate home exercise program for each patient. The goal of the program should be to enable the patient to return to his/her previous level of activity. For less severe injuries, immediate, protected ambulation should be encouraged, and physical therapy should emphasize the return of ROM, strength, endurance, and proprioception.
Medical Issues/Complications
Treatment during the acute phase of injury is meant to minimize swelling and allow the patient to begin walking.13 The acute phase of treatment should last for 1-3 days after the injury. A combination of protection, relative rest, ice, compression, elevation, and support is used. This approach can be remembered by using the mnemonic PRICES.4
- Protection - Protective devices include air splints or plastic and Velcro braces. Most sprains can be treated without casting. Depending on the severity of the sprain, protective devices are used for 4-21 days. Criteria to discontinue use of the device include minimal swelling and pain at the site of injury. The ROM should be smooth, particularly with dorsiflexion and plantarflexion.
- Relative rest - Relative rest is advocated, because it promotes tissue healing. Advise the patient to avoid activities that cause increased pain or swelling. Advocate early, pain-free movements during this time. The patient may perform alphabet exercises or towel stretches, if tolerated, to maintain his/her ROM.
- Ice - Use ice to control swelling, pain, and muscle spasm. As a rule, do not apply ice or cold pack directly to the skin; wrap the pack in a towel before use. Recommend that the patient apply ice for 15-20 minutes, 3 times daily. Contrast baths can be used 24-48 hours after injury.
- Compression - Recommend the use of compression with an ACE wrap, an elastic ankle sleeve, or a lace-up ankle support. Advise the patient that further support of the ankle can be facilitated by wearing high-top, lace-up shoes. This can help to minimize edema.6
- Elevation - Encourage elevation of the injured ankle to facilitate the reduction of swelling. Advise the patient to keep the ankle above the level of the heart.
- Support - This can include taping or the use of lace-up ankle supports with combination hook-eye (ie, Velcro) straps.6
Related eMedicine topic:
Ankle Taping and Bracing
Surgical Intervention
Surgery may be indicated when the fibulocalcaneal ligament is torn or a displaced or unstable fracture is identified. Most ankle sprains do not require surgical intervention.
Consultations
Consultations seldom are indicated unless the physician suspects that the ankle or a fracture is unstable. Most ligamentous injuries and fractures heal well after 4-6 weeks of guarded weight bearing and guarded motion, along with a progressive rehabilitation program (as previously outlined). Surgical intervention by an orthopedic or podiatric surgeon may be warranted in these situations. The clinician simply has to determine a comfort level in treating a particular condition. Once that level has been exceeded, consultation with the appropriate specialist is indicated.
Medication
Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) frequently are used to control pain and inflammation. Ultimately, the clinician has the prerogative to determine the most appropriate medication.
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or injuries.
Acetaminophen (Tylenol, Panadol, Aspirin-Free Anacin)
Used for mild pain or if patient cannot tolerate NSAIDs.
Adult
325-1000 mg PO/PR q4-6h; not to exceed 1 g/dose or 4 g/24 h
Pediatric
<12 years: 10-15 mg/kg PO/PR q6-8h prn
>12 years: 325-650 mg PO/PR q4-6h prn; not to exceed 4g/24h
Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; chronic alcohol use; G6PD deficiency; PKU
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Common reactions include rash, urticaria, and nausea; serious reactions include hepatotoxicity, nephrotoxicity, agranulocytosis, pancytopenia, thrombocytopenia, hemolytic anemia, pancreatitis, and angioedema; caution in impaired liver or renal function; hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen (APAP) is contained in many OTC products and combined use with these products may result in cumulative APAP doses exceeding recommended maximum dose
Nonsteroidal anti-inflammatory drugs
If significant ecchymoses is observed at presentation of acute injury, consider not prescribing for 24-48 h, which may prevent further hemorrhage into the site of injury. Several other NSAIDs are available. The ones listed here are considered first-line drugs on most formularies.4
Ibuprofen (Ibuprin, Motrin)
Used for analgesia and anti-inflammatory effect; take with food.
Adult
Mild to moderate pain: 400 mg PO q4-6h; not to exceed 2400 mg/d
Anti-inflammatory use: 600 mg PO qid or 800 mg PO tid x 7-14 d; not to exceed 2400 mg/d
Pediatric
4-10 mg/kg PO q6-8h prn; not to exceed 50 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding; ASA/NSAID-induced asthma
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure (CHF), hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Common reactions include dyspepsia, nausea, abdominal pain, headache, dizziness, rash, elevated liver enzymes, urticaria, drowsiness, fluid retention, and tinnitus; serious reactions include anaphylaxis, GI bleed, acute renal failure, bronchospasm, thrombocytopenia, Stevens-Johnson syndrome, interstitial nephritis, hepatotoxicity, and agranulocytosis
Naproxen (Aleve, Naprelan, Naprosyn, Anaprox)
Used as an analgesic and anti-inflammatory medication; take with food.
Adult
Mild to moderate pain and anti-inflammatory uses: 250-500 mg PO bid; not to exceed 1500 mg/d x 3-5d
Pediatric
10-20 mg/kg/d PO divided q8-12h
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; ASA/NSAID-induced asthma
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug; common reactions include dyspepsia, nausea, abdominal pain, headache, dizziness, rash, elevated liver enzymes, urticaria, drowsiness, fluid retention, elevated liver enzymes, and tinnitus; serious reactions include anaphylaxis, acute renal failure, bronchospasm, thrombocytopenia, Stevens-Johnson syndrome, interstitial nephritis, hepatotoxicity, and agranulocytosis; caution with nasal polyps; GI bleed; advanced age; hypertension; CHF
More on Ankle Sprain |
| Overview: Ankle Sprain |
| Differential Diagnoses & Workup: Ankle Sprain |
 Treatment & Medication: Ankle Sprain |
| Follow-up: Ankle Sprain |
| Multimedia: Ankle Sprain |
| References |
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References
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Further Reading
Keywords
ankle sprain, ankle strain, inversion ankle injury, eversion ankle injury, ankle pain, lateral ankle complex, talofibular ligament, calcaneofibular ligament, posterior talofibular ligament
