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Ankle sprains are among the most common cases seen in orthopedic emergencies, accounting for about 25% of musculoskeletal system injuries, with the vast majority being lateral ligament injuries.
During holidays, friends often head outdoors to enjoy themselves, but orthopedic doctors on emergency duty always encounter some unfortunate cases of “happiness turning to sorrow”—ankle sprains, which are among the most frequently seen cases in orthopedic emergency departments, accounting for about 25% of musculoskeletal system injuries, most of which involve lateral ligament injuries.
RICE Principle
As an emergency treatment measure for ankle sprains, the RICE principle is almost classic:
Rest: Stop walking, keep the injured area still to reduce further damage;
Ice: Lower the temperature of the injured part to reduce inflammatory responses and muscle spasms, relieve pain, and inhibit swelling. Apply for 10-20 minutes each time, more than 3 times a day; do not apply ice directly on the injury site; wrap ice cubes in a damp towel to avoid frostbite. Ice application is limited to within 48 hours after injury.
Compression: Use an elastic bandage to wrap the injured ankle with appropriate pressure to reduce swelling. Avoid excessive compression, as this may worsen swelling and ischemia distal to the wrapped area.
Elevation: Raise the limb above the level of the heart to increase venous and lymphatic return, reduce swelling, and promote recovery.
Is the RICE principle enough for ankle sprains? Which patients need immobilization? Which need surgery? Obviously, RICE is only the principle for emergency treatment (within 24-48 hours) of ankle sprains. What about subsequent management?
Grading of Ankle Sprains
Ankle sprains are generally classified into three grades based on severity:
Grade 1: Ligaments are stretched, with microscopic damage to ligament fibers; mild pain. Weight-bearing is allowed if tolerated; no splint or brace fixation is needed; isometric contraction exercises can be performed; if tolerated, full range of joint motion and strength training can be conducted.
Grade 2: Partial ligament fiber tear; moderate pain and swelling with limited range of motion; possible joint instability. Requires fixation with splint or brace, combined with physiotherapy and exercises for strength and joint mobility.
Grade 3: Complete ligament rupture; obvious swelling and pain; joint instability. Immobilization and rehabilitation training similar to grade 2, but with a longer recovery time; a few cases require surgical treatment.
Non-surgical Treatment
POLICE Principle
In 2012, the British Journal of Sports Medicine recommended replacing the RICE principle for ankle injury treatment with POLICE: Protect, Optimal loading, Ice, Compression, Elevation. This principle emphasizes early mobilization.
Research suggests that for grade 1 and grade 2 ankle sprains, performing joint mobility exercises a few days after injury and gradually increasing weight-bearing can promote faster recovery. For grade 3 ankle sprains (complete ligament rupture), evidence supports early immobilization within 10 days post-injury, followed by ankle joint mobilization. However, many scholars still support immobilization for 2-3 weeks in grade 3 injury patients.
General Recommendations
Phase 1: Within 1 week, apply the RICE principle to rest and protect the ankle and reduce swelling;
Phase 2: Weeks 2-3, gradually restore joint mobility, strength, and flexibility;
Phase 3: In the following weeks to months, gradually resume exercise starting with activities that do not require ankle twisting, ultimately returning to sports.
Medication Treatment
Current evidence only recommends taking non-steroidal anti-inflammatory drugs (NSAIDs) to control pain and inflammation.
It is worth mentioning that no topical medications or manual massage and reduction therapies currently have clear evidence supporting their effectiveness.
Surgical Treatment
Only a very small number of grade 3 injury patients require surgery after several months of systematic non-surgical treatment failure. These patients generally have severe injuries, obvious instability, and high demands for sports.
Ankle instability usually presents with positive anterior drawer and talar tilt tests; on ankle anteroposterior inversion stress X-rays, talar tilt may also be positive. Additionally, MRI helps assess ligament tears.
Later physical examinations aid in better assessing ankle stability.
Surgical options may include arthroscopic or open reconstruction to repair ligament structures.