This systematic review synthesizes 10 years of level-I evidence (3 meta-analyses, 16 RCTs) on the treatment and prevention of acute lateral ankle sprains. It addresses six clinical questions: surgery vs. conservative care, immobilization vs. functional treatment, optimal external support, and the role of neuromuscular training for rehabilitation and prevention. The goal is a practical, phase-adapted treatment algorithm grounded in the highest available evidence.
The practical take-away from this review is a phase-adapted treatment algorithm tied to the biology of ligament healing.
The inflammatory phase lasts roughly 10 days — this is the only window where short immobilization in a cast is justified for grade III injuries. After that window, immobilization becomes harmful: functional stress is required for proper type I collagen orientation during the proliferation phase (weeks 4–8), and a semi-rigid brace provides that protection without restricting healing.
Grades I and II injuries skip the casting phase entirely and go straight to a semi-rigid brace. Tape and elastic bandage are inferior options: tape generates skin complications in nearly 60% of patients, and elastic bandage is associated with slower return to activity and more reported instability.
For athletes with a prior sprain, add a proprioceptive home-based training program — the 2BFit trial (n=522) showed a one-third reduction in re-sprains, though the benefit is adherence-dependent. For previously uninjured athletes, balance training for primary prevention has not reached statistical significance in the available trials.
Surgery is not indicated as routine first-line care. Reserve it for cases with extensive grade III injury, massive hematoma, or athletes in whom objective instability is a career-limiting concern — and counsel patients that surgery trades lower re-injury rates for a meaningful risk of early osteoarthritis on MRI.
This systematic review synthesizes 10 years of level-I evidence (3 meta-analyses, 16 RCTs) on the treatment and prevention of acute lateral ankle sprains. It addresses six clinical questions: surgery vs. conservative care, immobilization vs. functional treatment, optimal external support, and the role of neuromuscular training for rehabilitation and prevention. The goal is a practical, phase-adapted treatment algorithm grounded in the highest available evidence.
The practical take-away from this review is a phase-adapted treatment algorithm tied to the biology of ligament healing.
The inflammatory phase lasts roughly 10 days — this is the only window where short immobilization in a cast is justified for grade III injuries. After that window, immobilization becomes harmful: functional stress is required for proper type I collagen orientation during the proliferation phase (weeks 4–8), and a semi-rigid brace provides that protection without restricting healing.
Grades I and II injuries skip the casting phase entirely and go straight to a semi-rigid brace. Tape and elastic bandage are inferior options: tape generates skin complications in nearly 60% of patients, and elastic bandage is associated with slower return to activity and more reported instability.
For athletes with a prior sprain, add a proprioceptive home-based training program — the 2BFit trial (n=522) showed a one-third reduction in re-sprains, though the benefit is adherence-dependent. For previously uninjured athletes, balance training for primary prevention has not reached statistical significance in the available trials.
Surgery is not indicated as routine first-line care. Reserve it for cases with extensive grade III injury, massive hematoma, or athletes in whom objective instability is a career-limiting concern — and counsel patients that surgery trades lower re-injury rates for a meaningful risk of early osteoarthritis on MRI.