Ankle sprain

An ankle sprain is a very common injury.^{1, 2} A sprain can heal well, but some people continue to experience pain, a feeling of weakness, or a sensation that their ankle is giving way. A review of studies following a first lateral sprain found that, one year later, 8.1% of people experienced instability (a feeling that the ankle gives way), 6.7% had pain, and 15.8% suffered a new sprain.³ Exercises and a gradual return to activities are part of rehabilitation—that is, the care that helps you regain your abilities. This guide explains how to recognize a sprain, when to seek medical attention, and how to resume your activities. The physical therapists at Physioactif can support you through this process. For an overview of conditions affecting this area, see our comprehensive guide on foot and ankle pain.

What exactly is an ankle sprain?

An ankle sprain occurs when you stretch or tear the ligaments that stabilize the joint. Ligaments are bands of strong tissue that connect bones to one another. A lateral sprain, which affects the outer ligaments, is the most common type of ankle sprain¹. Among American college athletes in basketball, women’s volleyball, and women’s gymnastics, the outer ligaments were involved in 77.1% of sprains⁴. This percentage applies to these college sports.²

The ankle has three main external ligaments. The anterior talofibular ligament (ATFL) is the one most commonly injured. It provides stability when your foot rolls inward. The calcaneofibular ligament (CFL) and the posterior talofibular ligament (PTFL) complete this stabilization system.

Ligaments limit excessive movement in a joint. Unlike muscles, they do not produce movement by contracting. Recovery depends largely on the severity of the tear. Unlike Achilles tendon tears, ankle sprains involve ligaments. A tendon connects a muscle to a bone.

How does an ankle sprain happen?

A sprain occurs when your foot twists beyond its normal range of motion. The most common type of sprain is an inversion sprain, in which your foot twists inward. This happens when you step on an uneven surface or land awkwardly after a jump.

Inversion—when your foot twists inward—can injure the ligaments on the outside of the ankle. Eversion—when your foot twists outward—can injure the deltoid ligament on the inside of the ankle.

Common circumstances for a sprain include:

• Walking on uneven ground
• Landing awkwardly after a jump (especially during intense sports activities)
• Changing direction quickly in a sport
• Falling off a step or curb

Athletes who participate in sports involving repeated jumping, such as basketball or volleyball, are frequently at risk of ankle sprains. A review of numerous studies found that the highest incidence of new sprains occurs in indoor and enclosed-field sports¹. In the university study, sprains often occurred during contact while jumping in basketball or volleyball⁴. These sports also place stress on the tendon located beneath the kneecap. Persistent pain associated with this tendon may indicate patellar tendinopathy.

A sprain usually occurs as a result of a sudden awkward movement or a fall. Pain that develops gradually should also be evaluated. It may be caused by Achilles tendinopathy—persistent pain in the tendon behind the ankle—or by another condition.

Ankle sprains are not uncommon. In a study conducted among military recruits in training, the ankle and foot region was the most frequently injured part of the body, ahead of the knee.⁵

What are the different grades of ankle sprains?

The three grades of sprains describe a stretch with small tears, a partial tear, or a complete tear of the ligament.

• Grade I (mild): A sprain with microscopic tears too small to be seen with the naked eye. Pain and swelling are usually mild, with no instability on examination.
• Grade II (moderate): partial tear, with pain, swelling, and ecchymosis—that is, a bruise under the skin. An examination may reveal some instability: the ankle is less stable.
• Grade III (severe): Complete tear of the ligament, with significant instability on examination. Pain and swelling may be severe. Recovery generally takes longer than for a mild sprain.

The intensity of the pain alone is not enough to determine the severity of the sprain. A severe sprain can also affect nerves; therefore, the healthcare professional checks the foot for sensation. Mild pain does not rule out a complete tear. The examination is used to determine the grade of the sprain and to check for other injuries. Source: Merck Manual on ankle sprains.

What are the symptoms of a sprain and how can you tell it apart from a fracture?

A sprain can cause pain, swelling, and difficulty walking; examining the foot and ankle helps distinguish it from a fracture, which can produce the same symptoms. The Ottawa Rules are screening tests that help healthcare professionals determine whether an X-ray is necessary. A negative result greatly reduces the likelihood of a fracture, though it does not rule it out entirely.^{6, 7}

Typical symptoms of a sprain

Typical symptoms include immediate pain after the injury, especially on the outside of the ankle. Swelling can appear quickly or within the following hours. You might also notice bruising, have difficulty walking, and feel instability.

Immediate symptoms include:

• Sharp pain at the time of injury
• A sensation that something snapped, sometimes accompanied by a crackling sound
• Difficulty putting weight on the foot

In the hours that follow, the following may occur: increasing swelling, redness, and warmth due to the body’s reaction to the injury, and bruising if small blood vessels have been affected. A minor sprain may not cause visible swelling. The bruise may move down toward the foot due to gravity. After an injury, heel pain should also be evaluated if it is severe or prevents you from bearing weight. Outside of an accident, pain under the heel can be caused by plantar fasciitis, which affects the band of tissue under the foot.

How to Tell the Difference Between a Sprain and a Fracture

The healthcare professional examines your ankle, the bones of your foot, and your ability to walk. Specific pain in a bone or an inability to bear weight warrants special attention. The Ottawa Rules link the site of pain to specific points to be examined; they are not limited to any pain in a bone.

In adults following an injury, the Ottawa Guidelines recommend an X-ray in the following situations:

• Pain around the bony prominences of the ankle, accompanied by at least one of the following signs: pain upon touch along the posterior edge of the last 6 centimeters or at the tip of one of these bony prominences; inability to take four steps immediately after the injury and during the examination.
• Pain in the middle of the foot, accompanied by at least one of the following symptoms: pain upon touch over the navicular bone or along the inner edge of the foot; pain at the base of the fifth metatarsal bone or at the bump on the outer edge of the foot; inability to take four steps immediately after the injury and during the examination.

These checks require careful examination. They are not intended to help you rule out a fracture on your own at home.

Both a sprain and a fracture can allow the person to take a few steps or prevent them from walking. The table summarizes factors that help guide the examination, though it does not, on its own, establish a diagnosis.

Walking alone is not enough to rule out a fracture. Seek medical attention immediately if you cannot put weight on the leg.

After an injury, go to the emergency room if your ankle is misshapen, if you heard a popping sound, if your foot feels numb or tingly, or if the skin on your foot turns blue, gray, or cold. Severe pain or a complete loss of mobility also requires immediate evaluation.

Seek urgent medical attention if the pain is severe or getting worse, if the swelling or bruising is significant or increasing, if you cannot put weight on your ankle or take a few steps, or if your ankle is very stiff or difficult to move. A high fever, a sensation of heat or cold, or chills also warrant seeking medical attention. You should also seek medical care if home treatment does not bring about any improvement. Source: NHS advice following a sprain or strain.

When to consult a physiotherapist for an ankle sprain?

Physical therapy treatment can begin within the first few days after a sprain, once any symptoms requiring urgent medical attention have been addressed. Contact the clinic to find out when the next available appointment is.

In Quebec, you can see a physical therapist directly at a private clinic. However, some insurance policies require a prescription for reimbursement; be sure to check your coverage. The OPPQ explains access and insurance coverage. If your physical therapist detects a complication, they will refer you to the appropriate specialist. To learn more about the role of physical therapy, check out our comprehensive guide.

During your first consultation, your physiotherapist will:

• Assesses the severity of the sprain (grade I, II or III)
• Checks for signs of a fracture and refers you for a medical evaluation or X-ray if necessary
• Establishes a tailored treatment plan

Seeking early medical advice can help you avoid common mistakes, such as resting too much or resuming activity too quickly. A healthcare professional can help you protect your ankle and gradually resume movement based on your tolerance. If immobilization is prescribed, follow their instructions. An examination of the lateral ligaments may be more accurate four to five days after the injury, once the initial swelling has subsided. However, this never justifies delaying care if there are signs of a fracture or a medical emergency.²

How does physiotherapy treat an ankle sprain, and is it effective?

Physical therapy for ligament pain helps restore mobility after a sprain through progressive exercises, guided movements, and advice on returning to activity. This treatment can improve mobility and function, relieve pain, and reduce the risk of another sprain.

Effectiveness demonstrated by research

The practice guidelines recommend exercises and a return to activities with ankle support as needed, rather than solely passive treatment received without active participation.² Gentle movements performed by the physical therapist can improve ankle mobility and reduce pain in the short term. The guide recommends combining these with exercises. The value of additional supervision varies depending on the individual and the program; patients with severe sprains may benefit more from it.

The physical therapist tailors the exercises to the severity of the sprain, the stability of your ankle, and your ability to sense its position—known as proprioception. The therapist also takes into account your activities, your concerns, and the exercises you are able to do at home. The number and difficulty of the exercises will change as your symptoms evolve. A 2022 review confirms that exercise programs reduce the risk of another sprain, but does not identify a single program or ideal number of exercises that works for everyone. Source: Wagemans et al.

In a trial involving 101 people with a Grade I or II sprain, exercises started during the first week improved function at weeks one and two, compared with standard care. There was no difference in pain or swelling between the groups. Source: study by Bleakley and colleagues.

How Does the Treatment Work?

The physical therapist helps you regain functional movement and adjust your activities during recovery. He or she works with you to address stiffness, strength, ankle control, and any fears that limit your movement.

Your body repairs tissue after an injury. Inflammation is part of this repair process. It is the body's response to the injury. During recovery, the professional assesses several factors:

• Concerns or fears
• The number and difficulty of the activities
• Joint or muscle stiffness

The goal is to support your recovery while allowing the tissues to heal. To better understand the mechanisms of pain and how to manage it, check out our guide on chronic pain.

Protection begins after the injury and is intended to manage pain and swelling. It may include a bandage, a splint to support the ankle, or crutches, depending on the examination. The PEACE and LOVE guide provides advice on protection and a gradual return to activity.

You can use an ice pack wrapped in a towel for up to 20 minutes at a time for comfort. Ice is not a substitute for proper range-of-motion exercises. Consult a healthcare professional before using ice if you have sensitivity or circulation issues. The NHS provides guidance on first aid.

Many people take anti-inflammatory pills after a sprain. They relieve pain and swelling, but the practice guideline on sprains advises caution: these medications may slow down the natural healing process.² A review of studies on fractures also found an association between these medications and delayed or absent bone healing in adults. The results were inconclusive for low doses or short-term use. This study focused on bone and does not prove the same effect on ligaments. Your pharmacist or doctor can help you choose an appropriate medication, dose, and duration of treatment.⁸

Recovery of mobility and strength begins gradually, depending on the level of pain and the recommended precautions. It includes ankle movements, followed by exercises using appropriate resistance.

Balance training can begin early on, provided the patient can tolerate it. It then progresses to everyday activities and sports. It is not necessary to automatically wait three weeks before starting.

Your return to activity follows a structured, multi-phase progression, with more challenging exercises based on your tolerance and your goals for returning to activity.

Your physical therapist will advise you on whether to use crutches, a splint, or a bandage, as needed. Learn how physical therapy treats foot and ankle pain, and check out our page on treating ankle sprains at the clinic.

What exercises help with recovery from an ankle sprain?

Mobility, strength, and balance exercises help with recovery from an ankle sprain. They progress to running and changes of direction once you can control these movements.

Proprioception and balance exercises improve ankle control and reduce the risk of another sprain in people who have already been injured.⁹

Proprioception allows you to sense the position of your ankle without looking at it. Exercises on an unstable surface or with your eyes closed increase the difficulty. Start with a support nearby and progress as your control improves. To restore ankle stability, a single-leg balance exercise is often part of the proprioceptive program. If you have also suffered a calf strain, the program must take this muscle injury into account. The preventive benefit observed for ankle sprains does not guarantee a reduction in calf strain recurrences.

Can you treat an ankle sprain on your own?

What Self-Treatment Can Do, and Its Limitations

Home care may be sufficient for a mild sprain, after ruling out any signs that would require a medical consultation. This includes initial protection, tolerated movements, and progressive exercises. Proprioceptive training reduces the risk of re-injury in people who have already been injured, with a reduction of about one-third in recurrence rates according to a review of trials.⁹ This translates to about one-third fewer new sprains compared to the control groups, though individual outcomes cannot be guaranteed.

In a study involving 522 athletes, an eight-week at-home balance program, added to standard care, reduced the incidence of new sprains over one year: 22% versus 33% with standard care alone. The program was not supervised. Source: Hupperets et al.

The 2001 Cochrane review found benefits primarily for ankle braces, with more limited evidence for balance exercises.¹⁰ It was withdrawn in 2011 because it was too old. The more recent studies cited here provide data supporting the exercises.

The Role of the Physiotherapist

The physical therapist assesses the stability of your ankle and any difficulties you may have with movement. He or she checks for signs of a fracture or nerve damage and refers you to the appropriate specialist if necessary. Together, you and the physical therapist will develop a progressive exercise program tailored to your abilities and goals.

A Combined Approach

Assessments and at-home exercises can complement each other. Follow-up visits are used to monitor your progress and adjust the program as your symptoms, activities, or challenges change.

How long does it take to recover from an ankle sprain?

Recovery from an ankle sprain can take about two weeks for a mild sprain and six to twelve weeks for a more severe sprain. These guidelines describe the plan for resuming activities; they do not guarantee complete healing of the ligaments by a specific date. Source: American Academy of Orthopaedic Surgeons.

Timeframes to be adjusted based on your situation

A Grade I sprain usually heals faster than a Grade II or III sprain. Some severe injuries can take several months to heal. The physical therapist will outline the steps and adjust the timeline based on your progress.

Several factors influence the duration:

• The severity of the injury (grade)
• Progress in your exercises and the activities you'd like to resume
• Your injury history

Don't base your return to sports solely on the absence of pain. Movement tests assess your strength, balance, and ability to perform the movements required for your sport. The professional will also take your confidence into account. If the pain persists, if your ankle remains unstable, or if you don't see any progress, consult a physical therapist.

The recovery times for other injuries do not automatically apply to your ankle. A meniscal tear, which affects a cartilage pad in the knee, or a hip fracture requires different types of care and a different recovery process.

Not all ankle pain is caused by the ligament. Nerves pass through a tunnel inside the ankle and can become compressed there. Numbness or tingling requires further evaluation. After a recent injury, these symptoms require urgent medical attention, as noted above.¹¹

How can you prevent another ankle sprain?

Balance and ankle stability exercises reduce the risk of another sprain. Continue the agreed-upon program even as the pain subsides, following the steps outlined with your healthcare professional. An ankle that still gives way requires follow-up care. In a review of studies, this sensation persisted in 8.1% of people one year after their first lateral sprain.³

The return to physical activity is being planned. In a study of 1,296 male military recruits aged 17 to 28, the weeks with the highest number of hours of vigorous training, running, and walking were associated with the highest injury rates⁵. This association alone does not prove the cause of the injuries. In practice, a gradual return to activity allows you to adjust the duration and intensity of your activities to your tolerance level.⁵

A previous sprain increases the risk of another one. Balance exercises and monitoring for persistent instability therefore remain important even after the pain has subsided. To learn more about another common joint condition, see our guide onknee osteoarthritis.

Tips for preparing to resume activities:

• Follow the steps outlined in your program and have it adjusted as needed
• Continue doing balance exercises after the pain subsides
• Strengthen the muscles around the ankle, including the calf muscles which play a stabilizing role.
• Gradually work up to the exercises during your warm-up
• Wear appropriate, comfortable shoes that are suited to your activity

Taping—a supportive adhesive bandage—or an orthosis, a brace worn around the ankle, can reduce the risk of another sprain during sports. These aids complement the exercises.² This guide does not recommend a specific type of shoe to prevent sprains. For athletes, a gradual return to activity helps them adjust their exertion levels. The principle of gradual progression also applies after a knee sprain, with a program tailored to this specific injury.

What are the key takeaways about ankle sprains?

The key points are to check for signs of a medical emergency, resume movement gradually, and do balance exercises to reduce the risk of another sprain. A sprain can be treated, and most people can resume their activities. The absence of pain alone is not enough to determine when to return to sports; strength, balance, and control of movement are also important.

For other foot and ankle conditions, see our guides on Morton's neuroma,hallux valgus, or metatarsalgia.

References

Links open in a new tab.

1. Doherty C, Delahunt E, Caulfield B, Hertel J, Ryan J, Bleakley C. The incidence and prevalence of ankle sprain injuries: a systematic review and meta-analysis of prospective epidemiological studies. Sports Med. 2014;44(1):123-40. (Back to sections: 1, 2, 3)
2. Vuurberg G, Hoorntje A, Wink LM, van der Doelen BFW, van den Bekerom MP, Dekker R, et al. Diagnosis, treatment, and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med. 2018;52(15):956. (Back to sections: 1, 2, 3, 4, 5, 6)
3. Michels F, Wastyn H, Pottel H, Stockmans F, Vereecke E, Matricali G. The presence of persistent symptoms 12 months following a first lateral ankle sprain: A systematic review and meta-analysis. Foot Ankle Surg. 2022;28(7):817-826. (Back to sections: 1, 2)
4. Lytle JB, Parikh KB, Tarakemeh A, Vopat BG, Mulcahey MK. Epidemiology of Foot and Ankle Injuries in NCAA Jumping Athletes in the United States During 2009–2014. Orthop J Sports Med. 2021;9(4):2325967121998052. (Back to sections: 1, 2)
5. Almeida SA, Williams KM, Shaffer RA, Brodine SK. Epidemiological patterns of musculoskeletal injuries and physical training. Med Sci Sports Exerc. 1999;31(8):1176-82. (Back to sections: 1, 2, 3)
6. Gomes YE, Chau M, Banwell HA, Causby RS. Diagnostic accuracy of the Ottawa Ankle Rule for ruling out fractures in acute ankle injuries in adults: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2022;23(1):885. (Back to section: 1)
7. Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of the Ottawa Ankle Rules for Excluding Fractures of the Ankle and Midfoot: A Systematic Review. BMJ. 2003;326(7386):417. (Back to section: 1)
8. Wheatley BM, Nappo KE, Christensen DL, Holman AM, Brooks DI, Potter BK. Effect of NSAIDs on Bone Healing Rates: A Meta-analysis. J Am Acad Orthop Surg. 2019;27(7):e330-e336. (Back to section: 1)
9. Rivera MJ, Winkelmann ZK, Powden CJ, Games KE. Proprioceptive Training for the Prevention of Ankle Sprains: An Evidence-Based Review. J Athl Train. 2017;52(11):1065-1067. (Back to sections: 1, 2)
10. Handoll HH, Rowe BH, Quinn KM, de Bie R. Interventions for preventing ankle ligament injuries. Cochrane Database Syst Rev. 2001(3):CD000018. (Back to section: 1)
11. Ferkel E, Davis WH, Ellington JK. Entrapment Neuropathies of the Foot and Ankle. Clin Sports Med. 2015;34(4):791-801. (Back to section: 1)