An ankle sprain is one of the most common sports injuries and is also the most frequently re-injured. Here you will find everything you need to know about diagnosing, treating and rehabilitating a sprained ankle including emergency first aid, exercises and ankle taping for an effective and speedy recovery.
On this page:
- Symptoms & diagnosis
- Causes & anatomy
- Complications & avulsion sprain
Sprained ankle symptoms & diagnosis
You often know instantly if you have sprained your ankle. The foot turns inwards under the weight of the body causing Instant pain around the ankle joint, specifically on the outside of the ankle where the damaged ligaments are located.
Swelling or bruising can appear immediately or may sometimes take up to 48 hours to develop, depending on the structures damaged and the severity of the sprain. Ankle sprains are graded 1, 2 or 3.
Grade 1 is a mild injury with some pain but little or no swelling. The joint may feel stiff and the athlete may be some difficulty in walking or running. However, more often than not, they will be able to play on and finish the training session or game. In grade 1 sprains, the ligaments are usually stretched rather than completely torn and recover relatively quickly, usually somewhere between 2 and 4 weeks.
Grade 2 sprains cause moderate to severe pain. The athlete would be unlikely to be able to play on as they will probably find it very difficult to walk. Minor bruising and swelling may occur immediately but can take up to 48 hours to develop. The ankle will feel very stiff and may also feel unstable from torn ligament fibres. Recovery time for moderate grade 2 ankle sprains is usually between 4 and 8 weeks.
Grade 3 is a complete, or near complete, tear of the ligament. There will be immediate, severe ankle pain and the ankle may feel very unstable and weak. Swelling usually develops immediately and bruising often develops over the next 48 hours. These injuries need to be assessed in a hospital and often require an x-ray to ensure no bones have been broken. Severe ankle sprains (grade 3) can take up to 3 months to recover.
Sprained ankle assessment
Assessment of any injury should include questions concerning the patient’s general health, any previous injuries and focused questions on the current injury. The aim of these questions is to determine which structure may be causing the pain and which treatment is appropriate. Following this, the therapist will perform a series of tests which may include the following:
- Observation is usually the first stage of any injury assessment. The therapist will usually observe the patient in both standing and lying down and will be looking closely for swelling, bruising and deformity, as well as postural issues such as over pronation of the feet or problems putting the foot on the floor.
- Palpation - the therapist will then palpate the entire ankle joint and surrounding area to assess if the joint is warm (due to acute inflammation) and swollen and if the ligaments are painful to touch.
- Range of Motion - the therapist will usually assess both active (the patient moves) and passive (the therapist moves the joint) movements of the ankle with the knee both straight and then bent. The ankle is often painful to move after an ankle sprain. Passive range of motion is usually pain-free as the muscles are not contracting, although the end of range into dorsiflexion (toes pointing upwards) may be painful as the muscles stretch.
- Flexibility - depending on the severity of the ankle injury, the therapist may assess the patient in standing to test the movement of the ankle when weight bearing.
- Resisted Muscle Tests - these tests are used to assess strength of the muscles around the ankle joint compared to the other side. They may be tested with the knee straight and then bent.
Special tests are used to assess the integrity of the ligaments and how badly damaged they are.
- “Anterior drawer test” will be used to assess the ATFL ligament
- “Talar Tilt” test will be used to test the CFL ligament
- External rotation and squeeze tests will be used to assess the high ankle ligaments (syndesmosis complex)
Functional tests are used to asses how the patient moves and how the ankle injury affects walking, hopping, jumping. The severity of the ankle injury will dictate which tests are selected.
Ankle sprain causes & anatomy
The ankle is supported by a number of ligaments which connect bone to bone. The main ones involved in a sprained ankle are the tibiofibular and the calcaneofibular ligaments on the outside of the ankle. Muscles and tensons (which join muscle to bone) on the inside of the leg and ankle (tibialis posterior and tibialis anterior) as well as the muscles on the outside of the ankle (peroneal muscles) help support and provide stability to the joint.
An inversion sprain, where the ankle rolls outwards (foot turns inwards and upwards) is most common. An eversion sprain, where the ankle rolls inwards flattening the foot can occur, although this is likely to happen in conjunction with a fracture of the fibula bone on the outside of the lower leg. When the ankle turns over too far or too quickly, these ligaments, muscles and tendons get damaged, stretched or torn. Mild ankle sprains may only damage one of the ligaments whereas a more severe sprain can damage two or three.
Poor proprioception is a leading cause of sprains, especially recurrent ankle sprains. This is the body's awareness and ability to judge the position of body parts. If you have ever started to turn your ankle over and reacted automatically to stop it then this is proprioception at work. Poor proprioception means the muscles would be less able to detect when the joint is at risk of injury and less able to correct the position of the ankle when needed, which can result in a sprain. Previous injury and inappropriate footwear are also likely to increase the risk of a sprained ankle.
An ankle avulsion fracture occurs when a tendon or ligament comes away from the bone often pulling a small piece of bone with it. The symptoms are similar to an ankle sprain, but unlike a sprain, an avulsion fracture pulls a piece of bone off when the ligament tears. An x-ray can determine which ankle injury you have and so how best to treat it.
Ankle avulsion fracture & complications
Symptoms of an ankle avulsion fracture are very similar to an ankle sprain and it is very difficult to tell the difference without an X-ray or MRI scan. There will be pain in the ankle immediately after the injury occurs with immediate swelling. Bruising may develop later and the athlete will most likely have difficulty moving or putting weight on the ankle.
Avulsion fractures can occur anywhere in the body, usually at joints. the ankle is one of the most common places for it to happen. When the ankle is sprained or twisted, a force is passed through the ligaments and tendons usually on the outside of the ankle. One of two things can then happen.
Either the ligament or tendon tears, resulting in a sprained ankle, or the ligament or tendon pulls so hard on its bony attachment, that it pulls a small piece of bone off. This is known as an avulsion fracture. It is impossible to know which of these has happened following an ankle injury, without an x-ray. This is why it is always important to get an x-ray following a moderate to severe ankle injury.
Treatment: Although treatment is often the same whether there is an avulsion fracture or just a sprain, it may depend on the severity of the fracture and also its alignment. Children are also more likely to be offered alternative treatment for a fracture as otherwise this could affect their skeletal growth.
More severe avulsion fractures or fractures in children, may require casting for 6-8 weeks to allow the bone to heal. Following this, a period of rehabilitation will be required to ensure that full strength and mobility are regained.
Sprained ankle treatment
Ankle sprain treatment involves immediate first aid to reduce pain and swelling, rest to allow healing, followed by a rehabilitation program to restore full mobility, strength, and proprioception or coordination to prevent re-injury.
You should apply the PRICE principles (protection, rest, ice, compression and elevation) as soon as possible after the injury. It is important to rest the ankle to prevent further damage and weight should only be applied when the pain allows. Applying ice wrapped in a wet tea towel, or better still a cold therapy and compression wrap, as soon as possible will reduce pain, inflammation, and swelling. Cold therapy can be applied for 10 mins every hour initially, reducing the frequency as symptoms improve. Do not apply ice directly to the skin as it may burn. Elevating the ankle at the same time as icing it can also help reduce swelling.
Wearing an ankle brace or support protects the injured ligaments and provide compression. Initially, a simple elastic compression sleeve or support is ideal, whilst later in the rehabilitation process, a stronger brace with additional lateral support at the side may help protect the ligaments.
When pain allows, a full rehabilitation program of mobilising, strengthening and finally functional exercises should be performed. Read more on our step-by-step ankle sprain rehabilitation program that takes you from the initial injury through to full fitness.
What can a professional therapist do?
A professional therapist can accurately diagnose the injury and give advice on the best and most efficient ways to treat it. They can advise on what exercises to do to repair the ankle and rehabilitate it. If you choose to see a professional therapist, he/she may choose to use electrotherapy such as ultrasound to help relieve pain, relax the muscles and reduce swelling.
Sports massage (play video) can be effective in treating a sprained ankle in a number of ways. Initially, light massage around the ankle, calf and shin muscles can be used to help reduce swelling from around 3 days after injury. As pain subsides, deeper techniques can be incorporated to help loosen the calf and shin muscles and improve range of motion.
After the acute phase, cross friction massage directly to the ligament can help in preventing scar tissue formation. This type of deep massage can be commenced from around 7 days after injury, or as pain allows.
Cross friction massage should be applied with the ligament in the stretched position. Direct pressure with a single finger to the tendon is applied (but within the limits of pain) backwards and forwards across the tendon - not along its length.
Taping is another treatment that can be used to both protect the injured ankle but also improve confidence following such an injury. Tape can help support the damaged structures in the ankle and activate the surrounding muscles, both for recovery and for when you return to sport. A professional therapist can apply the tape correctly, or you can try applying the tape at home by following the methods shown in our videos.
An expert will also be able to advise on rehabilitation exercises. Because they can assess the injury and where the damage has been done, they can recommend the best and most effective exercises for you to do. These exercises also involve strengthening the ankle and looking at any weaknesses that may have contributed to the injury. Performing these can help prevent any further injury in the future.
Sports Physiotherapist Neal Reynolds (play video) talks about how to treat a sprained ankle and top tips for ankle rehabilitation.
One of our top tips is:
“People often say they have 'weak' ankles but in most cases, they have ankles that are in fact “poor proprioceptively” and not weak at all. Proprioception is by far the most effective treatment for treating and is the secret to preventing re-injuries in ankle injuries.”
Read more on rehabilitation of ankle sprains.
Exercises for a sprained ankle
Mobility, strengthening and proprioceptive exercises are important in the rehabilitation of ankle sprains (download PDF record sheet).
Mobility and stretching exercises
Mobility exercises for the ankle can start very early in the rehabilitation process from day 2 in mild to moderate sprains. As a sprain can make the joint stiff, performing mobility exercises and stretches will help increase the range of movement. Sideways movements should be avoided early on so as not to put any stress at all on the injured ligaments. Later, when pain allows, exercises with lateral movements involving sideways motion can be done.
Active plantar flexion and dorsiflexion would be a good mobility exercise to begin with as it does not involve any sideways movements. It keeps the ankle mobile and also keeps the calf and shin muscles active.
These are also important to help prevent any further injuries. They can be started as soon as the pain has lessened, although exercises that involve sideways movements should be avoided in the early stages.
Once pain allows, isometric eversion and inversion exercises help to control the "rolling" action of the ankle. This is especially helpful in preventing future injuries. A therapist or a friend can provide the resistance, or you could use a wall.
Proprioceptive and functional exercises
One of the most important parts of ankle injury rehabilitation and in preventing re-injuries is proprioception. It is essential that proprioception exercises are performed to fire up the muscles around the ankle joint to prevent injuries from reoccurring. These can range from standing on one leg (which can be increased in difficulty by closing your eyes and standing on an unstable surface) to hopping (when pain allows).
As you increase the intensity, you can perform exercises with a more sports specific focus. For example, doing lunges, step backs and jumps will help build up strength and the muscles until you are able to train fully. The intensity of the exercises should be increased slowly, it is important not to rush the process.
Read more and watch videos on ankle rehabilitation exercises.
In addition to the ligament damage in ankle sprains, there may also be associated damage to tendons, the joint capsules, the bones, the cartilages, the nerves or other soft tissues. Severely sprained ankles result in complete or almost complete ruptures of the ligaments and may be associated with dislocations and fractures of the ankle bones.