An ankle sprain is a stretch or tear of the ligaments that support the ankle, most often when the foot rolls inwards [1]. Almost all sprains heal without surgery: protection and cold in the first days, then early movement, tape or a brace, and balance and strength exercises [1][3][4]. Most people feel clearly better in about two weeks; getting back to demanding activity such as running can take up to eight weeks, and severe sprains can take months [2].
What happens in a sprain?
The strong ligaments that hold the ankle together are stretched past their normal limit and partly or completely torn. In most sprains the foot rolls inwards and the ligaments on the outer side of the ankle are hurt; the inner ligaments are affected less often [1].
Sprains are graded in three degrees. In grade 1 the ligament is only stretched and symptoms are mild. Grade 2 is a partial tear with moderate swelling and some looseness. In grade 3 the ligament is torn through, pain is marked and the ankle feels unstable [1].
Symptoms
How strong the symptoms are depends on the damage to the ligaments. Common ones are [1][2]:
- Pain that increases when standing or moving
- Swelling and bruising on the outer side of the ankle
- Tenderness when touched
- Difficulty putting weight on the foot
- A feeling that the ankle may give way
Causes and who is at risk of another sprain
A sprain usually happens when the foot twists on uneven ground, in a fall, or in sports with jumping and sudden changes of direction [1]. Taking part in some sports raises the risk [3].
Poor balance, naturally loose ligaments, unsuitable footwear and an earlier sprain are the main risk factors for a new sprain [1].
Is an X-ray needed for every sprain?
The diagnosis is usually made by examination: swelling, tender spots, movement and stability of the ligaments are checked [1].
Not every sprain needs an X-ray. The Ottawa ankle rules look at tenderness over certain bony points and whether you can take a few steps; they rule out a fracture reliably and cut down unnecessary X-rays [5]. If a fracture is suspected an X-ray is taken, and stress views or an MRI scan may be used when ligament or cartilage damage is suspected [1].
The degree of ligament injury is judged more accurately at an examination four to five days after the injury, once pain and swelling have settled [3].
The first days
For the first two to three days protection, rest, ice, compression with an elastic bandage and elevation are recommended. Ice is wrapped in a cloth, used for short periods every few hours; heat, alcohol and massage are best avoided at this stage [2].
Anti-inflammatory painkillers can ease pain and swelling, but they may have side effects and could affect healing, so they should be used on medical advice [3][4].
Cast, brace or exercise?
A short period of immobilisation can ease pain and swelling. The evidence, however, favours early movement with tape or a brace together with an exercise programme over a long time in a cast [3][4].
Rehabilitation usually has three phases: controlling pain and swelling with protected weight-bearing; then range of movement, strength and balance work; and finally advanced strengthening, balance (proprioception) training and a gradual return to sport [1]. Supervised exercise programmes are preferred over passive treatments [3].
When is surgery considered?
Almost all ankle sprains heal without an operation [1]. Surgery is considered for people whose symptoms continue and whose ankle keeps giving way despite a thorough, well-followed exercise programme [3]. Problems inside the joint can then be treated by arthroscopy, or the damaged ligaments can be repaired or reconstructed [1].
Recovery time and preventing another sprain
Most people feel clearly better within about two weeks. Return to demanding activities such as running can take up to eight weeks, and severe sprains may take months [2].
Stopping rehabilitation too early is the main reason an ankle stays chronically unstable [1]. A brace and balance and coordination exercises help prevent another sprain [3][4], and exercise-based rehabilitation lowers the risk of re-injury [4]. For people who have sprained an ankle before, there is strong evidence that wearing a brace during sport helps prevent another one [4].
Warming up well before exercise, strengthening the muscles around the ankle, wearing supportive shoes and taking care on uneven ground are also advised [1].
When not to wait: go to the emergency department
These can point to a fracture, a dislocation or a problem with blood supply or nerves, so go without delay if [2]:
- You heard a crack or snap at the time of injury
- The ankle looks deformed or out of shape
- The foot is numb, tingling, cold, or blue or grey in colour
- You cannot put any weight on the foot
- Pain and swelling keep getting worse or do not improve with home care
Frequently asked questions
- How long does a sprained ankle take to heal?
- With mild and moderate sprains most people feel better in about two weeks. Return to demanding sports such as running can take up to eight weeks, and severe ligament tears may take months [2].
- Do I always need an X-ray?
- No. The Ottawa ankle rules check tenderness over specific bony points and the ability to walk and reliably rule out a fracture; if a rule is positive, an X-ray is taken [5].
- Will I need a cast?
- Usually not. Brief protection can ease pain, but early movement with tape or a brace plus an exercise programme gives better results than a long spell in a cast [3][4].
At our clinic we first examine the ankle after a sprain and decide with you whether an X-ray is needed.
Sources
- Sprained Ankle. American Academy of Orthopaedic Surgeons (OrthoInfo). orthoinfo.org
- Sprains and strains. NHS (nhs.uk), 2024. nhs.uk
- Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. British Journal of Sports Medicine (Vuurberg G, et al.), 2018. pubmed.ncbi.nlm.nih.gov
- Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis. British Journal of Sports Medicine (Doherty C, et al.), 2016. pubmed.ncbi.nlm.nih.gov
- Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ (Bachmann LM, et al.), 2003. pubmed.ncbi.nlm.nih.gov
This article is general information and does not replace an examination or imaging. If you have symptoms, see a doctor.
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