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Foot & ankle · treated under Sports Injury Physiotherapy

Ankle Sprain

Also called Twisted ankle, Rolled ankle, Lateral ligament injury.

A tear of the ligaments on the outer side of the ankle, almost always from rolling the foot inwards. It heals well, but it is the injury most likely to come back, and rehabilitation rather than rest is what prevents that.

Written by , BPT, MPT · MIAP License No. 69386

Updated · Awaiting clinical review

An ankle being wrapped with an elastic support bandage, close up, on a gym floor

What it is

An ankle sprain is a tear of one or more of the ligaments that hold the ankle joint together. Nearly always it is the ligaments on the outer side, because the foot rolls inwards, and the first to go is the short band at the front of the outer ankle bone, the anterior talofibular ligament, which is the weakest of the three and the one most often injured [3]. A bigger force tears the next ligament along as well. The ligament on the inner side and the ligaments that bind the two shin bones together above the joint, the so-called high ankle sprain, are torn far less often and cause more trouble when they are [3]. Sprains are graded by how much ligament has gone: a stretch with a few torn fibres, a partial tear, or a complete rupture [3].

It is one of the most common injuries there is. In a general population study, about two people in every thousand sprain an ankle each year, with a peak between the ages of 15 and 19, and half of all sprains happen in sport [2]. Indoor and court sports carry the highest rates [1]. The part that is less well known is what happens afterwards. In a systematic review of the course of the injury, between 5% and 33% of people still had pain a year later, and as many as 34% had sprained the same ankle again within three years [4]. The sprain that is treated as nothing much is the injury most likely to come back, which is why the rehabilitation matters more than the rest.

How it presents

  • A roll or twist of the foot inwards, often on a step, a kerb, uneven ground or another player's foot, sometimes with a pop or tearing feeling
  • Pain and swelling on the outer side of the ankle, in front of and below the bony bump, coming up within hours
  • Bruising that appears over a day or two and can track down into the foot and toes
  • Difficulty taking full weight and a limp, more marked the more ligament is torn
  • Stiffness, and a feeling of the ankle being weak or unreliable in the first days
  • Pain on the inner side, or high above the joint at the front, which points to a different ligament and a different plan

How much it swells is a poor guide to how much is torn: a small tear can swell impressively and a complete rupture can be surprisingly quiet at first. That is one reason the ligaments are examined more reliably a few days after the injury than on the day itself [5].

Who gets it and why

The mechanism is almost always the same: the foot is pointed down and rolls inwards under body weight, which is exactly the position in which the front outer ligament is under most strain [3]. Landing on someone else's foot, a misjudged step off a kerb or a stair, a pothole in the dark, or a sudden change of direction on a court all produce it. About half of all sprains happen in sport, and the rest in ordinary life [2]. In sport, the highest rates are in indoor and court games, badminton, basketball and volleyball among them, because of the jumping and the sudden changes of direction [1].

Some people are more likely to sprain an ankle than others. The clearest marker is having done it before: a previous sprain leaves the ankle with poorer position sense, and a history of sprain is itself a risk factor for the next one [3]. In sport, rates are higher in females than in males, and higher in children and adolescents than in adults [1]. Loose ligaments, the alignment of the leg and foot, unsupportive footwear, a poor warm-up and uneven ground all add to the risk [3].

Risk factors

  • A previous sprain of the same ankle, and the poorer balance and position sense it leaves behind [3]
  • Court and indoor sports with jumping and sudden changes of direction, which carry the highest rates [1]
  • Age: the peak is between 15 and 19, and children and adolescents sprain more often than adults [1][2]
  • Sex: in sport, females sprain an ankle at about twice the rate of males [1]
  • Loose ligaments, or the way the leg and foot line up [3]
  • Footwear without support, an inadequate warm-up and uneven playing surfaces [3]

How it is diagnosed

An ankle sprain is diagnosed from the story and the examination: how the foot went over, where it is tender, how much it has swollen and bruised, whether you can take weight, and a set of tests that gently stress each ligament to feel how much give there is. The examination is more reliable four to five days after the injury than on the day, once the swelling and guarding have settled enough for the ligament to be felt properly [5]. The assessment also checks the structures a sprain can hide: the tendons that run behind the outer ankle bone, the ligaments between the two shin bones above the joint, and the joint surface itself.

The one question that has to be answered on day one is whether anything is broken. Fewer than 15% of people who attend an emergency department with an ankle injury have a fracture [6], and a set of clinical criteria called the Ottawa ankle rules sorts out who needs an X-ray: bone tenderness at the back edge or tip of either ankle bone, tenderness at the base of the outer midfoot bone or over the top of the inner midfoot, or being unable to take weight both straight after the injury and when examined. A pooled analysis of 27 studies found the rules close to 100% sensitive, so a fracture is very unlikely when none of the criteria is met, and their use cuts unnecessary X-rays by 30% to 40% [6].

When imaging earns its place

An X-ray is for the criteria above, not for reassurance. A scan earns its place when something does not fit: pain high above the joint or on the inner side that suggests a high ankle or deltoid ligament injury, deep pain or locking that persists weeks after a proper programme, which can mean a chip off the joint surface, or an ankle that is still giving way after rehabilitation and is being considered for surgery. For a straightforward outer-ankle sprain, the guideline's answer is a delayed examination rather than a scan [5].

What the evidence says

Treatment by treatment, with the studies behind each verdict numbered to the sources at the end of the page.

  • Early weight bearing and movement, with a support

    Core treatment

    Getting the ankle moving in the first week is the best-supported principle. In a trial of 101 people with mild to moderate sprains, early therapeutic exercise produced better ankle function at one and two weeks than standard rest, ice, compression and elevation, and the exercise group walked more without any rise in re-injury [8]. An overview of 46 systematic reviews rated the evidence for early mobilisation as strong [10]. The guideline pairs it with tape or a brace, so the ligament is protected from rolling while you walk on it [5].

  • Balance and proprioceptive training

    Core treatment

    A sprain damages the ankle's position sense as well as its ligament, and retraining that is what prevents the next one. In a trial of 522 athletes, an eight-week home programme of balance exercises after usual care cut recurrent sprains over the following year from 33% to 22%, a 35% reduction in risk, with nine people needing to train to prevent one re-sprain [11]. A pooled review found exercise therapy cut the risk of recurrence by more than half after an acute sprain [12].

  • Strengthening, then hop and agility work

    Core treatment

    Balance alone is not enough for sport. The calf, the muscles that turn the foot outwards and the hip need rebuilding, and then hopping, landing and change of direction are added in stages so the ankle is tested before the sport tests it. Supervised exercise programmes are the guideline's preferred treatment because they restore functional stability rather than just comfort [5], and exercise therapy cut recurrence by more than half in people with an unstable ankle as well as after a fresh sprain [12].

  • A short cast or rigid brace for a severe sprain

    Second line

    The CAST trial randomised 584 people with severe sprains seen in emergency departments. A below-knee cast for ten days gave better ankle function at three months than a tubular compression bandage alone, a difference of 9%, and a rigid stirrup brace gave 8%; by nine months the groups were the same [7]. So a short spell in a cast or a rigid brace is reasonable for a severe sprain, and a compression bandage on its own was the least effective option throughout [7].

  • Ice, compression and elevation

    Helps alongside

    Reasonable for comfort, and weakly supported as treatment. A systematic review of 22 trials found them to be of low quality, with only marginal evidence that ice plus exercise helps after an ankle sprain, little evidence that adding ice to compression makes a difference, and no evidence on how long or how often to apply it [9]. Use ice for pain in the first days, keep the ankle up when you are sitting, and do not let any of it delay walking.

  • Anti-inflammatory tablets

    Helps alongside

    The overview of reviews rates the evidence for anti-inflammatory drugs as strong for pain, swelling and function after an acute sprain [10]. The guideline adds a caution: they carry their own risks and may blunt the natural healing response, so a short course for pain that is stopping you moving is the sensible use, not weeks of tablets [5].

  • Hands-on treatment

    Helps alongside

    Joint mobilisation restores the ankle's ability to bend upwards, which is the movement most often lost after a sprain. A systematic review found an early improvement in that range after manual mobilisation, though its importance on its own is uncertain [12], and the overview of reviews rates manual therapy as moderate evidence alongside exercise [10]. We use it to make walking and squatting possible sooner, not as the treatment.

  • A brace or tape for return to sport

    Helps alongside

    For preventing a recurrence, bracing has the strongest evidence of any measure [10], and the guideline says a brace should be considered an effective option for preventing a repeat sprain [5]. A lace-up or semi-rigid brace for the first months back is a small cost for a real reduction in risk. It does not replace the balance and strength work that makes the ankle trustworthy without it.

  • Surgery

    Second line

    For a fresh sprain, a Cochrane review of 20 trials found no reliable advantage for surgical repair over functional treatment, and some limited evidence of longer recovery, more stiffness and more complications after surgery [13]. The guideline reserves surgery for the ankle that is still unstable after a thorough exercise-based programme [5], and that is our reading too: it is the answer for a small minority, after rehabilitation has genuinely been done.

  • Prolonged rest or immobilisation

    Avoid

    Beyond a few days of protection, a rested ankle loses strength, range and position sense, and each has to be rebuilt afterwards. Even in the severe sprains of the CAST trial the cast came off at ten days, and its advantage had gone by nine months [7]. Rest is a starting position, not a treatment.

Put together, the evidence is unusually consistent for such a common injury. Protect the ankle for a few days, then walk on it and move it; use a brace or tape rather than a cast unless the sprain is severe; treat the pain with ice, elevation and a short course of tablets if needed; and then do the part most people skip, the weeks of balance and strength work that cut the chance of the next sprain by a third or more [11][12]. Surgery is for the small minority whose ankle still gives way after all of that [5][13].

How we treat it

At The Rym Space, Bagalur

  1. 1

    Assessment

    How the foot went over, what you could do afterwards, and where it is tender. The Ottawa criteria come first, with a same-day X-ray if any is met. Then each ligament, the tendons, the high ankle and the inner side are tested, so you leave knowing what is torn.

  2. 2

    A plan you start that day

    Compression and elevation for the swelling, a brace or tape so you can walk, and walking as normally as the ankle allows. Simple pain relief, ankle movements to do through the day, and a date to re-examine the ligament once the swelling has settled [5].

  3. 3

    Week 1: settle the swelling and get you walking

    3 to 5 sessions close together. Hands-on work and gentle mobilisation for swelling and stiffness, the brace or tape adjusted as the ankle changes, and a normal walking pattern rebuilt before a limp becomes a habit. The sprain is re-examined and graded properly around day four or five [5].

  4. 4

    Week 2 onwards: balance and strength

    Balance work as soon as you can stand on the leg: two feet, then one, eyes closed, then a cushion. Calf raises, band work for muscles that turn the foot outwards, hip strength. Sessions space out as the home programme carries the work, which is what reduces re-sprain risk [11].

  5. 5

    Return to sport

    Hopping, landing and change of direction added in stages, each cleared before the next. You go back when both legs hop and land alike and the ankle feels trustworthy, not on a date. A brace or tape on return, as the guideline advises [5], and the balance work continues.

  6. 6

    Discharge, or the next tier

    Done when you are back to what you came in for, with an ankle you trust and a short maintenance routine. Still giving way, locking or swelling after a proper programme means imaging and a surgical opinion, not more of the same. A small minority, and we say so early.

What to expect, and when

Ranges, not promises. Where a figure comes from a study, the study is numbered.

First 2 weeks
The worst of the pain and swelling. Pain falls fastest in the first two weeks [4], and in the accelerated-rehabilitation trial the people who exercised from the start had measurably better function at one and two weeks than those who rested [8]. The ligaments are re-examined around day four or five, when the grade can be judged properly [5].
By 3 months
This is where treatment choices show. In the CAST trial, people with severe sprains treated in a short cast or rigid brace had better function at three months than those given a bandage alone [7]. In the early-exercise trial, re-injury by sixteen weeks was 4% in both groups, in people following a structured programme [8].
By 9 to 12 months
By nine months the CAST treatment groups had converged [7]. In the SPRAINED cohorts, between 7% and 20% of people still had pain, functional difficulty or a lack of confidence in the ankle at nine months [14], and across the wider literature 5% to 33% still had pain at a year [4]. The balance programme is what shifts people out of that group: recurrences over a year fell from 33% to 22% with eight weeks of home training [11].
The next 3 years
Up to 34% re-sprain within three years, and 36% to 85% report full recovery in that time, depending on the study [4]. A brace for sport and a balance routine you keep are what tilt those odds [10].

The wide ranges are honest. The studies mix mild and severe sprains, athletes and non-athletes, and people who did and did not rehabilitate. What they agree on is that pain settles quickly and stability comes back slowly, and that the second half is the part that decides whether you are back here next season.

When to be seen sooner

Signs that this is something else, or that it needs looking at now rather than after a few weeks of self-care.

  • Any of the Ottawa criteria: bone tenderness at the back edge or tip of either ankle bone, at the base of the outer midfoot bone or over the inner midfoot, or being unable to take weight straight after the injury and again when examined. That needs an X-ray the same day [6]
  • Pain high above the ankle at the front, or pain when the two shin bones are squeezed together, which suggests a high ankle injury with a longer recovery [3]
  • Pain on the inner side of the ankle rather than the outer, which points to the deltoid ligament and is managed differently [3]
  • A snapping or popping feeling behind the outer ankle bone, or tendons that flick forward over the bone, which suggests a peroneal tendon injury
  • Deep pain, catching or locking that persists weeks after the sprain has otherwise settled, which can be a chip off the joint surface and needs a scan
  • Calf pain, warmth or swelling in the days after a cast or a spell off your feet, until a clot is ruled out; rare, but it happened in the CAST trial [7]
  • An ankle that still gives way, or keeps re-spraining, after a proper rehabilitation programme, which is chronic ankle instability and changes the plan [5]

Common questions

Do I need an X-ray?
Only if one of the Ottawa criteria applies: bone tenderness at the back edge or tip of either ankle bone or at two specific spots on the midfoot, or being unable to take weight both immediately and when examined. If none applies, a fracture is very unlikely; the rules are close to 100% sensitive [6]. We check them at the first visit and send you the same day if needed.
Should I rest it until the swelling goes?
No. Protect it for a few days, then walk on it with a brace or tape. Early movement produced better function at one and two weeks than rest, ice, compression and elevation in a randomised trial, with no increase in re-injury [8]. The swelling is managed with compression and elevation between walks, not instead of them.
Ice or heat?
Ice for comfort in the first few days, if you find it helps. The evidence that it speeds healing is weak [9]. Heat has no role in the first days while the ankle is still swelling. Neither is the treatment; walking, balance and strength are.
How long before I can play again?
When you can hop and land on the injured leg like the other one and change direction without the ankle feeling apprehensive, not on a date. For a mild sprain that comes soon; a severe one takes considerably longer, and the severe sprains in the CAST trial were still improving at three months [7]. Go back with a brace or tape, which the guideline recommends for preventing a repeat [5], and keep the balance exercises going.
Why does it keep happening?
Because the first sprain damaged the ankle's position sense as well as the ligament, and waiting does not retrain it. In a systematic review, as many as 34% of people had re-sprained within three years [4]. An eight-week home balance programme cut recurrence from 33% to 22% in athletes [11], and a brace for sport has the strongest evidence of any preventive measure [10].
Will I need surgery?
Very unlikely. For a fresh sprain, surgery showed no reliable advantage over functional treatment in a Cochrane review, with some evidence of more stiffness and complications [13]. It is reserved for the ankle that still gives way after a thorough exercise programme [5].

Further reading

Sources

Guidelines, systematic reviews and trials only. Each number in the text links to the entry here.

  1. 1.Doherty C, Delahunt E, Caulfield B, Hertel J, Ryan J, Bleakley C. The incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis of prospective epidemiological studies. Sports Med. 2014;44(1):123-140. pubmed.ncbi.nlm.nih.gov ↗
  2. 2.Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ Jr. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010;92(13):2279-2284. pubmed.ncbi.nlm.nih.gov ↗
  3. 3.Bergman R, Li D, Shuman VL. Acute Ankle Sprain. In: StatPearls. Treasure Island (FL): StatPearls Publishing; updated 2 August 2025. ncbi.nlm.nih.gov ↗
  4. 4.van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, Bierma-Zeinstra SM. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med. 2008;121(4):324-331.e6. pubmed.ncbi.nlm.nih.gov ↗
  5. 5.Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med. 2018;52(15):956. pubmed.ncbi.nlm.nih.gov ↗
  6. 6.Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003;326(7386):417. pubmed.ncbi.nlm.nih.gov ↗
  7. 7.Lamb SE, Marsh JL, Hutton JL, Nakash R, Cooke MW; Collaborative Ankle Support Trial (CAST Group). Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial. Lancet. 2009;373(9663):575-581. pubmed.ncbi.nlm.nih.gov ↗
  8. 8.Bleakley CM, O'Connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ. 2010;340:c1964. pubmed.ncbi.nlm.nih.gov ↗
  9. 9.Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sports Med. 2004;32(1):251-261. pubmed.ncbi.nlm.nih.gov ↗
  10. 10.Doherty C, Bleakley C, Delahunt E, Holden S. Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis. Br J Sports Med. 2017;51(2):113-125. pubmed.ncbi.nlm.nih.gov ↗
  11. 11.Hupperets MD, Verhagen EA, van Mechelen W. Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. BMJ. 2009;339:b2684. pubmed.ncbi.nlm.nih.gov ↗
  12. 12.van der Wees PJ, Lenssen AF, Hendriks EJ, Stomp DJ, Dekker J, de Bie RA. Effectiveness of exercise therapy and manual mobilisation in ankle sprain and functional instability: a systematic review. Aust J Physiother. 2006;52(1):27-37. pubmed.ncbi.nlm.nih.gov ↗
  13. 13.Kerkhoffs GM, Handoll HH, de Bie R, Rowe BH, Struijs PA. Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. Cochrane Database Syst Rev. 2007;(2):CD000380. pubmed.ncbi.nlm.nih.gov ↗
  14. 14.Schlussel MM, Keene DJ, Collins GS, et al. Development and prospective external validation of a tool to predict poor recovery at 9 months after acute ankle sprain in UK emergency departments: the SPRAINED prognostic model. BMJ Open. 2018;8(11):e022802. pubmed.ncbi.nlm.nih.gov ↗

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