Ankle sprains: how to recover well and keep it from happening again

Rolling an ankle is one of the most common injuries there is. A national study estimated more than 3.1 million ankle sprains treated in US emergency departments over five years, and many more never reach an ER [1]. The rate peaked between ages 15 and 19, and nearly half of sprains happened during sports, with basketball the most common sport involved [1].

Most sprains heal. The problem is that many people treat them as minor and never fully rehab them. In one study of people who sought care for a first sprain, about 4 in 10 developed chronic ankle instability, with an ankle that keeps giving way, within a year [2]. People who could not complete jumping and landing tasks two weeks after the sprain, or who had poorer balance and function at six months, were more likely to end up with ongoing instability [3].

Do you need an X-ray?

Not always. Doctors use the Ottawa ankle rules to decide whether an ankle or foot X-ray is needed to rule out a fracture [4] [6]. An X-ray is recommended if there is pain in the ankle or midfoot area and any of the following:

Ankle X-ray (pain around the ankle bones)	Foot X-ray (pain in the midfoot)
Bone tenderness at the back edge or tip of the outer ankle bone	Bone tenderness at the base of the fifth metatarsal (outer edge of the foot)
Bone tenderness at the back edge or tip of the inner ankle bone	Bone tenderness at the navicular bone (inner midfoot)
Unable to take four steps both right after the injury and at the exam	Unable to take four steps both right after the injury and at the exam

Sources: Stiell et al., JAMA, 1993 [4]; Tiemstra, American Family Physician, 2012 [6].

These rules catch nearly all fractures and can cut unnecessary X-rays by 30% to 40% [5]. They are a tool for clinicians, not a self-test, and they were developed for adults [5]. If you are unsure, get checked.

What treatment works

The physical therapy guideline for ankle sprains gives its strongest recommendations to [2]:

• External support and progressive weight bearing. Use a brace or tape and gradually put weight on the ankle, rather than staying off it.
• Short immobilization only for severe sprains. In more severe injuries, a semi-rigid brace or a below-knee cast may be used for up to 10 days.
• Structured exercise, in the clinic and at home, including range of motion, stretching, neuromuscular training and balance training.
• Hands-on therapy within pain-free movement, such as soft tissue and joint mobilization, alongside exercise.

Ice and anti-inflammatory medicines get weaker recommendations, as possible additions to an exercise program [2]. An international guideline adds that anti-inflammatories can reduce pain and swelling but are not without complications and may slow natural healing, so use them with care [7]. It also says that people with a torn ankle ligament benefit most from tape or a brace combined with exercise, that supervised exercise programs are preferred over passive treatments, and that surgery should be reserved for cases that do not respond to thorough exercise-based treatment [7].

How long it takes depends on the severity: about 2 weeks for minor sprains and up to 6 to 12 weeks for more severe ones [10]. The American Academy of Orthopaedic Surgeons notes that incomplete rehabilitation is the most common cause of chronic ankle instability after a sprain [10].

Preventing the next sprain

Balance training works. In a Dutch trial of 522 athletes who had sprained an ankle, an 8-week home balance program cut repeat sprains over the next year [8]:

• Usual care only33%
• Usual care plus 8-week balance program22%

Source: Hupperets et al., BMJ, 2009 [8]. Bars are scaled to 35%.

That was a 35% lower risk of another sprain, and nine athletes needed to do the program to prevent one repeat sprain [8]. The benefit was clearest in athletes whose first sprain had not been treated by a medical professional [8].

A review of the research found strong evidence for bracing and moderate evidence for neuromuscular training to prevent repeat sprains [9]. The physical therapy guideline recommends both a brace and balance-focused exercise after a first sprain to lower the risk of the next one [2]. For people who already have chronic instability, a brace or tape on its own is not enough to restore balance; exercise is what improves it [2].

When to get urgent care

Call 911 or go to the emergency room if [11]:

• You heard a crack when you got hurt
• The ankle or foot has changed shape or points at an odd angle
• The foot is numb or tingling
• The skin looks blue or gray, or feels cold

Get seen promptly if you cannot put any weight on the foot or walk more than a few steps, if the pain or swelling is severe or getting worse, or if you have a fever [11].

The takeaway

• Ankle sprains are common, and many people never fully rehab them.
• Not every sprain needs an X-ray; clinicians use the Ottawa ankle rules to decide.
• Support, gradual weight bearing and a structured exercise program work better than keeping the ankle still.
• Balance training and bracing lower the risk of spraining the same ankle again.

You can start physical therapy in Utah without a referral. If an ankle sprain is slow to settle or keeps giving way, an evaluation can get your recovery back on track.