Ankle Sprain

	Overview
	Health Tools
	FAQs
	Cause
	Symptoms
	When to Call a Doctor
	Exams and Tests
	Treatment Overview
	Home Treatment
	Other Places To Get Help
	References
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What is an ankle sprain?

Most people have twisted an ankle at some point in their life. But if your ankle gets swollen and painful after you twist it, you have most likely sprained it. This means you have stretched and possibly torn the ligaments in your ankle. See a picture of an ankle sprain.

Even though ankle sprains are common, they are not always minor injuries. Some people with repeated or severe sprains can develop long-term joint pain and weakness. Treating a sprained ankle can help prevent ongoing ankle problems.

What causes ankle sprains?

Most ankle sprains happen when you make a rapid shifting movement with your foot planted; such as when you play soccer or get tackled in football. Often the ankle rolls outward and the foot turns inward. This causes the ligaments on the outside of the ankle to stretch and tear. Less often, the ankle rolls inward and the foot turns outward. This damages the ligaments on the inside of the ankle. See a picture of the different types of ankle sprains.

An ankle sprain can range from mild to severe, depending on how badly the ligament is damaged and how many ligaments are injured. With a mild sprain, the ankle may be tender, swollen, and stiff. But it usually feels stable, and you can walk with little pain. A more serious sprain might include bruising and tenderness around the ankle, and walking is painful. In a severe ankle sprain, the ankle is unstable and may feel "wobbly." You can't walk, because the ankle gives out and may be very painful. See a picture of an ankle sprain.

What are the symptoms?

With most sprains, you feel pain right away at the site of the tear. Often the ankle starts to swell immediately and may bruise. The ankle area is usually tender to touch, and it hurts to move it.

In more severe sprains, you may hear and/or feel something tear, along with a pop or snap. You will probably have extreme pain at first and will not be able to walk or even put weight on your foot. Usually, the more pain and swelling you have, the more severe your ankle sprain is and the longer it will take to heal.

How is an ankle sprain diagnosed?

Your doctor will ask you how the injury occurred and if you have hurt your ankle before. He or she will check your foot and ankle, your lower leg, and even your knee to see if you are hurt anywhere else.

If the sprain is mild, your doctor may not order X-rays. But with more severe sprains, you may need X-rays to rule out a broken bone in the ankle or the foot. It is possible to break a bone in your foot or ankle at the same time as a sprain.

In most cases, doctors order X-rays in children with symptoms of an ankle sprain. This is because it is important to find and treat any damage to the growth plates in bones that support the ankle.

How is it treated?

In many cases you can first use the PRINCE approach to treat your ankle:

• Protection. Use a protective brace, such a brace with a built-in air cushion or another form of ankle support.
• Rest. Use crutches until you can walk without pain.
• Ice. For at least the first 24 to 72 hours or until the swelling goes down, apply an ice pack for 10 to 20 minutes every hour or two during the day.
• NSAIDs or acetaminophen. NSAIDs (such as Advil and Motrin) are medicines that reduce swelling and pain. Acetaminophen (such as Tylenol) reduces pain.
• Compression. An elastic compression wrap, such as an ACE bandage, will help reduce swelling. You wear it for the first 24 to 36 hours. Compression wraps do not offer protection. So you also need a brace to protect your ankle if you try to put weight on it.
• Elevation. Raise your ankle above the level of your heart for 2 to 3 hours a day if possible. This helps to reduce swelling and bruising.

Proper treatment and rehabilitation exercises are very important for ankle sprains. If an ankle sprain does not heal right, the joint may become unstable and may develop chronic pain. This can make your ankle weak and more likely to be reinjured. Before you return to sports and other activities that put stress on your ankle, it's a good idea to wait until you can hop on your ankle with no pain. Taping your ankle or wearing a brace during exercise can help protect your ankle. Wearing hiking boots or other high-top, lace-up shoes for support may also help. But use caution. Don't force your foot into a boot if you feel a lot of pain or discomfort.

If your ankle is still unstable after rehab, or if the ligament damage is severe, your doctor may recommend surgery to repair the torn ligaments.

What kind of rehabilitation program should you follow?

Rehab exercises can begin soon after the injury. You can try to walk or put weight on your foot while using crutches if it doesn't hurt too much. Depending on your pain, you can also begin range-of-motion exercises while you have ice on your ankle. These exercises are easy to do—you just trace the alphabet with your toe. This helps the ankle move in all directions.

Ask your doctor about other rehab. Stretching, strength training, and balance exercises may help the ankle heal totally and may prevent further injury.

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	Sprained ankle: Rehabilitation exercises
	Sprained ankle: Using a compression wrap

Ankle sprains occur when ligaments that connect the bones in the foot, ankle, and lower leg stretch or tear.

An inversion injury, the most common cause of ankle sprains, occurs when the ankle rolls outward and the foot turns inward. It results in stretching and tearing of the ligaments on the outside of the ankle.

In an eversion injury, the ankle rolls inward and the foot turns outward, damaging the ligaments at the inside of the ankle.

In a "high" ankle sprain, a less common type of injury, ligaments that join the two lower leg bones together above the ankle, called the syndesmosis, are injured. This usually happens if the foot is forced up, or if the leg is forcefully twisted while the foot is planted. This injury can occur either by itself or with an inversion or eversion sprain. If the ligaments of the syndesmosis are injured, the sprain is more severe and takes longer to heal.

See an illustration of types of ankle sprains.

Damage to the ligament varies from simply stretched or slightly torn to completely torn. Your doctor will grade your sprain accordingly.

• Grade I is stretching or slight tearing of the ligament with mild tenderness, swelling, and stiffness. The ankle feels stable, and it is usually possible to walk with minimal pain.
• Grade II is a larger but incomplete tear with moderate pain, swelling, and bruising. Although the ankle sometimes feels stable, the damaged areas are tender to the touch, and walking is painful.
• Grade III is a complete tear of the affected ligament or ligaments with severe swelling and bruising. The ankle is unstable and may feel "wobbly." Walking is usually not possible because the ankle gives out and there is intense pain, although initial pain may quickly subside. See an illustration of an ankle sprain.

People usually feel immediate pain at the site of an ankle sprain. Often the ankle starts to swell immediately and may develop bruising. The affected area is usually tender to touch and may feel "wobbly" or unstable.

In a mild sprain, swelling usually goes down within a few days.

The severity of your symptoms usually depends on how much tearing has occurred. In more severe sprains, you are often not able to walk or even put weight on your foot, and your ankle may feel unstable. You usually have extreme pain at first, but some people start to feel better fairly soon. You may also hear and/or feel a tearing sensation and a pop or a snap.

If a sprain does not heal correctly, your ankle joint may be more likely to be injured again or the pain may not go away. This often occurs with even a slight trauma, such as stepping off a curb or walking on uneven pavement. Some people complain of persistent pain and swelling.

See your doctor immediately if you notice any of the following:

• Your foot or leg bends at an abnormal angle.
• You feel severe pain.
• Your foot is cool or pale or changes color.
• You feel numbness or tingling in your foot or toes that lasts after the initial injury.
• You can't move your ankle.

You should see your doctor after an ankle sprain if you notice any of the following:

• You heard a popping sound at the time you sprained your ankle.
• You have moderate pain or severe swelling or bruising around your ankle.
• You can't walk or put weight on your affected foot, or your ankle feels unstable.
• You have redness, swelling, or pain in your leg or groin. These can be signs of a blood clot.
• You have no improvement in your ankle after 1 week.
• Your swelling and bruising last more than 2 weeks.

Also be sure to contact your doctor if you have a cast or splint around your ankle that feels too tight. If the cast hurts, pinches, or feels like it is digging into your skin, it may be too tight. If your foot feels numb or your skin feels cool, call your doctor immediately.

If your pain is mild and you are able to put some weight on your foot, you may follow the recommendations in the Treatment Overview and Home Treatment sections of this topic. Initial treatment and rehabilitation exercises ensure that your ankle heals properly. If treatment recommendations are not followed, your ankle may remain weak and unstable.

Who to see

For evaluation, diagnosis, or treatment of an ankle sprain, you may see:

• An emergency medicine doctor.
• A primary care professional (family medicine doctor, nurse practitioner, physician assistant, general practitioner, or internist).
• An orthopedist.
• A sports medicine doctor.

For further treatment, you may be referred to:

• A physical therapist (for stretching and strengthening exercises and to help you return to your usual activities).
• An orthopedist.

Your doctor will ask you when and how the ankle sprain occurred and ask about any prior injuries.

Next, your doctor will examine your foot, ankle, and lower leg and even your knee to see if additional injury occurred. He or she may ask you to move your foot up and down and to take a few steps if possible. Your doctor will then carefully try moving your foot and ankle to see if the ligaments are intact and what movements cause pain.

If your sprain is mild, an X-ray may not be taken. If your sprain is more severe, you will need X-rays to evaluate the ankle. X-rays can help your doctor find out whether you have any ligament tears, broken bones, or bones that have moved out of their normal positions.

X-rays are usually taken for children because of potential injury to the bone's growth plate and possible disruption of normal growth. Doctors may take X-rays of both ankles so they can compare the injured ankle with the one that is healthy.

Initial treatment for an ankle sprain is summarized as the PRINCE approach:

• Protection. Use a protective brace, such as a brace with a built-in air cushion or other form of ankle support, along with a compression wrap, such as an elastic ACE bandage, for the first 24 to 36 hours.
• Rest. Use crutches until walking is not painful without them.
• Ice. For the first 48 to 72 hours or until swelling goes down, apply an ice pack for 10 to 20 minutes every 1 to 2 hours during the day. After 48 hours, you can continue with ice or try contrast baths. There is not good scientific evidence that ice or contrast baths help, but they are often used.
• NSAIDs or acetaminophen. Examples of nonsteroidal anti-inflammatory drugs (NSAIDS) include ibuprofen (such as Advil or Motrin) and naproxen (such as Naprosyn). Common types of acetaminophen include Panadol or Tylenol.
• Compression. An elastic compression wrap will help decrease swelling and should be worn for the first 24 to 36 hours. A protective brace should also be worn if you try to bear weight on your injured ankle. Don't apply the wrap too tightly. Loosen the bandage if it gets too tight. Signs that the bandage is too tight include numbness, tingling, increased pain, coolness, or swelling in the area below the bandage. See instructions on how to wrap an ankle with an elastic bandage. Compression wraps do not offer protection, except by reminding you to be careful of your ankle.
• Elevation. Raise your ankle above the level of your heart for 2 to 3 hours a day if possible to decrease swelling and bruising.

Also, it can help to wear hiking boots or other high-top, lace-up shoes for support.¹ But use caution. Don't force your foot into a boot if you feel a lot of pain or discomfort.

Your doctor may suggest that you keep some or all of your weight off your ankle as it heals. If this happens, learn to use your crutches or walker properly and safely.

• Using crutches
• Using a walker

Almost all ankle sprains heal on their own with proper treatment and rehabilitation exercises. For more information, see the Home Treatment section of this topic.

Surgery to repair torn ligaments is usually only considered when there is a severe ligament tear (or tears) or if the ankle remains unstable after rehabilitation. Surgery is also a consideration if you have broken a bone.

For more information on the correct way to wrap a sprained ankle, see:

Sprained ankle: Using a compression wrap.

Ankle sprains take an average of 6 weeks to heal but can take can up to 4 months, depending on the severity. An ankle brace, air stirrup, hiking boots, or other form of ankle support should be worn during this time to protect the ligaments. After the ankle is healed, wearing an ankle brace or taping the ankle may help prevent reinjury.

For more painful and severe sprains, you may not be able to walk, although you might be able to bear some weight while using crutches and a protective brace, such as a brace with a built-in air cushion or other form of ankle support. If pain is severe, use crutches until your doctor tells you that you can begin to bear weight. In general, if your pain is bearable, you should try to walk or bear some weight while using crutches and a protective brace, because these activities promote healing.

Some people with repeated or severe sprains can develop long-term joint pain and weakness. Treating a sprained ankle can help prevent ongoing ankle problems. Rehabilitation exercises for an ankle sprain can be done at home to promote proper healing and prevent chronic pain and instability. When rehabilitation exercises are not followed after a sprain, the ankle can become weak and unstable.

In the case of a minor sprain, rehabilitation exercises begin soon after the injury with walking. Wear hiking boots or other high-top, lace-up shoes for support.¹ But use caution. Don't force your foot into a boot if you feel a lot of pain or discomfort.

Stretching exercises should be continued on a daily basis and especially before and after physical activities to prevent reinjury. Even after your ankle feels better, continue with muscle-strengthening exercises and balance and control exercises several times a week to keep your ankles strong.

The timing and type of rehabilitation exercises may vary according to your doctor's or physical therapist's preferences. Following are some examples of typical rehabilitation exercises.

Range-of-motion exercises

Begin range-of-motion exercises right after your injury while you have ice on your ankle. Perform a set of exercises by repeating them 10 to 30 times. Do each set 3 to 5 times a day.

Try the following simple range-of-motion exercises:

• Trace the alphabet with your toe, encouraging ankle movement in all directions.
• Sit in a chair with your foot flat on the floor. Slowly move your knee side to side while keeping your foot pressed flat.

Towel curls. While sitting, place a hand towel on a smooth floor, such as wood or tile. While keeping your heel on the ground, curl your toes and grab the towel with your toes to scrunch the towel. Let go, and continue scrunching up the entire length of the towel. When you reach the end of the towel, reverse the action by grabbing the towel with your toes, scrunching it, and pushing it away from you. Repeat, until you have pushed the entire length of the towel away from you.

Stretching exercises

Start exercises to stretch your Achilles tendon as soon as you can do so without pain. The Achilles tendon connects the calf muscles on the back of the lower leg to the bone at the base of the heel.

Towel stretch. If you cannot stand, sit with your knee straight and a towel looped around the ball of your foot. Gently and slowly pull back on the towel for about 15 seconds until you feel your calf stretch. In moderate to severe ankle sprains, it may be to painful at first to pull your toes far enough to feel a stretch in your calf. Use caution and let pain be your guide. A little pain is normal, but you should not feel moderate to severe pain. Do 15 to 20 repetitions of this exercise, 3 to 6 times a day, for about a week. Then, make Achilles stretches part of your daily routine to maintain flexibility.

Calf stretch. If you are able to stand, you can do this exercise by facing a wall with your hands at shoulder level on the wall. Place your injured foot a little behind the other foot, with the toes pointing forward. Keep your heels down and your back leg straight. Slowly bend your front knee until you feel the calf stretch in the back leg. Hold this position for at least 20 seconds, and repeat. Try to do this stretch 3 to 6 times a day.

Strengthening exercises

Talk to your doctor or physical therapist about the timing of strengthening exercises for the ankle. Generally, you can start these exercises once you are able to stand without increased pain or swelling as long as you do not feel pain while you do them.

These exercises should be held for 3 to 5 seconds. Do 15 to 20 repetitions one or two times a day for 2 to 4 weeks, depending on the severity of your injury.

Start by sitting with your foot flat on the floor and pushing it outward against an immovable object, such as a wall or heavy furniture. After you feel comfortable with this, try using rubber tubing looped around the outside of your feet for resistance.

While still sitting, put your feet together flat on the floor. Press your injured foot inward against your other foot.

Next, place the heel of your other foot on top of the injured foot. Push down with the top heel while trying to push up with your injured foot.

Balance and control exercises

You can usually start balance and control exercises when you are able to stand without pain. But talk to your doctor or physical therapist about the exact timing. You should not feel pain while doing these exercises. Also, don't try these exercises if you could not have done them easily before your injury. If you think you would have felt unsteady doing these exercises when your ankle was healthy, you are at risk of falling when you try them with an injured ankle.

One of the easiest ways to increase your balance and control is to stand on just your injured foot while holding your arms out to your sides with your eyes open. When you can do this for 60 seconds, try adding the advanced moves in the next level.

Stand on your injured foot only and:

• Hold your arms across your chest with your eyes open.
• Hold your arms out to the sides and close your eyes.
• Hold your arms across your chest and close your eyes.

Do these exercises 6 times for 60 seconds one time a day.

For more information on exercising to strengthen your ankle and prevent reinjury, see:

Sprained ankle: Rehabilitation exercises.

Organizations

References

Citations

1. Fongemie A, et al. (2006). Health Care Guideline: Ankle Sprain, 7th ed., pp. 1–25. Bloomington, MN: Institute for Clinical Systems Improvement.

Other Works Consulted

• Hertling D, Kessler RM (2006). Ankle sprain section of Lower leg, ankle, and foot. In Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods, 4th ed., pp. 601–604. Philadelphia: Lippincott Williams and Wilkins.

• Mann JA, et al. (2006). Ligamentous injuries about the ankle joint section of Foot and ankle surgery. In HB Skinner, ed., Current Diagnosis and Treatment in Orthopedics, 4th ed., pp. 521–524. New York: McGraw-Hill.

• Struijs P, Kerkhoffs G (2006). Ankle sprain, search date March 2005. Online version of Clinical Evidence (15).