Sprained ankle: what to do now, exercises, and stopping the next one

Do I need an X-ray? The Ottawa ankle rulesStrong evidence

After a twisted ankle, clinicians use the Ottawa ankle rules to decide who needs an X-ray. An ankle X-ray is needed if the back edge or tip of either ankle bone is tender to press, or you couldn't take four steps straight after the injury or when you are examined. A foot X-ray is needed if the navicular (the bony bump on the inner midfoot) or the base of the fifth metatarsal (the bump halfway along the outer edge of the foot) is tender, or the same four-step test fails.

The rules are very good at ruling fractures out. In the study that refined them, they picked up every fracture and could cut ankle X-rays by about a third; a review of 27 studies (15,581 people) found they missed almost no ankle or midfoot fractures, in children too, and could cut X-rays by 30 to 40%.

They are a guide for clinicians, not a self-test. If you can't walk four steps, if pressing on one of those bony points hurts, if the foot looks out of shape, or if you're unsure, get it checked the same day. Ligament damage is best judged 4 to 5 days after the injury, once the swelling has gone down.

Sources 11, 12, 8, 1

Grades, in plain words

You may see sprains graded 1 to 3. In plain words, the ligaments are stretched, partly torn or fully torn. The clinical guideline grades severity on examination, and says ligament damage is best judged 4 to 5 days after the injury, once swelling has gone down. Healing times vary too much to give a fixed time for each grade, so this page gives ranges instead.

Most sprains are on the outside of the ankle. High ankle and inner ankle sprains are less common.

Sources 6, 8, 13

How long a sprained ankle takesStrong evidence

The NHS says most sprains feel better after 2 weeks, that you should avoid strenuous exercise such as running for up to 8 weeks, and that severe sprains can take months. NHS hospital leaflets say most improve within 6 to 12 weeks, but swelling and pain can continue for 3 to 6 months, often worse at the end of the day.

In a review of 31 studies, pain fell fast in the first 2 weeks, but 5% to 33% still had pain at a year, and 36% to 85% reported full recovery within 3 years. A Dutch guideline suggests returning to desk work at about 2 to 6 weeks and to physical work and sport at 6 to 8 weeks. Recovery is slower with older age, a higher BMI, more pain, being unable to take weight on it, and previous sprains.

Sources 1, 5, 6, 14, 8, 9

High ankle sprainEmerging evidence

Pain above the ankle, between the shin bones, usually after the foot is forced outwards, is a high ankle (syndesmosis) sprain. It is often more than a simple sprain: in 83 such injuries in American football players, only 13% were isolated. Return to full play took a median of 27 days without a fracture or a major tear of the inner ligament, 175 days with a complete tear of the deep inner ligament or a widened joint, and 250 days with a fracture.

Those were elite players assessed by MRI, but the message holds: get a suspected high ankle sprain assessed.

Sources 27, 8

Protect, then load: a brace and early walking beat a castStrong evidence

The clinical guideline's top grade goes to a brace or tape with gradually more weight through the foot. For more severe sprains, a semi-rigid brace or a below-knee cast for up to 10 days may help. In the CAST trial of 584 people with severe sprains, a 10-day below-knee cast gave faster recovery than a tubular compression bandage (ankle function 9% better at 3 months), a semi-rigid brace 8% better and a walking boot no better; by 9 months there were no differences. Four weeks in a cast delayed the return to work and sport compared with functional treatment.

NHS hospital leaflets: walk as comfort allows; a boot or crutches may be given for comfort but haven't been proven to help healing; wean off a support after 2 to 3 weeks.

Sources 8, 9, 17, 5, 6

Start gentle exercise in the first weekEmerging evidence

In 101 people with mild to moderate sprains (grade 1 or 2), an accelerated programme with exercise in week 1 gave better function at weeks 1 and 2, and more walking, than standard rest, ice, compression and elevation, with no extra re-injury (4% in each group). The guideline recommends structured exercise for range, stretching, strength and balance, in clinic and at home, and an overview of reviews found strong evidence for early mobilisation and moderate evidence for exercise.

Sources 16, 8, 10

Rest, ice, compression and elevation: standard first aid, thin evidenceMixed evidence

For the first 2 to 3 days, the NHS advises protection, rest, ice (up to 20 minutes every 2 to 3 hours), compression and elevation, and avoiding heat, alcohol and massage; then keep the ankle moving once pain doesn't stop you. A review of 11 trials (868 people) found too little evidence to judge rest, ice, compression and elevation, and the guideline says repeated ice may be used alongside exercise.

Sources 1, 15, 8

Painkillers: short-term relief, with a cautionMixed evidence

Anti-inflammatories reduce pain and swelling in the short term, but the Dutch guideline urges care because of side effects and possibly slower healing. The NHS suggests paracetamol and ibuprofen gel first, then tablets if needed. Ask a pharmacist.

Sources 10, 9, 1

Balance training and a brace cut repeat sprainsStrong evidence

Exercise-based rehab lowered re-injury over the following year in two meta-analyses (odds ratios 0.53 and 0.60), with no link between how much training people did and the benefit. In the 2BFit trial of 522 athletes, an unsupervised 8-week home balance programme cut repeat sprains from 33% to 22%: one fewer sprain for every 9 people who trained, even though only 23% completed it fully. Sessions were three a week of up to 30 minutes, ideally as a warm-up, starting once usual care had ended and sport had resumed, and progressed from standing on a flat surface, to eyes shut, to a balance board.

A brace for sport cuts repeats too: in one trial 15% re-sprained with a brace against 27% with home training alone, and lace-up braces cut ankle injuries in 1,460 school basketball players. The guideline recommends both a brace and balance training after a first sprain.

Sources 18, 19, 20, 21, 24, 25, 8

Balance training to prevent a first-ever sprain is unprovenMixed evidence

Balance training reduced sprains in sporting groups overall and in people who had sprained before, but the evidence for preventing a first sprain is inconclusive. In volleyball, a balance board programme reduced sprains only in players with a previous sprain.

Sources 23, 22, 8

Back to sport: more than timeEmerging evidence

An international consensus of 155 professionals bases the return to sport on five checks (PAASS): Pain during sport and over the next 24 hours; Ankle range, strength, endurance and power; the Athlete's confidence and feeling of stability; Sensorimotor control, meaning balance; and Sport performance: hopping, jumping, agility, sport drills and finishing a full session. In one cohort, not being able to complete jump-landing tasks 2 weeks after a first sprain predicted later chronic instability.

If recovery stalls, a physiotherapist can check how the injury happened, the bones and ligaments, and the movement and balance problems linked to an ankle that keeps giving way.

Sources 26, 28, 29

What not to rely onStrong evidence

The guideline advises against therapeutic ultrasound. An overview of reviews found too little evidence for ultrasound and conflicting evidence for acupuncture and surgery, and the Dutch guideline keeps surgery for sprains that don't respond to thorough exercise-based treatment.

Sources 8, 10, 9