Pilates for the ankles: stiff, weak and wobbly ankles, balance and strength, after a sprain, footwork, the evidence, and a routine

Ankles means three different things

Stiff ankles bend up less than you'd like; weak ankles have weaker muscles that point, lift and turn the foot; wobbly ankles keep giving way after a sprain. Each needs something different.

Sources 1, 2, 3

Pilates itself has barely been tested

The one study in unstable ankles let 51 footballers choose Pilates or balance training, with no untrained group, about a month after a sprain. No Pilates trial has counted sprains, and a registered trial has no results yet.

Sources 4, 5, 6

For wobbly ankles, balance training is what works

An 8-week home balance programme, 3 times a week, cut repeat sprains from 33% to 22%: one fewer for every 9 people who trained. A brace or tape for sport works at least as well.

Sources 7, 8, 9

For weak ankles, strength in all four directions, plus balance

Strength plus balance work did best for ankles that already feel unstable; strength work alone didn't improve balance by a detectable amount.

Sources 10, 11, 12

For stiff ankles, stretch and raise

Calf stretching adds a few degrees of ankle bend, and full-range calf raises do about as well and add strength. Ankle range hasn't been shown to predict sprains.

Sources 1, 13, 14

Pilates adds the parts around the ankle

One-leg standing work, footwork shapes on a wall, side-lying hip work and trunk control. Reformer footwork's load on the ankle has never been measured, and mat Pilates on its own did less for balance than balance training.

Sources 15, 16, 17

Two joints, four directions

The ankle joint itself, between the shin bones and the talus, bends the foot up (dorsiflexion) and points it down (plantarflexion). The joint below it, the subtalar joint, tips the sole in (inversion) and out (eversion). The calves point the foot and lift you onto your toes; the muscle at the front of the shin lifts the foot; the peroneals on the outside of the shin turn the sole out and react fast when the ankle starts to roll; and the tibialis posterior on the inside turns it in and holds up the arch. Our ankle and foot joint guide has the anatomy.

Stiff ankles

Stiff usually means less upward bend than you'd like: your knee won't travel far over your toes with the heel down. The calf is part of it, mostly how much stretch you tolerate. After a sprain, the joint itself can glide less: "Dorsiflexion range of motion was restored in the population studied despite evidence of restricted posterior glide of the talocrural joint." A pinch at the front of the ankle can be bone or soft tissue catching there (anterior impingement). Calf tightness after a sprain "may develop as an adaptive response to immobilization".

Sources 13, 18, 19, 20

Weak ankles

Weak usually means the muscles that turn the sole in and out, the shin and the calf: "Individuals with CAI have ankle inversion and eversion strength deficits." (CAI is chronic ankle instability.) Across reviews, "There is strong evidence to support the contribution of dynamic balance, peroneal reaction time and eversion strength deficits" to ankles that give way.

Sources 21, 2

Wobbly ankles

Researchers call it chronic ankle instability: "a propensity for recurrent ankle sprains, frequent episodes or perceptions of the ankle giving way, and persistent symptoms such as pain, swelling, limited motion, weakness, and diminished self-reported function", more than 12 months after the first sprain. Their definition asks for "at least 2 episodes of giving way in the 6 months prior to study enrollment". A loose ligament isn't the whole story: the injured ankle also senses its position less well and sways a little more on one leg.

Sources 3, 22, 23, 24

How common, and how many sprains don't settle

Ankle sprains are the most common injury in active people; across 181 prospective studies, women sprained more often than men, and court and indoor sports most. Many don't fully settle: 5% to 33% of people still had pain after a year. Up to about 4 in 10 people with a first sprain are estimated to develop a wobbly ankle, a figure from expert estimates and one cohort; in 9 studies of active young people, the share with lasting instability after a sprain was 46%, ranging from 9% to 76%. The figures vary a lot between studies, so "many" is the honest word (our reading).

Sources 25, 26, 27, 3, 28, 29

Why it matters

Lasting instability goes with less activity and "increasing rates of post-traumatic ankle osteoarthritis". Ankle arthritis is uncommon and follows an old injury in more than 75% of cases, but most people who sprain never get it: in 195,393 adults, it was diagnosed in 3.85% after a sprain against 2.66% without one.

Sources 25, 30, 31

Where people differ

Risk factors differ by sex: in men, a previous sprain, weaker hip strength and worse balance; in women, "only lower concentric dorsiflexion strength was identified as a risk factor". In older adults, "fallers exhibited decreased ankle flexibility, more severe hallux valgus deformity, decreased plantar tactile sensitivity, and decreased toe plantarflexor strength" (hallux valgus is a bunion). Hypermobile people can have loose ankles that sprain easily.

Sources 32, 33, 34

No proper trial in wobbly anklesEmerging evidence

The one Pilates study in "chronic ankle instability" recruited 51 male college footballers who had sprained "within the previous one-month period" and let them choose: "The allocation of training was based on the players’ preferences." There was no group that did neither. Both improved, Pilates more on a triple hop and balance training more on two directions of a reach test, and "The strength of inversion and plantar flexion did not change significantly with PT or BT." (PT is Pilates and BT balance training.) A sprain that recent suggests the players were still recovering, so they don't meet the research definition, which asks for a first sprain at least 12 months earlier (our reading of its entry criteria). Its Pilates programme included standing one-leg work alongside the mat work.

Sources 4, 22

No Pilates trial after a fresh sprain, or counting sprains

Our searches found no Pilates trial after a fresh sprain, none that counted sprains or repeat sprains, and none using an ankle instability questionnaire. A randomised Pilates trial in footballers with unstable ankles was registered in 2025, is listed as not yet recruiting, and has passed its planned finish date with no results.

Sources 5, 35, 36, 6

Ankle range: one positive trial, one notMixed evidence

Reformer Pilates once a week for 10 weeks improved right ankle bend against no exercise in 55 people aged 65 to 95 at risk of falls (one side only; falls weren't counted). In 32 women over 60, Pilates improved ankle bend no more than static stretching. Ankle-focused Pilates in 22 women aged about 76 improved range and walking, with no control group.

Sources 37, 38, 39

Balance in older adults: like other exercise, and falls not shownEmerging evidence

Across 39 studies of 1,770 older adults, "Pilates can be recommended to enhance static and dynamic postural balance in older adults, but not to reduce the number of falls or the fear of falling." A network analysis of 423 trials put Pilates high for moving balance, but "These estimates do not establish superiority." In 48 healthy older adults, "Mat-based Pilates training did not cause relevant adaptations in trunk strength and balance performance, whereas balance training substantially improved balance and trunk strength." Our Pilates for balance guide covers falls.

Sources 17, 40, 41, 16

Young athletes and dancers: tiny studiesMixed evidence

Reformer Pilates beat mat Pilates on one-leg hopping and agility in 30 footballers; Pilates and yoga improved a reach balance test about equally in 20 fencers; mat Pilates didn't change hip-hop dancers' moving balance; and in 91 young women, Pilates "did not improve postural control and proprioception in individuals with flatfeet".

Sources 42, 43, 44, 45

Footwork's load on the ankle: never measured

Our searches found no study that measured ankle range, the calf, shin or peroneal muscles, or the load on the ankle during reformer footwork, prances, the Wunda chair or the jumpboard. The closest is one volunteer on a footbar fitted with sensors, where estimating the force from the springs was "imprecise".

Sources 15, 46, 47

Slow, breath-paced work builds less shin strengthEmerging evidence

In 44 older adults, ordinary resistance training built more shin strength than the same training paced by Pilates breathing: "The dorsiflexion strength was higher in the RT group compared to RT + P group." (RT is resistance training.)

Source 48

After a sprain, balance training cuts repeat sprainsStrong evidence

In 522 athletes, an 8-week home programme, "three training sessions a week, with a maximum duration of 30 minutes a session", cut re-sprains over a year: "56 (22%) in the intervention group and 89 (33%) in the control group. Nine athletes needed to be treated to prevent one recurrence". Only 23% fully kept to it, so the effect may be an underestimate. Across 7 trials, exercise after a sprain about halved the odds of a re-sprain at 7 to 12 months, and across 14 trials, "Training volume varied considerably across studies but did not affect the odds of sustaining a re-injury." Balance training cut sprains in sport "particularly those with a history of ankle sprain"; for preventing a first sprain, the evidence "remains inconclusive".

Sources 7, 8, 49, 50

A brace or tape for sport works at least as wellStrong evidence

A semi-rigid brace for sport after a sprain did at least as well as training (re-sprains 15% against 27%), and reviews find "strong evidence for bracing and moderate evidence for neuromuscular training in preventing recurrence". The Dutch guideline update suggests tape or a brace "in combination with an exercise programme".

Sources 9, 51, 52, 53

A caution on the trialsMixed evidence

"RCTs informing primary and secondary prevention of ankle sprain are fragile." (RCTs are randomised controlled trials): in 80% of them, more people dropped out than the number of different results it would take to change the conclusion. The newest pooled review gives two different figures for the same outcome, so we don't quote it, and the old Cochrane review on preventing sprains was withdrawn as out of date with no replacement.

Sources 54, 55, 56

Ankles that already feel unstableEmerging evidence

Exercise is the main treatment: "Balance training provided comprehensive benefits, improving patient-reported function, dynamic balance, joint position sense, concentric strength and functional performance." (58 trials, 2,097 people). Strength plus balance did best for how the ankle feels, the instability score rose by about 4.6 points with exercise, home programmes did about as well as supervised ones, and hip strengthening helped balance too. Most of this evidence is low to moderate certainty.

Sources 57, 11, 58, 10, 59, 60, 61

Strength alone, bands and position senseEmerging evidence

Strength work alone didn't change reach balance by a detectable amount; band work held its own against balance training on reach and function, at low certainty. Exercise didn't fully restore the ankle's sense of position, and our search found no review that pooled re-sprains in people whose ankles were already unstable.

Sources 12, 62, 63, 64

What to put in a programmeEmerging evidence

Most rehab exercises are "simple exercises in the sagittal plane that do not reflect mechanisms of re-injury" (forward and back only), and the authors call for "multiplanar single limb challenges, and jumping and landing exercises". A suggested dose is "three times a week, lasting for 20 to 30 min over a period of 4 to 6 weeks". For Pilates, that means one-leg work in several directions and side-lying hip work, not only footwork (our reading). Our Pilates after an ankle sprain guide has the stages.

Sources 65, 66

Stretching adds a few degreesStrong evidence

"Calf muscle stretching provides a small and statistically significant increase in ankle dorsiflexion. However, it is unclear whether the change is clinically important." That was about 2 to 3 degrees across 5 trials; across 20 controlled trials, static stretching added about 5 degrees. Heel raises improved ankle bend too, and in 36 young men, "SS and RT increased ROM similarly" (static stretching and calf training both raised range of motion), while only the calf training built strength.

Sources 1, 67, 68, 13

Stiffness after repeated sprains can be the jointEmerging evidence

Joint mobilisation by a clinician "can mildly improve DFROM among individuals with chronic ankle instability" (DFROM is the range of upward ankle bend), and manual therapy helped at very low certainty in a 2025 review. A physiotherapist can check which it is.

Sources 69, 70, 20

Does a stiff ankle cause sprains? Not clearlyMixed evidence

One study of 1,093 army recruits found ankle range "a strong predictor of injury", and an older review called the link "preliminary". But two meta-analyses of studies that followed people forward found "no significant difference in the ankle joint ROM (dorsiflexion/plantar flexion/inversion/eversion) between the injury and noninjury groups". So range is for comfort and how you squat and walk; strength and balance matter more for sprains (our reading).

Sources 71, 72, 14, 32

The knee-to-wall testEmerging evidence

The test is reliable, but a change of about 1.6 to 1.9 cm is needed before it's more than measuring error. Unstable ankles reached about 1.7 cm less than stable ones, and one ankle often bends less than the other after a sprain. Our ankle mobility guide has the full drill.

Sources 73, 74, 75, 76

Which musclesEmerging evidence

Unstable ankles have weaker muscles turning the sole in and out, and the peroneus longus reacts later when the ankle rolls (from only 2 studies each). In studies that followed people forward, weaker turning-in strength and slower peroneal reactions went with sprains, and in women, weaker shin muscles.

Sources 21, 77, 14, 32

How they're trained

In trials: bands for turning the sole in and out, heel raises, shin raises and balance work. Mat Pilates points and flexes the foot without much load, so the moves below add the bands and raises (our reading). Our guide to strengthening your ankles has a full plan.

Older adults: ankle work helps strength and balance; balance training cuts fallsStrong evidence

Across 16 trial papers, "Very low- to low-quality evidence showed that ankle-foot exercises effectively improve ankle plantarflexion strength, flexibility, and balance with eyes open, whereas no effect on falls was found." What does cut falls is balance and functional exercise: 23% fewer falls across 59 studies, at high certainty. The world falls guidelines ask for sessions "three times or more weekly which are individualised, progressed in intensity for at least 12 weeks and continued longer for greater effect", and note that supervised group exercise "such as Pilates or yoga" had the largest effects on concerns about falling.

Sources 78, 79, 80

Reformer footwork

Classical footwork is "4 Springs" and "10x each position", with "Promotes foot flexibility and strength" among its goals. One maker's classical manual lists "Ankle issues - please consult a physician before performing this exercise" as a footwork precaution, and its contemporary guide adds "Flex/Releve" (raising and lowering the heels with straight legs) and "Running in place". The Wunda chair's exercises "engage the core, legs, and arms". How hard any of this works the ankle's muscles has never been measured.

Sources 81, 82, 83, 84

On the mat

On the mat your feet mostly point and flex, in leg circles, the side kick series and the hundred, without carrying your body weight. Standing and wall work, such as heel raises, one-leg balance and the wall bridge, puts weight through them (our reading, as our Pilates for feet guide says).

Footwork without a reformer

Our Pilates for feet guide maps the footwork series to the wall: a wall bridge with the heels on the wall and then the balls of the feet, heel raises in parallel and in a small V, and running on the spot holding the wall. It has the steps.

Bare feet and shoesMixed evidence

Minimalist shoes and foot exercises strengthen the small foot muscles a little, at low to very low certainty, with nothing measured for ankle strength or sprains. For older adults, "Walking indoors barefoot or in socks and walking indoors or outdoors in high-heel shoes have been shown to increase the risk of falls in older people." Bare feet or grip socks in class are fine for most people; with numb feet, keep shoes on (see below).

Sources 85, 86, 87

After a sprainEmerging evidence

Early, gentle exercise is safe: "The reinjury rate was 4% (two in each group)." Severe sprains may need a short time in a cast or brace first. Our Pilates after an ankle sprain guide has the stages, with band work kept in a pain-free range for the first 2 weeks.

Sources 88, 89

After a broken ankleEmerging evidence

Across 53 studies of 4,489 adults, early weight-bearing and removable supports after surgery helped a little, but "We were uncertain whether any physical therapy interventions were more effective than usual care or other physical therapy interventions." Supervised exercise added nothing to advice after an uncomplicated fracture in one trial, and early home ankle exercise after surgery gave better scores to 24 weeks, "with convergence by week 52". Your fracture team's plan comes first; start Pilates when they say, with seated ankle circles and mat work with the foot resting, then standing work once you're allowed to put weight through it (our suggestion).

Sources 90, 91, 92

Ankle arthritisEmerging evidence

"Ankle osteoarthritis affects 1% of the population and, unlike gonarthrosis or coxarthrosis, is secondary to previous trauma in more than 75% of cases." (unlike knee or hip arthritis, it usually follows an injury). In UK adults over 50, ankle pain affected 11.7%. No full trial has tested exercise for it, and "there are no clinical guidelines for ankle OA" (OA is osteoarthritis). Strength and range work is sensible by analogy with the hip and knee, but untested (our reading); see a GP or physiotherapist.

Sources 30, 93, 94, 95

Everyday swollen ankles

Puffy ankles are usually fluid. The NHS lists "standing or sitting in the same position for too long", "eating too much salty food", "being overweight", "being pregnant", some medicines and varicose veins among the causes, and less often "problems with your kidneys, liver or heart", "a blood clot" or "an infection". It suggests raising your legs and gentle exercise, "like walking, to improve your blood flow".

Source 96

Pilates hasn't been tested for it

Our search found no Pilates study of swollen ankles. Ankle circles and calf raises keep the calf pump working, and lying with your legs up a wall is a gentle way to raise them (our suggestion). Our Pilates for circulation, varicose veins and lymphatic drainage guides cover the circulation side.

Source 97

When swelling needs help, not exercise

One swollen ankle, sudden or painful swelling, or swelling with breathlessness needs the warning signs below first. Our Pilates for heart failure guide covers exercise with a heart condition.

Sources 96, 98, 99

The doses that workedStrong evidence

Balance programmes that cut repeat sprains ran 3 times a week for 8 weeks, sessions of up to 30 minutes; a review of programmes for unstable ankles suggests 3 times a week, 20 to 30 minutes, for 4 to 6 weeks. For older adults, balance and strength work 3 or more times a week, progressed for at least 12 weeks.

Sources 7, 66, 80

Our suggested week

Our ankle class 2 or 3 times a week, on days that aren't back to back. On other days, 5 minutes of ankle circles, the knee-to-wall rock and both calf stretches if your ankles feel stiff. Practise one-leg balance daily while you brush your teeth or wait for the kettle, with a counter in reach, and make it harder over the weeks (no hand, head turns, then eyes closed for a few seconds). After a sprain, or if an ankle keeps giving way, keep the balance work going 3 times a week for at least 8 weeks and wear a brace or tape for sport. This is our editorial starting point, built from the trials and guidelines above.

Sources 7, 49, 1, 80

In the first weeks after a sprain

Follow the stages in our Pilates after an ankle sprain guide, including its moves to change for now: rolling the sole inwards hard, kneeling on the tops of the feet, toes tucked under your weight, and jumps.

Ball-of-foot pain or big toe arthritis

The slow calf raise's page says: "With pain in the ball of the foot or big toe arthritis, stop short of full tiptoe."

A pinch at the front of the ankle

If the ankle drill gives you a pinch at the front of the ankle rather than a stretch in the calf, don't force it: keep your heels raised and see our anterior ankle impingement guide.

The wobble board with a past knee injury

The balance board's page says: "In one trial, players with a past knee injury had more knee overuse problems during board training." One-leg balance on the floor trains the same skill (our reading).

Source 100

Ankle weights

Strapped above the foot, they make leg lifts harder for your hips and thighs, not for the muscles that move the ankle (our reading); our guide to ankle weights has the rules.

Cramps in footwork and pointed-foot work

No study has looked at it. Pointing the foot hard in leg work can bring on a cramp in the sole or calf: ease the point, flex the foot, and build up foot work gradually (our suggestion). Cramp-like pain with numbness, a cold or pale foot, or pain that carries on at rest isn't ordinary cramp: see the warning signs on this page.

After a broken ankle or ankle surgery

After a broken ankle or ankle surgery, follow your team's advice on when to start.

After an Achilles rupture

No strong calf stretches, no heel drops off a step, and no running, hopping, hills or brisk walking yet: one NHS trust says you're most vulnerable to a re-tear in the first 8 weeks out of the boot.

Numb feet or diabetes

If your feet are numb, the international foot guideline advises not walking barefoot or in socks without shoes, even indoors. Do standing moves in shoes, check your feet before and after, and with an open sore keep to lying and seated moves.

The exceptions: pain in one spot on a bone should be pain-free, because it could be a stress fracture; burning, tingling or numbness means stop that movement; and if your feet are numb, pain won't warn you, so check your skin after exercise.

Very flexible ankles

Keep foot and ankle work in the middle of the range rather than pushing to the end (our suggestion, from our Pilates for hypermobility guide).

Shaky balance or a recent fall

Stop if you feel dizzy or light-headed. Keep a counter or wall within reach, and have someone nearby for the hardest moves if you've fallen recently (our suggestion, as in our older adults guide).

Pregnancy

In pregnancy, after the first trimester, keep time flat on your back to a few minutes: prop your upper body up, or use a side-lying or all-fours version.

Call 999 or go to A&E

• Call 999 or go to A&E: after an injury, you heard a crack, the foot or ankle has changed shape or points at an odd angle, a bone is sticking out, there is a bad cut over it, you're in severe pain, or the toes look blue or white, feel numb or are cold to touch. These can mean a broken bone. Don't drive yourself.
• Call 999 or go to A&E if breathing suddenly becomes difficult, if pain in your chest or upper back comes on suddenly with breathlessness or a very fast heartbeat, or if someone passes out. Do not drive yourself. It can be a blood clot that has reached the lungs.
• Call 999 or go to A&E: a leg that is suddenly cold, pale, numb, weak or very painful. A sudden loss of blood supply to a leg is a vascular emergency.

Sources 101, 102, 99

Not being able to put weight on it

Same day (NHS 111 or an urgent treatment centre): after an injury, you can't put weight on it or walk more than a few steps, the pain is very bad or getting worse, there is a lot of swelling or bruising or it is getting worse, it feels very stiff, or it's not feeling any better after treating it yourself. Get the same help if you also have a very high temperature, or feel hot, cold or shivery: this could be an infection. If you think it's broken, don't treat it yourself.

Contact NHS 111: after an injury, severe ankle pain, feeling faint, dizzy or sick from the pain, a snap, grinding or popping noise at the time of the injury, the ankle or foot at an odd angle, or not being able to walk. These might be signs of a broken ankle or an infection.

Sources 101, 102, 103

A swollen, painful calf, or a cast that's too tight

Same day (urgent GP appointment or NHS 111): throbbing pain in one leg (rarely both), usually the calf or thigh; swelling in one leg (rarely both); red, blue or darkened skin around the painful area, which may be harder to see on brown or black skin; or swollen veins. It could be a blood clot (DVT). Watch for it after an ankle injury or time in a cast or boot.

Same day: in a cast or boot, pain that is getting worse, toes that are numb or burning, a cast that feels too tight, toes that are swollen, blue or white, or a bad smell from under the cast.

Sources 99, 102

The same day: a snap at the back of the heel

• Same day: a sudden snap or pop at the back of the heel or calf, or a feeling of being kicked there, then walking flat-footed and being unable to push off, stand on tiptoe or climb stairs. It could be an Achilles tendon rupture or a broken heel bone. Go to A&E or a minor injuries unit, or contact NHS 111.
• A suspected rupture that was never examined, or a weak push-off weeks after what seemed to be a sprain or calf strain: ask for an assessment. A rupture found late may need different treatment.

Sources 104, 99

Swollen ankles

• Ask for an urgent GP appointment or get help from NHS 111 if you have swelling in 1 ankle, foot or leg and you don't know what's causing it; a lot of swelling after an injury, or swelling that is getting worse; swelling that is severe, painful or starts very suddenly; swelling in other parts of your body too, such as your face or tummy; a swollen area that is red or feels hot; a very high temperature, or you feel hot, cold or shivery; or diabetes and swollen feet or ankles. Call 999 if you also feel short of breath or are struggling to breathe, your chest feels tight, heavy or painful, you're coughing up blood, your heartbeat is more noticeable (palpitations), or you feel lightheaded, faint, confused, sick or clammy.
• Ask for an urgent GP appointment or get help from NHS 111 if you feel breathless when lying down or from everyday activity, you're coughing up frothy pink phlegm, or you have suddenly gained weight, especially with swollen ankles. These can be signs of heart failure. Call 999 if you're having severe difficulty breathing (gasping, choking or not able to get words out), your lips or skin are pale, blue or grey, or someone has passed out and is not responding normally.
• Both ankles, feet or legs swollen, and it hasn't improved after a few days of looking after it at home, it gets worse, or you have a condition that affects your heart, kidneys or leg veins: see a GP.

Sources 96, 98

A hot, swollen joint

Same day: a sudden, very painful, hot, swollen, red joint, often the big toe but sometimes the middle of the foot (the midfoot) or the ankle, especially with a high temperature, feeling shivery or being unable to eat. It may be gout, but it could be a joint infection (septic arthritis), which is urgent.

Contact your doctor straight away

Contact your doctor straight away if your Achilles tendon becomes painful or swollen while you're taking a fluoroquinolone antibiotic (such as ciprofloxacin, levofloxacin, moxifloxacin or ofloxacin), or in the months after. The UK medicines regulator (MHRA) advises stopping the antibiotic at the first sign and resting the painful area until you've been seen; the risk is higher over 60, with kidney problems, after an organ transplant and with steroid medicines.

Sources 104, 99

See a GP or physiotherapist

• Pain that isn't better after 2 weeks of looking after it yourself, is getting worse, keeps coming back, or stops you doing normal things.
• An ankle that keeps giving way months after a sprain.
• Pain or swelling still there 6 to 12 weeks after a sprain, or deep pain inside the joint with catching or locking: see your GP. A damaged patch of cartilage and bone on the talus (an osteochondral lesion) is one cause, X-rays often miss it, and it has its own guide.
• Tingling or loss of feeling in the foot, or a foot that feels weak.
• Any foot pain if you have diabetes: foot problems can be more serious.

Source 103

Several swollen joints

Swelling in several joints, or morning stiffness that lasts more than 30 minutes: see a GP. It can be an inflammatory arthritis such as rheumatoid arthritis rather than osteoarthritis.

Ankles that keep spraining and loose joints

If you're hypermobile, don't use mobility work to push further: the NHS says "do not overextend your joints just because you can". See a GP if you think you have joint hypermobility syndrome: for example, your joints keep dislocating, or you keep getting sprains, strains, pain or stiffness.

Source 105

Falls

• Call 999 if you or someone else has fallen and may have injured the head, back, neck or hip, or cannot get up.
• Get help from NHS 111 if you or someone else has fallen and may be in pain, injured or unwell.
• See a GP if you're worried about your balance or mobility, or you've had a fall. You may be able to refer yourself to a falls service, which can include strength and balance training.

Source 106

During a session: the pain rules

Some discomfort during exercise is fine. Aim for pain you would call mild to moderate, no more than about 5 out of 10, that settles within an hour, with no more swelling or stiffness the next morning. If it's worse the next day, do a little less (a smaller range, fewer reps, a lighter band), not nothing.

After a sprain, NHS hospital leaflets say the exercises should not increase your pain, and gentle exercise from the first week was safe in a trial: re-injury was 4% with or without it.

Sharp pain at the back of the heel during footwork or a calf raise, rather than a dull ache, means stop that move (our suggestion).

Source 88

Chest pain or fainting while exercising: call 999

Call 999 if:

• You get sudden pain or discomfort in your chest that doesn't go away; it can feel like squeezing or pressure, burning or indigestion.
• The pain spreads to your left or right arm, or your neck, jaw, stomach or back.
• You have chest pain and feel sweaty, sick, light-headed or short of breath.
• Someone faints while exercising, can't be woken within 1 minute, or has chest pain or a pounding, fluttering or irregular heartbeat.

Sources 107, 108, 109

Unusual breathlessness

Call 999 or go to A&E (accident and emergency) straight away for severe difficulty breathing (gasping, choking or not able to get words out), a chest that feels tight or heavy, pain that spreads to your arms, back, neck and jaw, lips or skin turning very pale, blue or grey, or sudden confusion. If you're more short of breath than usual, or your heart is racing, fluttering or skipping beats, contact NHS 111.

Source 110

A heart condition

If you have a heart condition, follow your cardiac team's advice on how hard to work, and stop for the warning signs above. People with long-term conditions may wish to ask their specialist before starting. With uncontrolled high blood pressure, avoid straining against a held breath; the high blood pressure guide has more.

Older adults

See your GP first if you get chest pain, breathlessness or dizziness when you are active, if you have a heart condition and want to exercise harder, or if you have had a fall.

Source 111

Stop the session if

You feel any pain or become unwell, as the NHS advises for its Pilates videos, and especially for chest pain or pressure, unusual breathlessness, dizziness or fainting. If you have a health problem, an injury or any symptoms, get advice from a healthcare professional, such as a GP, before you start.

Source 112

Before you start

The NHS advises getting advice from a healthcare professional first if you have a health problem, an injury or symptoms, or have recently had a heart attack or an operation.

If you have a heart, lung or joint condition, are pregnant or have recently been unwell, start gently and read our guide for your condition. Muscle soreness for a day or two after a new exercise is common and fades as you repeat it.

Source 112

"Pilates rebuilds ankle stability on its own"Emerging evidence

No proper trial has tested it, mat Pilates did less for balance than balance training in older adults, and what cut repeat sprains was dedicated balance training and a brace for sport. Pilates can be part of the plan, as the trunk and hip work around the balance and ankle work.

Sources 4, 5, 16, 7, 9

"Stiff ankles cause sprains, so stretching prevents them"Mixed evidence

One study of army recruits found a link, but meta-analyses of studies that followed people forward found ankle range didn't predict sprains. Stretch for comfort and how you move; train balance and strength for sprains.

Sources 71, 14, 32

"Once you've sprained an ankle, it's always weak"Emerging evidence

Many sprains do leave lasting symptoms, but balance and strength training improve how unstable ankles feel and perform, and balance training cut repeat sprains. Our guide to strengthening your ankles makes the same point.

Sources 27, 11, 10, 7

"Reformer footwork strengthens your ankles"

Unmeasured: no study has measured the ankle muscles' work or the load in footwork, and the one study of footbar force had one volunteer. Footwork is good leg work; for the ankles, add standing raises, bands and balance.

Sources 15, 47

"Ankle weights in Pilates strengthen your ankles"

Strapped above the foot, ankle weights load the hips and thighs in leg lifts, not the muscles that move the ankle (our reading; we found no study). Our guide to ankle weights covers when they help.

"You need a wobble board for weak ankles"

The trial that cut repeat sprains used home exercises, some on a board, but one-leg balance on the floor, with reaches and eyes closed, trains the same skill (our reading). With a past knee injury, board training brought on more knee overuse problems in one trial.

Sources 7, 65, 100