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  • Writer's pictureMary Brooking

Injury spotlight: Ankle sprain

Lateral ankle ligament sprains are a common injury often caused by twisting an ankle whilst turning or landing awkwardly. Slipping off a kerb, step or uneven surface can cause the ankle to collapse into a void unexpectedly, having the same effect.

Runners are often affected, often those who venture onto trails when a treadmill or pavement is their normal running surface, as are players of sports with lots of lateral motion requirements, such as football or tennis, but they can impact everyone.

Injury spotlight: ankle sprain

These injuries are normally acute, caused by a specific incident so there are no early warning signs, in contrast to chronic or overuse injuries when the pain builds slowly over time. The most important immediate action is to determine whether your ankle is sprained, and if so how severely, or whether it could be broken. This is assessed based on pain levels, extent of swelling & bruising, and whether the ankle can bear any weight.

Self-assessment clues:

Grade 1 sprain (Ligament fibres overstretched but intact, damage to a single ankle ligament): Range of movement same as unaffected side, pain is bearable, only mild bruising and golf ball sized swelling

Grade 2 sprain (Partial rupture of ligament fibres in one ankle ligament, other ligaments with fibres strained but intact): Ankle feels slightly more lax, ie easier to move from side to side, than the other ankle, pain is extremely high, significant bruising and swelling around the ankle and along the outside of the foot

Grade 3 sprain (Multiple ankle ligaments with complete or partial rupture): Ankle feels significantly more lax, pain is unbearable and bruising could be mistaken for a sock.

Check for a broken ankle: If there is significant bruising, intense pain on touching any bony area of the ankle or lower leg and the ankle is unable to bear weight for 4 steps then a fracture should be suspected and an x-ray should be sought.

Initial treatment:

For at least the first 3 days and longer to extent that swelling and pain remain:

  • Protect: Taping or the use of an ankle supports reduces the risk of reinjury, which is significantly increased in the period after an initial injury. Evidence also shows that if you have a subsequent ankle sprain after an initial one then the increased laxity in the ankle may become long term, making use of tape or supports really important for a prolonged period, perhaps months if the initial injury was severe.

  • Rest the ankle to prevent further damage and keep weight off it

  • Movement: Early mobility is essential to increase ligament strength and restore function. These should start with non-weight bearing exercises in a pain free range of motion such as writing the alphabet in the air with your toes or, when seated, slowly moving your knee from side to side while your foot is flat on the floor or scrunching a towel under your toes.

  • Compression: Wrapping the injured ankle in a compression bandage will help keep it imobile and supported, protecting it from re-injury whilst also helping reduce swelling

  • Elevation to at least level of heart to reduce swelling and pain

  • No anti inflammatories or ice - give your body’s natural healing response time to work. These can be introduced after 3 days if swelling is still prsent and is causing pain or discomfort.


Rehabilitation aims to restore ankle mobility, strength, proprioception and function. Sports massage and physiotherapy can play a key role in rehabilitation by gently mobilising soft tissues, working on the ankle ligaments directly to encourage repair, reducing scar tissue, maintaining range of motion through the entire leg kinetic chain and progressively introducing appropriate exercises.

Once pain levels are manageable exercises for the ankle can start to build strength, balance and proprioception. These will build progressively from static/isometric non weight bearing exercises with resistance bands through to hopping & jumping exercises and agility training before returning to sport/activity.. These exercises are important not only to recover from the initial incident but to protect against the same injury happening again. It's also advisable to continue to tape or use a support, perhaps for months depending on the severity of the sprain to also reduce re-injury risk.

Some examples of exercises are set out below, however their appropriateness and rate of progression is something that should always be discussed with a therapist. 

Foot and ankle proprioception:

Start with balancing on the floor, just standing on one leg for 20seconds at a time. Then move onto standing on a pillow or cushion. When this becomes easy try with your eyes closed. A further challenge is provided by wobble cushions or Bosu balls and progressing from standing still to aiming to complete lunges or other movements on them.

Calf stretches: Hold for 45 seconds 3 times a day. Its important to do both as they stretch different calf muscles.

Upper calf: Place your foot against the wall with toes just above skirting board height and heel away from wall so  the foot is at approximately a 45 degree angle. Use your back foot to push you gently forwards, bringing your knee towards the wall and achieving a calf stretch in the front leg.

Lower calf: Stand facing a wall with your feet 10-20cm from the wall, one foot in front of the other. Bend both knees until you feel a stretch deep in the calf muscle, closer to your heel than the previous stretch.

Ankle eversion:

Make a resistance band into a loop and place over foot to be worked. Hook the remaining lengthof band around the other foot and bring the free end to your hand. Twist the long lateral edge of the foot out to the side against the resistance of the band (don’t rotate around the ankle - there shouldn't be any rotation of the foot out to the side). Start by holding for 45s, then progress to pushing out 15 times against the band, repeated 3 times.

Clock lunges:

Stand with enough room to step out in all directions and imagine you are in the middle of a clock face.. Lunge first forwards to 12o/clock, then 1 o’clock etc until you are lunging backward to 6 o’clock. Change legs and return to 12 o’clock on the other side.

Multi directional hopping:

Stand on one leg, hop forwards and land on a bent knee, hop backwards to starting position. Hop to left, then back to centre. Hop right and then back to centre. Hop backwards and then forward to return to the centre. Continue to hop in a variety of directions, including diagonals, in no particular pattern. 

Less is more with these hops. Start with 3 sets of 4 to 6 hops, then slowly build up.

Timeframes for returning to activity:

With a grade 1 sprain it's probably a couple of weeks before it’s advisable to run or return to intense exercise, and a tape or a support should be used when returning. Don’t do ankle strengthening exercises just before your run/sport otherwise the fatigue of the exercises could increase injury risk.

A grade 2 ankle sprain/partial tear probably means an absence of 6-8 weeks and for a Grade 3 sprain/tear return will be delayed for a long time and the ligament will remain fragile, with risk of re-injury high, for months so careful adherence to a rehabilitation programme is essential.

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