Ankle sprains are very common. Each year, around 230,000 Australians see a GP for an ankle sprain or strain. While we don’t have exact statistics here, we do know from a 16-year nationwide survey of colleges and universities in the USA that ankle sprains are the most common injury in sport. One in seven of the 182,000 injuries in this survey were ankle sprains (14.8%).

We also know from a review of studies conducted around the world that ankle sprains are common in specific sports – court games (tennis, squash) and team sports (rugby, soccer, volleyball, handball and basketball) are the standouts. 

Knee injuries are also common. Find out more about acute knee injuries. 

A sprain is an injury caused by excessive movements that damage ligaments.

In around 80% of ankle sprains, the excessive movements are a combination of the foot 1) pointing downwards and 2) then twisting inwards (ouch!).

This combination damages the ligament on the outer side of your ankle, called the lateral ligament.

Classically, this happens when you are:

• walking, but unexpectedly step into a hole in the ground
  
• running and quickly change direction, especially on an uneven surface like a grass field
  
• jumping when playing a team sport and land on another competitor’s foot.

Your health professional diagnoses which structure in your ankle has been damaged and how badly it’s been damaged.

An accurate diagnosis will help your health professional to recommend the most effective and safest treatment.

However, making an accurate diagnosis can sometimes be a challenge. Damage to different structures can cause similar symptoms such as pain, swelling, bruising and difficulty walking and running.

So how does your health professional make an accurate diagnosis? In most cases it is a combination of history and physical examination.

Taking your history

A history involves your health professional asking you specific questions. It particularly includes questions such as ‘how did the injury happen?’ and ‘Were you able to walk immediately after the injury?’

Conducting a physical examination

A physical examination involves your health professional checking for symptoms such as swelling and bruising, and assessing joint movements and muscle strength, and responses to physical tests that assess your ligaments.

An ultrasound can be used for an acute ankle injury to help your health professional diagnose an ankle sprain.

However the research shows that a history and physical examination performed by an experienced health professional is just as accurate at diagnosing an injury, if not more accurate, than an ultrasound.

It’s recommended that your health professional only refer for an ultrasound when the diagnosis after a history and physical examination is still unclear AND if confirming diagnosis with an ultrasound will change the treatment you receive.

If your health professional recommends an ultrasound, asking the 5 questions recommended by Choosing Wisely Australia can help make sure you end up with the right amount of care — not too much and not too little.

X-rays can make an accurate diagnosis of a bone fracture (break). They are poor, however, at finding a damaged ligament due to an ankle sprain.

So how does a health professional decide you need an X-ray?

In 1992 doctors in Ottawa, Canada, developed a set of rules, called the Ottawa Ankle Rules, that can identify which people presenting with an acute ankle injury are most likely to have a fracture.

These rules can help a health professional decide if you need an X-ray. These rules can also help you avoid having a dose of radiation due to an unnecessary X-ray.

Just like with an ultrasound, if your health professional refers you for an X-ray, use the 5 questions recommended by Choosing Wisely Australia to make sure you end up with the right amount of care — not too much and not too little.

A healthy ligament is a strong, fibrous tissue. A ligament sprain effectively means that the fibres in it are torn.

The amount of fibres that are torn (how severe your ankle sprain is) can be defined as one of three grades:

• Grade I: only a few tissue fibres torn
  
• Grade II: considerable proportion of tissue torn
  
• Grade III: complete tear of the ligament
  

Different grades of sprain may need specific treatments.

If your health professional has decided (following a history and physical examination) that your injury will settle with simple treatment such as rest and ice, you can manage your injury yourself under their supervision in the first few days.

RICE

• Rest – avoid using the injured joint for at least 2 days.
  
• Ice – apply ice packs for 20 minutes every 2 hours (never apply ice directly to skin – it can burn)
  
• Compression – firmly bandage the injury.
  
• Elevation – lie or sit with leg raised.
  

No HARM

• No Heat.
  
• No Alcohol
  
• No Running or similar activity
  
• No Massage
  

Your health professional may also recommend using over-the-counter pain relief medicines.

Exercises are an essential part of recovery after an ankle sprain.

Your health professional usually recommends starting with gentle range of movement exercises and exercises to keep up your muscle strength.

As your ligament heals and pain decreases, you can begin with exercises that are part of your sport or physical activities at work. These are called functional exercises.

For example, if you play sports that involve jumping, such as basketball, you would be advised to include jumping as a functional exercise.

Last, but most importantly, you need to do proprioception exercises.

Proprioception is an important nerve function defined as unconscious sensations of 3D spatial awareness, joint position and movement.

These sensations help maintain balance and coordination and enable activity to be performed with precision and skill. And together with wearing tape or a brace (under the supervision of your health professional) they can be highly effective at preventing a sprain of your ankle again in the future.

Surgery is rarely needed

Grade I and II ankle sprains don’t need surgery to heal.

In the past, Grade III ankle sprains were treated with surgery to reconnect a completely torn ligament. But studies conducted to see how effective the surgery was found that surgery was no better than non-surgical treatments such as exercises.

The current recommended treatment for Grade III sprains is either:

Plaster slab for 4–6 weeks that allows you to walk around until the ligament has repaired, or

Strapping, taping, bandage or semi-rigid ankle support

Both treatments should be followed by exercises (see above).

Your health professional may ask you to return in a few days once the swelling has gone down, so they can check your progress.

But if the pain, swelling or stiffness does not settle, or worsens, despite following medical advice including RICE, no HARM and pain-relief medications, or if you develop a fever or redness at the injury site, go back to see your health professional as soon as possible.

How long it takes for you to get back to work or sport will vary

There is no fixed time when you are ready to return to sport or physical work after an ankle sprain.

In general, the worse your ankle sprain, the longer it takes to return to sport or physical activity. For example, it may take weeks to months for you to recover from a grade II or III sprain and return to your normal, pre-injury level of activity.

What determines the specific timing is when you can successfully do functional exercises without pain.

It’s also important to give yourself time to build up to your sport or physical activity. Warm up and cool down before and after activity, and allow time between sessions. Taping or bracing the joint under the supervision of your health professional may also help.

If you are overweight, weight loss can reduce pressure on the joint and lowers the chance of further injury.

Choosing Wisely Australia

Choosing Wisely Australia is an initiative that brings the community together to start important conversations amongst healthcare providers and consumers. These conversations aim to improve the quality of healthcare through considering tests, treatments, and procedures where evidence shows they provide no benefit or, in some cases, lead to harm. Facilitated by NPS MedicineWise, it is led by a large cross-section of colleges, societies and associations that have identified practices that warrant scrutiny, and by examining the evidence and drawing on the expert opinion of their members, have developed lists of recommendations. Three colleges and associations recommend that health professionals use the Ottawa Ankle Rules:

• Royal Australian and New Zealand College of Radiologists
  
• Australian Physiotherapy Association
  
• Australian College of Nursing
  

Better Health Channel

Fully funded by the Victorian Government, this website provides health and medical information that is quality-assured and reliable, up-to-date, locally relevant and easy to understand. The information about ankle sprains is general in nature.

healthdirect

Jointly funded by the Australian Federal Government and the governments of the Australian Capital Territory, New South Wales, Northern Territory, South Australia, Tasmania, and Western Australia, this website provides services including high quality information by acting as a portal to reliable and reputable sources. The information about ankle sprains is general in nature.

InsideRadiology

Produced by Australian and New Zealand radiologists and other health professionals about radiology tests and procedures. It contains information for health consumers and treating health professionals, endorsed by the Royal Australian and New Zealand College of Radiologists (RANZCR). It provides specific information about imaging tests for injuries of the musculoskeletal system (bones, ligaments, muscles and more).

RadiologyInfo

Public information resource for patients developed by physicians from the Radiological Society of North America (RSNA) and the American College of Radiology (ACR). It provides specific information about imaging tests for injuries of the musculoskeletal system (bones, ligaments, muscles and more).

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