Ankle Sprains: Causes, Symptoms, and How We Can Help

All information in this blog is supported by NICE guidance and peer-reviewed research. Reference numbers appear throughout, with the full list at the bottom of the page.

What Is an Ankle Sprain?

An ankle sprain is genuinely one of the most common musculoskeletal injuries, with an estimated 25,000 occurring every day in the USA alone, equating to roughly 1 sprain per 10,000 people daily. ¹ Research has found that ankle sprains occur considerably more often in females than males, and more often in children and adolescents than in adults, reflecting how widespread and varied this injury genuinely is across different groups. ¹

As covered in our wrist sprain blog, NICE classifies sprains by severity using the same three-grade system: ²

• Grade I (mild): mild stretching of the ligament complex, without joint instability

• Grade II (moderate): partial rupture of the ligament complex, without joint instability

• Grade III (severe): complete rupture of the ligament complex, with instability of the joint

The vast majority of ankle sprains are lateral sprains, involving the ligaments on the outer side of the ankle, typically caused by the foot rolling inward (an inversion injury).

Common Signs and Symptoms

• Pain, swelling, and bruising around the ankle, typically on the outer side

• Difficulty or pain when weight-bearing

• A feeling of instability or the ankle "giving way"

• Reduced range of movement

• Tenderness on palpation over the affected ligaments

Risk Factors

• Previous ankle sprain, one of the most consistently identified risk factors for further injury ³

• Sports involving cutting, jumping, or uneven surfaces, including football, basketball, and trail running

• Female sex, research has found a meaningfully higher incidence of ankle sprain in females compared with males ¹

• Younger age, with higher rates seen in children and adolescents compared with adults ¹

• Reduced proprioception (joint position sense), recognised as a contributing intrinsic risk factor ⁴

• Previous incomplete rehabilitation, a significant proportion of people who sprain their ankle for the first time go on to develop chronic ankle instability if the original injury isn't properly rehabilitated ⁵

Do I Need an X-Ray? The Ottawa Ankle Rules

This is genuinely useful to understand, since it's the tool used to decide whether imaging is needed. Traditionally, almost everyone with an ankle injury would be sent for an X-ray, despite fewer than 15% having a clinically significant fracture. ¹ The Ottawa Ankle Rules were developed specifically to give clinicians a rapid, accurate way to avoid unnecessary imaging while still safely identifying fractures. ¹

The rules generally indicate an X-ray is needed if there is bone tenderness at specific points around the ankle and midfoot, or if the person is unable to bear weight both immediately after the injury and during assessment. ⁶ Research validating this tool has found it has high accuracy for ruling out significant fractures, supporting its widespread use to genuinely reduce unnecessary radiation exposure and healthcare costs. ⁷ NICE Clinical Knowledge Summaries reference these same principles as part of standard sprain and strain assessment. ⁸

What to Look Out For

Please seek prompt medical assessment if you experience:

• Inability to bear weight, both immediately after injury and on assessment

• Bone tenderness at specific points around the ankle (assessed using the Ottawa Ankle Rules)

• A visible deformity

• Numbness, tingling, or weakness in the foot, which can occasionally indicate nerve involvement following a significant ankle sprain ⁹

• Significant, rapidly developing swelling

Myths vs Facts

"I should rest completely and avoid weight-bearing." A comprehensive review of current clinical practice guidelines found early ambulation to be one of only a handful of interventions with strong enough evidence to be highly recommended for ankle sprain management, alongside manual therapy, cryotherapy, functional support, and rehabilitation. ¹⁰ Prolonged immobilisation is not generally supported.

"All ankle sprains heal fully on their own." Not always, genuinely. Research following people after a first-time lateral ankle sprain found that a significant proportion go on to develop chronic ankle instability, recurring giving way and reduced function, particularly where the original injury wasn't properly rehabilitated. ⁵

"Acupuncture and electrotherapy aren't proven for this." It's more nuanced than that. The same comprehensive guideline review found that whilst areas like acupuncture, electroacupuncture, and pharmacopuncture had fewer studies, the science backing them where it existed was rated as high quality, with the guideline authors specifically noting that future research is needed to build a fuller picture. ¹⁰ In contrast, treatments like ultrasound, laser, electrotherapy, and diathermy were found to have genuinely poor supporting evidence. ¹⁰

How We Can Help

A comprehensive 2022 review of current clinical practice guidelines for ankle sprain identified six interventions with strong enough evidence to be highly recommended: the Ottawa Ankle Rules for appropriate imaging decisions, manual therapy, cryotherapy, functional supports, early ambulation, and structured rehabilitation. ¹⁰

Osteopathic manual techniques and manual therapy: identified as one of the most strongly evidenced interventions for ankle sprain management, supporting joint mobility and overall recovery. ¹⁰

Deep tissue and sports massage: targeted soft tissue work for the surrounding muscles, supporting circulation and reducing compensatory tension during rehabilitation.

Medical acupuncture: whilst still building a fuller evidence base specifically for ankle sprain, the available research has been rated as high quality, and we're happy to discuss this as part of a broader treatment plan if you're interested. ¹⁰

Functional support: appropriate bracing or taping, identified as a well-evidenced part of management, particularly helpful for protecting the ankle during early rehabilitation and return to activity.

Early ambulation guidance: in line with current evidence, advice on appropriate, early weight-bearing rather than prolonged rest and immobilisation. ¹⁰

Exercise and Rehabilitation: The Cornerstone of Long-Term Recovery

Structured rehabilitation is genuinely essential, not optional, for preventing the chronic instability that affects so many people following an initial ankle sprain. ⁵ ¹⁰

• Early range of motion exercises: gentle, guided movement introduced as soon as appropriate to maintain mobility.

• Proprioceptive and balance training: given how strongly reduced joint position sense is linked to risk of future sprains, balance-focused exercise is a genuinely core part of rehabilitation. ⁴

• Progressive strengthening: building strength in the muscles surrounding the ankle to better support the joint going forward.

• Functional and sport-specific training: a structured progression back to cutting, jumping, or sport-specific movements before full return.

• Graded return to activity: criteria-based, rather than time-based, to reduce the risk of re-injury and long-term instability.

  
  

Your practitioner will guide a programme tailored to the grade of your sprain and your specific activity goals.

What to Expect at Your First Appointment

We will take a thorough history of the mechanism of injury, and carry out a hands-on assessment, applying the Ottawa Ankle Rules where relevant to determine whether imaging is needed. We will explain clearly what we find and build a progressive, evidence-based rehabilitation plan, with a particular focus on proprioceptive training to reduce your risk of chronic instability.

Frequently Asked Questions

Do I need an X-ray? Not always. The Ottawa Ankle Rules help determine this based on specific findings during assessment, avoiding unnecessary imaging in the majority of cases.

Will I need a brace? Functional support, such as bracing or taping, is well-evidenced for ankle sprain management, particularly in the earlier stages of recovery and return to activity.

Why does my ankle keep giving way, even though the original sprain healed months ago? This is genuinely common and reflects chronic ankle instability, which develops in a meaningful proportion of people following a first sprain, particularly where proprioceptive and balance-focused rehabilitation wasn't completed properly the first time.

How long will it take to recover? This depends on the grade of sprain, mild sprains often improve within a couple of weeks, while more significant injuries take longer and benefit considerably from structured, complete rehabilitation rather than just waiting for symptoms to settle.

Recognise these symptoms? Get in touch using the contact form and we will assess and build the right treatment plan for you.

BOOK YOUR APPOINTMENT HERE

References

1. Ottawa Ankle Rules. Physiopedia. Available at: https://www.physio-pedia.com/Ottawa_Ankle_Rules

2. National Institute for Health and Care Excellence (NICE). Sprains and strains. Clinical Knowledge Summary. Available at: https://cks.nice.org.uk/topics/sprains-strains/

3. Kobayashi T, Tanaka M, Shida M. Intrinsic Risk Factors of Lateral Ankle Sprain: A Systematic Review and Meta-analysis. Sports Health. 2016;8(2):190-193.

4. Delahunt E, Remus A. Risk Factors for Lateral Ankle Sprains and Chronic Ankle Instability. Referenced via: https://www.physio-pedia.com/Ankle_Sprain

5. Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Delahunt E. Recovery From a First-Time Lateral Ankle Sprain and the Predictors of Chronic Ankle Instability: A Prospective Cohort Analysis. American Journal of Sports Medicine. 2016;44(4):995-1003.

6. Ottawa ankle rules. Wikipedia. Available at: https://en.wikipedia.org/wiki/Ottawa_ankle_rules

7. Gomes YE, Chau M, Banwell HA, Causby RS. Diagnostic accuracy of the Ottawa ankle rule to exclude fractures in acute ankle injuries in adults: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2022;23(1):885.

8. Sprains and strains: assessment. NICE Clinical Knowledge Summaries. Available at: https://cks.nice.org.uk/topics/sprains-strains/diagnosis/assessment/

9. Mitsiokapa E, Mavrogenis AF, Drakopoulos D, Mauffrey C, Scarlat M. Peroneal nerve palsy after ankle sprain: an update. European Journal of Orthopaedic Surgery & Traumatology. 2017;27(1):53-60.

10. Ruiz-Sánchez FJ, Ruiz-Muñoz M, Martín-Martín J, Coheña-Jimenez M, Perez-Belloso AJ, Romero-Galisteo RP, Gónzalez-Sánchez M. Management and treatment of ankle sprain according to clinical practice guidelines: A PRISMA systematic review. Medicine (Baltimore). 2022;101(42):e31087.