Ankle Injury: Sprains, Fractures and Recovery

Common types of ankle injury

Sprained vs broken ankle

You cannot always tell without an X-ray. Bruising and swelling can be dramatic in a sprain, and some fractures allow walking. Doctors use the Ottawa ankle rules: an X-ray is needed if there is pain around the ankle and any of:

• tenderness along the back edge or tip of the outer ankle bone (lateral malleolus), over the bottom 6 cm (2.5 inches)
• tenderness along the back edge or tip of the inner ankle bone (medial malleolus), over the bottom 6 cm
• inability to bear weight for 4 steps both right after the injury and when examined

Similar rules for the midfoot look for tenderness at the base of the fifth metatarsal and the navicular bone. These rules are very good at ruling out fractures and reduce unnecessary X-rays.

Grades of ankle sprain

• Grade 1: ligament stretched with microscopic tears; mild pain and swelling; walking possible. Recovery 1 to 3 weeks.
• Grade 2: partial tear; moderate pain, swelling and bruising; walking painful. Recovery 3 to 6 weeks.
• Grade 3: complete tear; severe swelling and bruising; ankle may feel unstable. Recovery 6 to 12 weeks or more.

See ankle sprain for more detail.

First aid in the first 48 to 72 hours

• Protect: use a brace or supportive shoe; crutches if walking is very painful.
• Rest: avoid activities that hurt, but keep moving the toes and foot gently.
• Ice: 15 to 20 minutes every 2 to 3 hours, wrapped in a cloth; never directly on the skin.
• Compress: an elastic bandage from the toes up to the calf, firm but not tight; loosen it if toes tingle or change color.
• Elevate: keep the ankle above heart level when resting.
• Pain relief: acetaminophen (paracetamol) or ibuprofen, following the label dose. Avoid NSAIDs if you have kidney problems, stomach ulcers or take blood thinners.

Avoid heat, alcohol, running and massage for the first 2 to 3 days, which can increase swelling.

Treatment

Sprains

Early, protected movement heals ankles faster than prolonged immobilization:

• a lace-up brace or air stirrup for moderate sprains, worn for a few weeks
• a short period in a walking boot for severe sprains
• walking as pain allows, then a structured exercise program
• surgery is rarely needed, except for some severe or recurrent instability

Fractures

• Stable fractures (such as many isolated outer ankle bone breaks): a walking boot or cast for about 6 weeks.
• Unstable fractures (both sides broken, joint shifted, or high ankle ligament torn): surgery with plates and screws, then protected weight-bearing. See ankle fracture.

Achilles rupture

Treated with surgery or a boot with the foot pointed down, followed by structured rehab. See Achilles tendon rupture.

Rehab exercises

Start once pain allows, usually within a few days for sprains:

1. Range of motion: trace the alphabet with your big toe, pump the foot up and down.
2. Strength: resistance band exercises in all directions; calf raises on both feet, then one.
3. Balance: stand on the injured leg for 30 seconds, progressing to eyes closed and then a cushion or wobble board. Balance training is the single best way to prevent re-injury.
4. Return to sport: jogging, figure-of-eights, hopping and cutting once you can do single-leg calf raises and hops without pain.

A physical therapist can guide this, especially for athletes or after severe sprains.

Complications

• Chronic ankle instability: repeated giving way and sprains, affecting up to a third of people after a sprain, especially without rehab.
• missed fractures or cartilage injuries causing ongoing pain
• stiffness and early arthritis after severe injuries or fractures
• rarely, complex regional pain syndrome

Preventing ankle injuries

• complete a balance and strengthening program after any sprain
• wear supportive, well-fitting shoes for your sport
• consider a brace or taping when returning to high-risk sports for 6 to 12 months after a sprain
• warm up, and take care on uneven ground

Frequently asked questions

How do I know if my ankle is sprained or broken?

A broken ankle is more likely if you cannot take 4 steps, the ankle looks deformed, or there is sharp tenderness when pressing on the back edge or tip of the ankle bones. Swelling and bruising occur with both. An X-ray is the only way to be sure.

How long does a sprained ankle take to heal?

A mild sprain usually heals in 1 to 3 weeks, a moderate sprain in 3 to 6 weeks, and a severe sprain in 6 to 12 weeks or more. Ligaments keep strengthening for months, so continuing balance exercises helps prevent re-injury.

Should I walk on a sprained ankle?

Yes, as pain allows, usually with a brace or supportive shoe. Early walking and gentle movement speed healing compared with complete rest. Use crutches for a few days if walking is very painful, and get an X-ray if you cannot take 4 steps.

When should I see a doctor for an ankle injury?

See a doctor if you cannot bear weight, there is bone tenderness or deformity, numbness, severe swelling, a pop at the back of the heel, or no improvement after a week. People with diabetes should be checked sooner.

Why does my ankle keep rolling?

After a sprain, stretched ligaments and impaired balance sensors make the ankle prone to giving way again. This is chronic ankle instability. A physical therapy program focusing on balance and strength fixes most cases; surgery is an option if it fails.