Ankle sprains remain one of the most common reasons people seek urgent or follow-up care, whether from a sudden twist during a run or a misstep on uneven ground. Even mild sprains and strains can disrupt daily routines, limit mobility and take longer to heal than many expect. Understanding the difference between an ankle sprain and strain—and knowing when to seek care—can help patients protect their long-term joint health.
The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines and how to take charge of their health through preventive care.
In this installment, Aly M. Fayed, MD, an orthopaedic surgeon with University of Iowa Health Care in North Liberty, Iowa, took time to discuss what patients need to know about ankle sprains and strains.
University of Iowa Health Care is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Ankle sprains are common injuries
“One of the most common injuries that we see in orthopaedics is an ankle sprain,” Dr. Fayed said, noting that ankle sprains account for about 10% of all emergency department visits and more than 15–20% of sports-related injuries.
As a common ankle injury, it is also helpful to recognize the differences between an ankle strain versus an ankle sprain.
“Usually, we use the term sprain if the ligament—which is a structure connecting two bones—is injured,” he said. “We use the term strain if it affected the muscle or tendon, which is more dynamic. And the fracture, of course, is if a bone was injured or broken.”
Anyone can sprain their ankle
An ankle sprain often happens during a “sports activity. Sometimes we see it in high energy trauma such as motor vehicle accidents,” said Dr. Fayed. “But sometimes it happens even with everyday activity, such as walking and having a misstep on an uneven surface. So, it actually can happen to anyone.”
“There are different variables with variable degrees of energy. It could be high energy, as mentioned, so a motor vehicle accident, or as low as someone who was just walking on an uneven surface,” he said, noting “the cause of the sprain is important when we talk to the patient to see exactly how it happened because it will not only tell you what ligament might have been injured, but also give you more perspectives on if their ankle is prone to future sprains.”
“For example, if someone was just walking and they sprain their ankle or they sprain their ankle too many times, it may that be they are having an acute sprain on top of chronic ankle instability,” Dr. Fayed said. This is “in comparison to someone who was playing soccer or football and someone stepped on his foot, and he inverted his ankle, which is more likely an acute sprain.”
“It is important to differentiate between an acute sprain and chronic ankle instability because it might alter their outcome and also their treatment plan,” he said.
A fracture needs to be ruled out
“When we first see a patient, we want to see if there’s a fracture or not,” said Dr. Fayed, noting “for an ankle sprain there is the Ottawa Ankle Rules, which is helpful in certain situations to determine if an X-ray is needed for a foot or ankle injury.”
An ankle X-ray is needed if there is:
- Inability to bear weight on the foot and ankle.
- Tenderness at the medial malleolus, which is the bony bump on the inner side of the ankle that is the end of the shinbone.
- Tenderness at the lateral malleolus, which is the bony prominence on the outer side of the ankle that is formed by the end of the fibula bone.
“Also, on exam there are certain areas that we palpate to see if they are tender or not,” he said. “During examination, physicians also rule out other injuries that can be overlooked or misdiagnosed as ankle sprains. For example, a fracture at the base of the fifth metatarsal or a fracture of the anterior process of the calcaneus bone,” which is the large bone forming the heel.
There are different types of ankle strains and sprains
“The most common type of ankle sprain involves the lateral ligaments on the outside of the ankle,” said Dr. Fayed. “Less common types include high ankle sprains, which affect the syndesmotic ligaments connecting the tibia and fibula, and medial ankle sprains that involve the deltoid ligament on the inside of the ankle.”
“For ankle sprains, the classical grading is grade 1, 2 and 3. Grade 1 is stretch of the ligament, and they are still intact with minimal swelling, pain and tenderness,” he said. “And the patient usually is able to have weight bearing with minimal discomfort.”
“Grade 2 is more severe injury, so more swelling, more pain, maybe some partial tear of the ligament and patients may be able to bear weight and likely need crutches for a few days,” Dr. Fayed said. “And grade 3 is when the ligaments are completely torn and the ankle joint might be unstable. There is more severe pain, more swelling and it would require more prolonged time and some form of immobilization with rehab.”
You’re at risk for recurrent sprains
“Unfortunately, when someone sprains their ankle,” said Dr. Fayed, “it puts them at risk of recurrent sprains in the future.”
“The most common risk factor of chronic or recurrent ankle instability is a previous ankle sprain,” he said.
Wear a supportive ankle brace
To help with ankle sprain or strain recovery, “typically, we provide either a brace or, if there’s significant swelling, sometimes we provide a fracture boot for immobilization,” said Dr. Fayed. “The main goal for this is to rest your ankle until acute inflammation and swelling improve..”
“Once pain and swelling have improved, the patient begins a formal physical therapy program focused on ankle range-of-motion exercises, strengthening of the peroneal muscles—which serve as secondary stabilizers of the ankle joint—and proprioceptive training to optimize recovery and reduce the risk of recurrence or progression to chronic ankle instability.”
For sprained ankle treatment, follow the RICE method
While you can’t heal a sprained ankle overnight, there are steps you can take to help with the recovery. In the first 24 to 48 hours, it is important to follow the RICE protocol, which is rest, ice compression and elevation.
“So, rest and try to minimize bearing weight for the first 24 to 48 hours,” Dr. Fayed said. “Then submerge in ice for 20 minutes every two to three hours or apply an ice pack. But don’t apply it directly to the skin because it can cause irritation.”
“Compression you can do at home using an ACE wrap around the ankle joint and then put the ice on top of the wrap so you’re protecting the skin too,” he said, adding that “elevation is crucial in the first two days. Elevate above the level of the heart or toes about the nose. If you’re laying down, you should be able to see the tips of your toes.”
“This elevation is important because it decreases the swelling and when you have less swelling over the injured ligaments, you will have less pain and a faster recovery,” Dr. Fayed said. “If you did not elevate as much, you might end up having severe swelling that would take several weeks to resolve and it would slow down your recovery time.”
Over the counter pain relief can help
If you are experiencing pain in your ankle, “you can take ibuprofen,” Dr. Fayed said, noting that “some people also use Voltaren gel, which is approved by the Food and Drug Administration for arthritis. It is a topical gel or cream that you can apply over the injured area, delivering topical NSAIDs as an anti-inflammatory to the injured ligaments which are just under the skin.”
“Ultimately, you can do any over the counter pain killers such as ibuprofen or you can use Voltaren gel over the sprained ligament,” he said.
Ankle strain recovery time varies
Many people may wonder how to heal a sprained ankle overnight, but it is important to note that recovery does take time. However, the first 24 to 48 hours are key for quicker recovery if sprained ankle treatment is followed.
Often times, swelling does not appear immediately after a twisted ankle unless it’s severe type or associated fractures—it can take several hours to develop.
The key for ankle sprain recovery is giving it time to heal. Recovery time for a sprained ankle does vary depending on the severity and can take anywhere from two weeks to heal a mild ankle sprain to several weeks. About 10–30% of patients might experience mild residual pain at one year after the injury.
These “red flags” mean emergency care
“With a bad sprain, if the foot appears to be deformed or the ankle is out of its socket, even if it reduced spontaneously, you have to visit your doctor or go to an emergency department or urgent care because this means further evaluation is needed,” said Dr. Fayed. “Also, if you’re unable to get up and put any weight on your foot, this is also a red flag because you would benefit from further evaluation with physical exam and maybe radiographs to exclude acute fractures.”
“If there is no deformity and you can put weight on your foot and you were able to continue your activity, but the swelling continues to increase or you feel that your ankle is very unstable or loose, that also signals further evaluation by a specialist,” he said. “Even during the later stages of recovery from an ankle sprain, if after several weeks you still have worsening pain, that is also a red flag that you would need to see an orthopaedic specialist.”
Physical therapy can help prevent ankle sprains
“The idea behind physical therapy,” said Dr. Fayed, “is that you work with the patient to decrease swelling, improve range of motion and regain a proper proprioception.”
This “is the body’s sense of its own position, movement and force that allows for coordinated actions without conscious thought and without relying on vision,” he added.
Take your time returning to activities
“Sometimes patients rush to get back to activity, but that is not good to do. You need to give the ligament some time to heal,” Dr. Fayed said. “With physical therapy guidance, the patient should regain functional range of motion with reduced swelling around the ankle joint and be able to walk without pain.”
“If you are planning to get back to a specific sport, we will progress with sports-specific training. If it’s everyday activity such as walking, good range of motion and good strength of all the muscles signals it is OK to get back to all of their activities,” he said. “But start with a protective brace that you can wear inside your shoes and use it for about four to six weeks as you transition back to activity to have that support.”
Address chronic ankle instability
“To prevent another ankle sprain, you need proper treatment of that sprain,” said Dr. Fayed. “That means if you need immobilization because the sprain was very severe, you should be immobilized properly, and you will need a good supervised physical therapy to work on the rehab before returning back to your activity.”
“Sometimes we will have to study certain factors because some patients might be at a higher risk of recurrence, especially patients who have certain foot deformities,” he said. For example, “patients who have a high arch or their heel is inverted or what we call a cavovarus foot we know are at higher risk of recurrent sprains.”
“If you have chronic ankle instability, we can discuss surgical treatment to stabilize your ankle ligaments,” Dr. Fayed said.
