Ankle sprains are one of the most common musculoskeletal injuries and occur when the ligaments supporting the ankle joint are overstretched or torn. These injuries range from mild, short-term discomfort to severe ligament disruption that can lead to joint instability, ongoing pain, and reduced mobility if not appropriately treated.

While many ankle sprains recover fully with early and appropriate management, some can progress to chronic instability, requiring specialist assessment and in some cases surgical reconstruction. At London Bridge Orthopaedics, our multidisciplinary team provides evidence-based care for both acute and chronic ankle injuries.

Anatomy and Function

he ankle is a complex joint involving the tibia, fibula, and talus. Several ligaments support and stabilise the joint, preventing excessive twisting or rolling. The most commonly injured structure is the lateral ligament complex, which includes:

• The anterior talofibular ligament (ATFL)
• The calcaneofibular ligament (CFL)
• The posterior talofibular ligament (PTFL)

Less commonly, the medial (deltoid) ligament or the syndesmosis (ligament between the tibia and fibula) may also be affected, particularly during high-energy or twisting injuries.

Ligaments stabilise the joint while still allowing functional movement. When excessive force is applied, fibres can stretch or tear, resulting in swelling, pain, and instability.

Causes and Mechanism of Injury

Most ankle sprains occur when the foot turns inwards sharply, commonly during:

• Running or walking on uneven ground
• Sudden changes of direction in sports
• Landing awkwardly from a jump
• Slipping or tripping

High-energy injuries or forced external rotation may damage the syndesmosis, often referred to as a high ankle sprain, which typically requires longer recovery.

Who Is Most at Risk?

Ankle sprains can affect anyone, but the risk is higher if:

• You participate in pivoting or jumping sports (e.g., football, tennis, rugby, gymnastics)
• You have high-arched feet or biomechanical alignment issues
• You have a previous history of ankle sprains
• You experience poor balance or proprioception
• You wear unsupportive footwear during high-impact activities

Grades of Injury

Sprains are categorised depending on the severity of ligament damage.

Grade	Description	Severity
Grade 1	Ligament overstretching with microscopic fibres damaged	Mild
Grade 2	Partial ligament tear with moderate swelling and pain	Moderate
Grade 3	Complete ligament rupture, severe swelling, instability, difficulty weight-bearing	Severe

Low vs High Ankle Sprains

• Low ankle sprains affect the lateral or medial ligaments. These are far more common.
• High ankle sprains involve the syndesmosis and often require specialist imaging and longer recovery times.

Signs and Symptoms

Symptoms may include:

• Pain around the ankle, often on the outer side
• Swelling and bruising, sometimes spreading into the foot
• Difficulty weight-bearing
• Feeling of instability or “giving way”
• Reduced movement, particularly during walking or stairs

In chronic cases, recurrent sprains, persistent swelling, stiffness, or popping sensations may indicate long-term instability.

Assessment and Diagnosis

A thorough clinical assessment is essential to determine the extent of injury. This includes:

• Mechanism-of-injury history
• Observation of swelling, bruising, and deformity
• Palpation to assess ligament tenderness
• Range-of-motion and strength testing

Special Tests

Common clinical tests include:

• Anterior drawer test (ATFL integrity)
• Talar tilt test (CFL involvement)
• Squeeze or external rotation test (syndesmosis injury)

Imaging

Imaging may be necessary, especially in moderate or severe sprains.

• X-ray is used to rule out fractures.
• Ultrasound can assess ligament fibre disruption in real time.
• MRI is the gold standard in cases of suspected full tears or chronic instability.

Management and Treatment

Acute (Early) Management

Immediately following injury, swelling and pain control is key. Early management typically includes rest, elevation, ice application, compression, and protected weight-bearing as tolerated.

Pain relief and anti-inflammatory medication may also be helpful in the early phase.

Rehabilitation and Physiotherapy

Rehabilitation focuses on restoring joint movement, balance, strength, and stability. Exercises may progress from simple range-of-motion movements to sport-specific activities.

Bracing and Supports

In moderate to severe injuries, functional bracing or taping may help protect the joint while allowing controlled movement.

Surgical Management

Surgery is typically reserved for:

• Complete ligament ruptures causing instability
• High ankle sprains affecting the syndesmosis
• Chronic instability that has not improved despite structured rehabilitation
• Associated injuries such as cartilage damage

Surgical options include:

• Ligament repair or reconstruction
• Syndesmosis stabilisation with screws or flexible fixation devices
• Arthroscopy to treat cartilage injuries or scar tissue

Following surgery, patients usually follow a structured rehabilitation programme lasting several months.

Acute vs Chronic Sprains

Feature	Acute Sprain	Chronic Instability
Symptoms	Pain, swelling, difficulty weight-bearing	Recurrent sprains, instability, discomfort during activity
Treatment	Early management + progressive rehab	Further imaging, specialist referral, possible surgery
Prognosis	Good with early rehab	May require surgical stabilisation if persistent

Prognosis and Long-Term Outlook

Most Grade 1 and 2 sprains recover well within 6–12 weeks. Grade 3 sprains or syndesmotic injuries often take longer, and in some cases may require surgery. With appropriate treatment, most individuals return to full activity, including sport, without long-term consequences.

Untreated or poorly rehabilitated sprains can lead to chronic instability, persistent pain, arthritis, and repeated injuries.

Frequently Asked Questions

How long does it take to recover from an ankle sprain?
Recovery time varies but typically ranges from 2–6 weeks for mild to moderate sprains and up to 3–6 months for severe or high ankle sprains.

Do I need imaging for an ankle sprain?
Not always, but imaging is recommended if you cannot bear weight, there is significant swelling, or symptoms do not improve within 1–2 weeks.

Should I walk on a sprained ankle?
Walking is allowed if tolerated, but excessive early strain may delay healing. A brace or support may help.

When should I see a specialist?
If pain, swelling, or instability persists beyond 6 weeks or if you repeatedly sprain the ankle, specialist review is recommended.

Can ankle sprains become long-term problems?
Yes, without proper rehabilitation, ankle sprains can lead to chronic instability, requiring further assessment or surgical intervention.

References

Fong, D.T-P., Chan, Y-Y., Mok, K-M., Yung, P.S-H. and Chan, K-M. (2009) ‘Understanding acute ankle ligamentous sprain injury in sports’, Sports Medicine, 39(1), pp. 49–64.

NHS (2024) Sprains and strains. Available at: https://www.nhs.uk/conditions/sprains-and-strains (Accessed 2 December 2025).

Van Rijn, R.M., van Os, A.G., Bernsen, R.M., Luijsterburg, P.A., Koes, B.W. and Bierma-Zeinstra, S.M. (2008) ‘What is the clinical course of acute ankle sprains?’, American Journal of Medicine, 121(4), pp. 324–331.