A sprain is an injury to a ligament. PRICE (Protection, Rest, Ice, Compression, and Elevation) and avoiding HARM (Heat, Alcohol, Running, and Massage) are commonly advised for the first 48-72 hours after a sprained ankle. Painkillers may be needed. Most sprains heal within a few weeks. Physiotherapy may help. For severe sprains where the ligament ruptures (tears badly), a brace or plaster cast may be helpful. In some cases, surgery may be advised for a severe sprain. Note: this leaflet does not advise on how to distinguish what injury you have. For example, if you have an ankle injury, it is sometimes difficult to tell if you have a bone fracture. Therefore, see a doctor or nurse if you suspect that you have a fracture. This leaflet assumes you know that you have a sprained ankle (for example, having been told by a doctor or nurse) and nothing more serious.
What is a sprain?
A sprain is an injury to a ligament. Ligaments are strong tissues around joints which attach bones together. They give support to joints. A ligament can be injured, usually by being stretched during a sudden pull. The ligaments at the side of the ankle are the ones most commonly sprained.
A damaged ligament causes inflammation, swelling, and bleeding (bruising) around the affected joint. Movement of the ankle joint is painful when you have a sprained ankle. The picture shows a badly sprained ankle with fairly extensive bruising.
The severity of a sprain is graded into:
- Grade I - mild stretching of the ligament without joint instability.
- Grade II - partial rupture (tear) of the ligament but without causing joint instability (or with mild instability of the joint).
- Grade III - complete rupture (tear) of the ligament with instability of the joint. Sometimes this is simply called a severe ankle sprain.
A high ankle sprain is a sprained ankle in which the ligament above the ankle joint is torn. This ligament links the two bones of the lower leg (the tibia and fibula). It may get torn during certain types of ankle injuries, such as skiing or football injuries. A high ankle sprain takes longer to heal compared to the usual type of ankle sprain, where the ligaments at the side of the joint are injured. A high ankle sprain may be suspected if the joint is still painful more than six weeks after the original injury. Another name for this type of sprain is syndesmosis sprain, because the ligament involved is also called a syndesmosis.
What is the aim of treatment?
Usually, the damaged ligament heals by itself over time. Some scar tissue may be produced where there has been a tearing of tissues.
The main aims of treatment are to keep inflammation, swelling, and pain to a minimum, and to be able to use the ankle joint normally again as quickly as possible.
What is the treatment of a sprained ankle?
For the first 48-72 hours think of:
- Paying the PRICE - Protect, Rest, Ice, Compression, Elevation, and
- Do no HARM - no Heat, Alcohol, Running or Massage.
Paying the PRICE
P rotect the injured ankle from further injury. For example, a bandage and/or ankle support may help with this. A lace-up shoe or boot with high sides is also protective.
R est the ankle joint for 48-72 hours following injury. For example, consider the use of crutches when wanting to be mobile.
I ce should be applied as soon as possible after injury, for 10-30 minutes. Less than 10 minutes has little effect. More than 30 minutes may damage the skin. Make an ice pack by wrapping ice cubes in a plastic bag or towel. (Do not put ice directly next to skin, as it may cause ice-burn.) A bag of frozen peas is an alternative. Gently press the ice pack on to the injured part. The cold from the ice is thought to reduce blood flow to the damaged ligament. This may limit pain and inflammation. After the first application, some doctors recommend re-applying for 15 minutes every two hours (during daytime) for the first 48-72 hours. Do not leave ice on while asleep.
C ompression with a bandage will limit swelling, and help to rest a joint. A tubular compression bandage or an elastic bandage can be used. The bandage should not be too tight - mild pressure that is not uncomfortable and does not stop blood flow is the aim. A pharmacist will advise on the correct size. Remove before going to sleep. You may be advised to remove the bandage for good after 48 hours, so that the joint can move. However, sometimes it is advisable to kept the bandage on for longer, to help lessen the swelling and to keep the joint more comfortable.
E levation aims to limit and reduce any swelling. For example, keep the foot up on a chair to at least hip level when you are sitting. (It may be easier to lie on a sofa and to put your foot on some cushions.) When you are in bed, put your foot on a pillow.
Avoid HARM for 72 hours after injury. That is, avoid:
H eat - for example, hot baths, saunas, heat packs. Heat has the opposite effect on the blood flow than ice. That is, it encourages blood flow. So, heat should be avoided when inflammation is developing. However, after about 72 hours, no further inflammation is likely to develop and heat can then be soothing.
A lcohol drinks, which can increase bleeding and swelling and decrease healing.
R unning, which may cause further damage.
M assage, which may increase bleeding and swelling. However, as with heat, after about 72 hours, gentle massage may be soothing.
Your doctor will advise. The advice may typically include:
- Do not stop moving the joint. Don't do anything that causes much pain, but gently get the joint moving again. Perhaps do gentle exercises several times a day. The aim is to get the ankle joint moving in all normal directions, and to prevent it becoming stiff.
- Consider wearing some sort of ankle support whilst going about your normal activities until symptoms have gone. There are various forms of ankle supports and braces which can be used - from an elasticated bandage to a specialised brace. The braces can be lace-up or pneumatic (pumped with air, rather like an inflatable life jacket around the ankle), for example. The aim is to give some support to the joint whilst the damaged ligament is healing, but to allow the ankle to be able to move to a reasonable degree.
- Physiotherapy may help for more severe sprains, or if symptoms are not settling. A physiotherapist can advise on exercises and may give heat, ultrasound, or other treatments. The aim of physiotherapy includes:
- To get the ankle joint back to a full range of normal movement.
- To improve the strength of the surrounding muscles. The stronger the muscles, the less likely it is that a sprain will recur.
- Exercises designed to improve proprioception. This means the ability of your brain to sense the position and movement of your joints. Good proprioception helps you to make immediate, unconscious minor adjustments to the way you walk when walking over uneven ground. This helps to prevent you overstretching ligaments and causing further sprains.
- You should not play sport or do vigorous exercise involving the ankle for at least 3-4 weeks after the injury.
Treatment of severe sprains
Extra treatment may be needed for some types of ankle sprain:
- Severe sprains (where the ligaments are badly torn or the joint is unstable).
- A high ankle sprain, where the ligament above the ankle joint is torn (as explained above).
There is some evidence that these types of sprain may heal more quickly if treated with a short period of immobilisation. This means wearing a brace or a plaster cast on the lower leg and ankle for a few weeks.
In some cases, if ligaments are very badly torn or the joint is too unstable, surgery may be advised. Your doctor will assess if this is necessary (but it is not needed in most cases).
If the sprained ankle is still very painful six weeks after the original injury, you may be advised to have additional tests to look at the joint. Sometimes there are torn ligaments or small fractures which do not show up at when the injury first happens, since the ankle may be very swollen at this time and is difficult to test fully. So if a sprained ankle is not healing in the expected time, your doctor may suggest another examination of the joint, a further X-ray or a scan.
What about medication?
You may not need any medication if the sprain is mild and you can tolerate the pain. If needed, painkiller options include the following:
Paracetamol and codeine
Paracetamol is useful to ease pain. It is best to take paracetamol regularly, for a few days or so, rather than every now and then. An adult dose is two 500 mg tablets, four times a day. If the pain is more severe, a doctor may prescribe codeine, which is more powerful, but can make some people drowsy and constipated.
These medicines are also called non-steroidal anti-inflammatory drugs (NSAIDs). They relieve pain and may also limit inflammation and swelling. There are many types and brands. You can buy two types (aspirin and ibuprofen) at pharmacies, without a prescription. You need a prescription for the others. Side-effects sometimes occur with anti-inflammatory painkillers. Stomach pain, and bleeding from the stomach, are the most serious. Some people with asthma, high blood pressure, kidney failure, and heart failure may not be able to take anti-inflammatory painkillers. So, check with your doctor or pharmacist before taking them, to make sure they are suitable for you.
There has been debate about whether anti-inflammatory painkillers may delay healing. The logic is that some inflammation is a necessary part of the healing process. On the other hand, anti-inflammatory painkillers may be helpful for relieving the pain of a sprained ankle. Current advice from UK guidelines is to put off taking this type of painkiller until 48 hours after the actual injury. Further research is needed to clarify the use of anti-inflammatory painkillers following an injury.
If you take anti-inflammatory medication, ibuprofen is recommended as the one least likely to cause side-effects.
Rub-on (topical) anti-inflammatory painkillers
Again, there are various types and brands. You can buy one containing ibuprofen at pharmacies, without a prescription. You need a prescription for the others. There is debate as to how effective rub-on anti-inflammatory painkillers are compared to tablets. Some studies suggest that they may be as good as tablets for treating sprains. Other studies suggest they may not be as good. However, the amount of the medicine that gets into the bloodstream is much less than with tablets, and there is less risk of side-effects.
When to see a doctor
You should see a doctor if there is any concern about the injury, or if the injury is severe. In particular, see a doctor if:
- You suspect a bone may be broken or a ligament is ruptured.
- You have a lot of tenderness over a bone.
- The leg or joint looks deformed (out of shape) rather than just swollen - this may mean there is a fracture or dislocation which needs urgent treatment.
- There is loss of circulation in the foot (a numb, cold foot with pale or bluish skin) - if this occurs, treatment is urgent.
- The pain is severe, or if you cannot walk because of an injury.
- Bruising is severe.
- The joint does not seem to work properly after the pain and swelling have gone down. This may be a sign of an additional injury such as a torn tendon.
- Symptoms and swelling do not gradually settle. Most sprains improve after a few days, and the pain gradually eases. However, the pain often takes several weeks to go completely, especially when you use the injured joint.
You can help to prevent ankle sprains by wearing boots that give ankle support rather than shoes when hiking across country or rambling over hills and uneven ground. Boots are often best for manual labourers too.
Also, exercises to build up the muscles around the ankle and to improve proprioception (described earlier) help to prevent ankle sprains. A physiotherapist can advise on these exercises.
Further reading & references
- Sprains and strains, Prodigy (July 2008)
- Slimmon D, Brukner P; Sports ankle injuries - assessment and management. Aust Fam Physician. 2010 Jan-Feb;39(1-2):18-22.
- Young CC et al, Ankle sprain, Medscape, Sep 2011
- Kemler E, van de Port I, Backx F, et al; A systematic review on the treatment of acute ankle sprain: brace versus other Sports Med. 2011 Mar 1;41(3):185-97.
- Seah R, Mani-Babu S; Managing ankle sprains in primary care: what is best practice? A systematic Br Med Bull. 2011;97:105-35. Epub 2010 Aug 14.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Tim Kenny
Dr Naomi Hartree
Dr Tim Kenny