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Ankle sprain prevention and rehabilitation

By Doug James – Podiatrist and Physiotherapist 

Ankle sprains are a very common injury. Described as ‘the most common sporting injury’ [1] they can also occur when not exercising or participating in sport and account for 5% of hospital emergency department admissions [6]. Ankle sprains can result in significant amounts of pain, time off work and exercise [4], and may have long term side effects if not managed well. The following article offers advice on how to manage the injury in the unfortunate instance that it does occur.

What is an ankle sprain?

Ankle sprains occur when the foot moves in a way that stretches, or in some cases – ruptures, the ligaments that attach the foot to the lower leg bones. Lateral ankle sprains are the most common type and occurs when the foot rolls outwards stretching one or more of the three lateral ankle ligaments. Additionally, fractures and damage to cartilage in the ankle joint can occur resulting in a more complex injury. Details of these complex injuries and a description of the grading of ankle injuries are covered in a recent article read here.

The impact of ankle sprains

In most cases, an ankle sprain will result in some degree of ankle pain [1,2,5,6,7]. This is most likely due to injury of the lateral ankle ligaments, but may also be due to a strain in an adjacent muscle or tendon, a nerve injury or broken bone. While most ankle sprains will become less painful within a few days, around 40% of cases will have resultant ligament laxity [2] and Chronic Ankle Instability (CAI). Chronic ankle instability causes ongoing pain, swelling, and/or giving way for at least a year after the initial sprain [5]. CAIs are known to result in early osteoarthritis [1,3,5]. Additionally, 73% of people that have had an ankle sprain before will likely have another one [1].

How to avoid long term problems

Ankle sprains are frequently dismissed as an insignificant injury [3]. The attitude that it’s “just an ankle sprain” tends to result in little follow up once the initial pain has settled. However, to reduce the risk of ongoing instability, increased sprain risk, and possible early onset ankle osteoarthritis, certain principles should be abided [3].

Phase 1: Reduce pain and swelling

The longstanding rehabilitation principles ‘R.I.C.E.’ (Rest, Ice, Compression, Elevation) for acute injuries, still stands true for ankle sprains – after all, they were employed with good effect over the past few decades. RICE later evolved into P.R.I.C.E. (adding in ‘Protection’ or bracing), then P.R.I.C.E.R. (‘Rehabilitation’ was included), and more recently an ankle sprain specific mnemonic ‘NICE & EASY’ [3] was formulated. ‘NICE’ relates to the use of Non-steroidal anti-inflammatories (NSAIDs such as ibuprofen), and applying ICE packs to the ankle. Care is required in both cases to avoid gastro-intestinal upset and skin damage respectively.

The ‘EASY’ component involves using an External Ankle Support (i.e. an ankle brace) for up to 1 Year [3]. It is important to note however that the brace is supplementary to, and does replace a rehabilitation program [7].

Phase 1 is usually employed for the first 3-7 days post injury, or longer as required.

Phase 2: Regaining movement

Fear of movement is not uncommon, nor unexpected following a painful and traumatic injury such as an ankle sprain [3]. If you’re able to stand up without extreme pain, there is a fairly low risk of any fractures present, and so resuming some movement is important. Movement can not only help improve tissue healing, but help to reduce pain and swelling in the ankle [3]. A simple yet effective way to encourage movement is to use your foot each hour to draw the alphabet in the air. More specific and advanced exercises are available from a Sports Podiatrist or Physiotherapist. Phase 2 can usually begin within a few hours to a few days after commencing Phase 1 depending on pain tolerance.

Phase 3: Co-ordination training

Ankle sprains frequently result in reduced ankle stability. This can be due partly to laxity in the ankle ligaments caused by the sprain itself, however delayed activation and reduced strength in the active ankle evertor muscles (on the outside of the lower leg) will also play a role. It’s been found that use of an ankle brace (as advocated in Phase 1) tends to result in reduced ankle evertor muscle activation [3,7,8], and so dedicated strength, balance, and proprioception (awareness of limb position) training is necessary. Traditionally Phase 3 would start once ankle pain has ceased, however research is suggesting that it can begin early in the rehab phase [3]. As with Phase 2, seeing a sports specific Health Professional for a rehabilitation plan is ideal. Most exercises can be completed at home with everyday items, with the addition of resistance bands for improved strength.

Phase 4: Return to Sport training

Neglecting the first three phases of ankle sprain rehabilitation increases the risk of long term issues such as Chronic Ankle Instability and early onset ankle arthritis [1,3]. Additionally, by neglecting a considered Return to Sport training phase, you not only increase your likelihood of being one of the 73% of people likely to sprain your ankle repeatedly [1], you are at a statistically higher chance of developing an additional injury. During the first year following an ankle sprain it is recommended to brace or tape your ankle for added support [1].

A return to sport program should include training drills and strengthening exercises that are specific to the sport you are involved in. For distance running this can include things like hopping, bounding and short interval runs to improve conditioning and fitness. Trail running requires slightly more focus on balance and reaction time drills due to the unpredictable nature of the terrain, and the higher risk of ankle injury when running off-road. Seeing a Sports Podiatrist or Physiotherapist that specialises in injury management of your sport is key to a successful return.

Have you had this injury before? If so, you’ve got a 73% chance of getting it again! Learn how to reduce your risk, and enjoy your running.

Come and see the intraining running injury clinic team

If you’ve sprained your ankle in the past year, or are planning to participate in trail running it’s worth booking an appointment at the intraining running injury clinic. The running specialist Podiatrists and Physiotherapist can help:

Doug James Colour 2020 1

Doug James – intraining Podiatrist and Physiotherapist 

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  1. Collado, H, Coudreuse, J. M, Graziani, F, Bensoussan, L, Viton, J. M, & Delarque, A. (2010). Eccentric reinforcement of the ankle evertor muscles after lateral ankle sprain. Scandinavian Journal of Medicine & Science in Sports, 20(2), 241–246.
  2. Kerkhoffs, Gino M, van den Bekerom, Michel, Elders, Leon A M, van Beek, Peter A, Hullegie, Wim A M, Bloemers, Guus M F M, de Heus, Elly M, Loogman, Masja C M, Rosenbrand, Kitty C J G M, Kuipers, Ton, Hoogstraten, J W A P, Dekker, Rienk, ten Duis, Henk-Jan, van Dijk, C Niek, van Tulder, Maurits W, van der Wees, Philip J, & de Bie, Rob A. (2012). Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. British Journal of Sports Medicine, 46(12), 854–860.
  3. McKeon, Patrick O, PhD,A.T.C., C.S.C.S., & Donovan, Luke,PhD., A.T.C. (2019). A Perceptual Framework for Conservative Treatment and Rehabilitation of Ankle Sprains: An Evidence- Based Paradigm Shift. Journal of Athletic Training, 54(6), 628-638.
  4. Schiftan, Gabriella Sophie, Ross, Lauren Ashleigh, & Hahne, Andrew John. (2014). The effectiveness of proprioceptive training in preventing ankle sprains in sporting populations: A systematic review and meta-analysis. Journal of Science and Medicine in Sport, 18(3), 238–244.
  5. Vuurberg, Gwendolyn, Hoorntje, Alexander, Wink, Lauren M, van der Doelen, Brent F W, van den Bekerom, Michel P, Dekker, Rienk, van Dijk, C Niek, Krips, Rover, Loogman, Masja C M, Ridderikhof, Milan L, Smithuis, Frank F, Stufkens, Sjoerd A S, Verhagen, Evert A L M, de Bie, Rob A, & Kerkhoffs, Gino M M J. (2018). Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. British Journal of Sports Medicine, 52(15), 956–956.
  6. O’Connor SR, Bleakley CM, Tully MA, McDonough SM (2013) Predicting Functional Recovery after Acute Ankle Sprain. PLoS ONE 8(8): e72124.
  7. Raymond, Jacqueline, Nicholson, Leslie L, Hiller, Claire E, & Refshauge, Kathryn M. (2012). The effect of ankle taping or bracing on proprioception in functional ankle instability: A systematic review and meta-analysis. Journal of Science and Medicine in Sport, 15(5), 386–392.
  8. Kemler, Ellen, van de Port, Ingrid, Schmikli, Sandor, Huisstede, Bionka, Hoes, Arno, & Backx, Frank. (2015). Effects of soft bracing or taping on a lateral ankle sprain : a non-randomised controlled trial evaluating recurrence rates and residual symptoms at one year. Journal of Foot and Ankle Research, 8(1), 13–13.