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Health condition · Clinically reviewed

Ankle sprains, grading, Ottawa Rules and the rehabilitation that stops the next one.

A single guide covers lateral, high ankle and recurrent sprains. See our companion piece on the single ankle sprain for the first-episode journey, and on chronic ankle instability for the roughly 40% who go on to recurrent symptoms.

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A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against NICE CKS, BOFAS and peer-reviewed sports medicine sources listed at the end.

  • 03

    Current for 2026

    Reflects modern UK practice: Ottawa Ankle Rules, POLICE over PRICE, and functional rehabilitation as first-line.

Key facts

Ankle sprains at a glance.

What actually gets injured, how we grade it, and the two things that most change outcomes: excluding fracture early, and finishing rehabilitation properly.

  • What it is

    Ligamentous injury to the ankle, most commonly the lateral ligament complex, from an inversion force during walking, sport or a stumble.

  • How common

    One of the most common musculoskeletal injuries in the UK, with roughly 5,600 sprains treated every day across A and E departments.

  • Grading

    Grade I is a stretch, Grade II a partial tear, Grade III a complete rupture with instability. Grade guides recovery, not just pain.

  • High ankle sprain

    Syndesmotic injury from external rotation. Rarer, harder to spot on plain films, and slower to settle than a lateral sprain.

  • Excluding fracture

    The Ottawa Ankle Rules select who needs an X-ray. They are highly sensitive and reduce unnecessary imaging.

  • Foundation care

    POLICE (Protection, Optimal Loading, Ice, Compression, Elevation) plus early functional rehabilitation beats prolonged rest.

Why this guide matters

Common, treatable, and often mismanaged.

An ankle sprain is usually shrugged off in the first week, then blamed for weakness a year later. The three points below drive the rest of this page.

  • Exclude fracture first

    The Ottawa Ankle Rules take seconds and reliably select who needs an X-ray. Miss a fracture and everything downstream gets harder.

  • Load early, don't rest for weeks

    Optimal loading (the L in POLICE) is the modern standard. Prolonged immobilisation stiffens the ankle and delays return to activity.

  • Finish rehabilitation

    Around 40% of sprains become recurrent. Proprioception, strength and sport-specific drills for at least 6 weeks are what stops the next one.

How the diagnosis is made

From twist to a clear rehabilitation plan.

The steps a UK GP, physiotherapist or foot and ankle specialist will normally follow, in order - so you know what to expect and why.

  1. 01

    Assessing

    Mechanism and timing

    Inversion (foot rolls inward) is by far the most common. Eversion, external rotation or a "pop" at the time of injury changes what you look for.

  2. 02

    Assessing

    Focused examination

    Swelling and tenderness pattern over the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), posterior talofibular ligament (PTFL) or syndesmosis.

  3. 03

    Assessing

    Stability tests

    Anterior drawer for ATFL, talar tilt for CFL, squeeze and external rotation tests for a syndesmotic (high ankle) injury.

  4. 04

    Confirming

    Ottawa Ankle Rules

    X-ray if there is bony tenderness at the posterior edge or tip of either malleolus, the base of the fifth metatarsal, the navicular, or inability to weight-bear four steps.

  5. 05

    Confirming

    Ultrasound or MRI

    Reserved for persistent symptoms beyond 4 to 6 weeks, suspected osteochondral lesion, syndesmotic disruption or when planning surgery.

  6. 06

    Preparing

    Grade the injury

    Grade I: microscopic ATFL damage, minimal swelling. Grade II: partial ATFL with or without CFL, moderate swelling. Grade III: complete rupture with instability.

  7. 07

    Preparing

    Plan the rehabilitation ladder

    Set expectations, agree the weight-bearing, proprioception and strength stages, and score progress with FADI or AOFAS.

Typical timeline: Grade I settles in 1 to 2 weeks, Grade II in 3 to 6 weeks, Grade III and high ankle sprains often 3 to 6 months.

Grading and subtypes

Not all sprains are the same.

The mechanism tells us which ligaments are at risk. The grade tells us how long recovery is likely to take and whether early bracing is needed.

  • Grade I - stretch

    Microscopic damage to the ATFL. Minimal swelling, normal stability, weight-bearing possible. Usually settles in 1 to 2 weeks with POLICE and early rehab.

  • Grade II - partial tear

    Partial ATFL rupture, sometimes with CFL involvement. Moderate swelling and bruising, painful weight-bearing, mild laxity on drawer testing. 3 to 6 weeks to walk comfortably, up to 3 months for sport.

  • Grade III - complete rupture

    Complete rupture of ATFL and CFL, often with PTFL involvement. Marked swelling, unable to weight-bear, gross instability. Boot immobilisation early, structured rehabilitation, occasionally surgery.

  • High ankle sprain - syndesmotic injury

    External rotation mechanism. Pain above the joint line, positive squeeze test. Longer immobilisation, slower return - often measured in months, not weeks.

  • Medial (deltoid) sprain

    Eversion mechanism, uncommon in isolation. Consider an associated fracture (Weber B or Maisonneuve) and image the whole fibula.

  • Recurrent sprain - what to look for

    Three or more sprains, or persistent giving way, warrants investigation for osteochondral lesion, syndesmotic injury, peroneal tendon subluxation, tarsal coalition or accessory navicular.

    • Symptoms

    What a sprained ankle actually feels like.

    Pain, swelling and difficulty walking - and the subtler features that hint at a higher-grade injury or a hidden fracture.

    • Lateral pain and swelling

      Classic pattern after an inversion twist. Tenderness maximal over the ATFL, just anterior to the lateral malleolus.

    • Bruising within 24 to 48 hours

      Bruising tracks distally into the foot with gravity. Extensive bruising suggests a higher-grade injury.

    • Difficulty weight-bearing

      Unable to take four steps immediately and in clinic is one of the Ottawa criteria for imaging.

    • Feeling of giving way

      The ankle rolls or buckles on uneven ground. A key marker for functional instability and chronic sequelae.

    • Stiffness and reduced range

      Loss of dorsiflexion in particular limits stairs, squats and running gait during recovery.

    • High ankle pain

      Pain above the ankle, worse with external rotation or push-off. Suggests syndesmotic (high ankle) injury.

    • Recurrent sprains

      A second or third sprain in the same ankle is a signal to investigate for structural or proprioceptive problems.

    • Red flag - deformity or numbness

      Obvious deformity, unable to bear any weight, numbness or a cold, dusky foot need urgent assessment for fracture-dislocation.

    Treatment

    How ankle sprains are treated in the UK.

    POLICE in the first days, functional rehabilitation as the main event, and bracing or surgery reserved for the injuries that truly need them.

    • POLICE in the first 72 hours

      Protection, Optimal Loading, Ice, Compression, Elevation. Optimal loading has replaced strict rest - gentle early movement speeds recovery.

    • Short-term brace or air-cast

      A semi-rigid brace for two to four weeks in Grade II and III sprains reduces pain and re-injury while allowing walking.

    • Analgesia

      Paracetamol first line, topical NSAIDs (ibuprofen gel) as adjunct. Short-course oral NSAIDs if not contraindicated.

    • Functional rehabilitation

      Progressive weight-bearing, range of motion, calf and peroneal strengthening, then balance and proprioception drills - the single biggest driver of good outcomes.

    • Proprioception training

      Wobble board, single-leg stance and hop drills reduce recurrence. Continue for at least 6 weeks after symptoms settle.

    • Sport-specific return to play

      Graded reintroduction using FADI or AOFAS scoring - hopping, cutting, sprinting - before match play. Bracing or taping for the first season back.

    • High ankle sprain protocol

      Longer immobilisation (often boot for 4 to 6 weeks), non-weight-bearing initially, and a slower rehabilitation - recovery is measured in months, not weeks.

    • Surgery for the right cases

      Rarely needed acutely. Considered for Grade III injuries in elite athletes, frank syndesmotic diastasis, or established chronic instability - typically Brostrom repair.

    What this guide is based on

    The sources behind every claim on this page.

    UK national guidance and specialist society standards, current at the time of last review.

    Key references

    Guidelines and standards we relied on.

    A quiet reminder

    This guide is for information, not medical advice.

    Your GP, physiotherapist or foot and ankle surgeon knows your history and can tell you which parts apply to you. If in doubt, get seen.

    • NICE CKS. Sprains and strains.

    • British Orthopaedic Foot and Ankle Society (BOFAS). Guidance on lateral ligament injuries and chronic ankle instability.

    • Ottawa Ankle Rules - Stiell et al, original derivation and validation studies.

    • Kerkhoffs GMMJ et al. Diagnosis, treatment and prevention of ankle sprains: ESSKA position statement.

    Red flags

    When an ankle sprain needs urgent attention.

    Most sprains settle with time and rehabilitation. These are the situations that don’t - and where imaging or specialist review is warranted.

    • Unable to weight-bear at all

      Complete inability to take four steps, immediately and in clinic, meets the Ottawa criteria - image to exclude a fracture.

    • Bony tenderness at malleoli

      Point tenderness at the posterior edge or tip of either malleolus is an Ottawa criterion - X-ray is warranted.

    • Deformity or neurovascular compromise

      Obvious deformity, cold or pale foot, or new numbness needs urgent A and E assessment for fracture-dislocation.

    • Suspected syndesmotic (high) sprain

      Pain above the joint line, positive squeeze or external rotation test - manage in a boot and refer for specialist review.

    • Recurrent giving way

      Three or more sprains, or persistent instability beyond three months - see the ankle-instability guide and consider imaging.

    • Locking or catching

      Mechanical symptoms after a sprain raise concern for an osteochondral lesion of the talus - MRI is the imaging of choice.

    • Peroneal tendon pain or clicking

      Snapping behind the lateral malleolus can indicate peroneal tendon subluxation - a treatable but often missed diagnosis.

    • Persistent symptoms beyond 6 weeks

      If pain, swelling or instability persist past 6 weeks despite rehabilitation, escalate for imaging and specialist opinion.

    • Recurrent sprains in a child

      Consider tarsal coalition, accessory navicular or an underlying hypermobility syndrome - refer for paediatric orthopaedic review.

    Living with it

    A short injury, a longer rehabilitation.

    Four things that make the biggest difference: early sensible loading, restoring balance, scoring before returning to sport, and protecting the ankle in high-risk activity.

    A quiet reminder

    Rehabilitation stops the next sprain, not the crutches.

    A first sprain is a warning shot. The people who never sprain again are the ones who finish their proprioception and strength programme.

    1. 01 Load

      Move it, don't rest it

      Optimal loading means early, gentle weight-bearing as pain allows. Prolonged rest slows healing and stiffens the joint.

    2. 02 Rehab

      Balance is the missing step

      Most re-sprains happen because proprioception was never restored. Wobble board and single-leg drills matter as much as strengthening.

    3. 03 Return

      Score before you play

      Use a FADI or AOFAS score, plus hop and cutting tests, before returning to sport. Confidence follows capability.

    4. 04 Protect

      Brace or tape for high-risk sport

      For the first season back - and lifelong in cutting sports - a brace or tape reduces re-injury without hampering performance.

    Frequently asked

    Everything we get asked about ankle sprains.

    Quick answers on grading, imaging, POLICE, recovery time and recurrent sprains.

    • What is an ankle sprain?

      A stretch or tear of one or more ligaments around the ankle - most commonly the anterior talofibular ligament (ATFL) on the outside of the joint, caused by rolling the foot inwards. Severity ranges from a microscopic stretch (Grade I) to a complete rupture with instability (Grade III).

    • How is a sprain different from a fracture?

      A sprain injures ligaments, a fracture breaks bone - but they often look similar in the first hours. The Ottawa Ankle Rules select who needs an X-ray: bony tenderness at the malleoli, base of the fifth metatarsal or navicular, or inability to take four steps. If any of those apply, we image.

    • Do I need an X-ray?

      Only if you meet the Ottawa Ankle Rules. Most Grade I and II sprains do not need imaging. Persistent pain beyond 4 to 6 weeks, mechanical symptoms or suspected high ankle injury may prompt ultrasound or MRI later.

    • PRICE or POLICE - which is right?

      POLICE has replaced PRICE in modern practice. The change is Optimal Loading instead of strict Rest - early, gentle weight-bearing within pain limits speeds recovery. Protection, Ice, Compression and Elevation still apply for the first 48 to 72 hours.

    • How long will it take to recover?

      Grade I sprains usually settle in 1 to 2 weeks. Grade II takes 3 to 6 weeks to walk comfortably and up to 3 months for full sport. Grade III and syndesmotic (high ankle) sprains often take 3 to 6 months. Structured rehabilitation shortens all of these.

    • Why do I keep spraining the same ankle?

      Around 40% of people develop chronic ankle instability after a first sprain, usually because proprioception was never rebuilt. Recurrent sprains also warrant investigation for an osteochondral lesion of the talus, syndesmotic injury, peroneal tendon subluxation, tarsal coalition or an accessory navicular. See our dedicated chronic ankle instability guide.

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