Overview
Three ligaments on the outside of the ankle hold the talus in its socket when the foot rolls inward; the anterior talofibular ligament (ATFL) tears in nearly every sprain and the calcaneofibular ligament (CFL) goes next in harder injuries. A sprain is graded I to III by how much tissue has given way. Ligaments heal at the length they are held in, and the position sense they provide returns more slowly than the pain fades, which is why an unrehabilitated sprain keeps rolling.
A first sprain is a rehabilitation problem, not a surgical one; the visit rules out a fracture or cartilage injury and starts the program the same week. Chronic instability, an ankle that gives way despite proper therapy, is what Dr. O'Donnell considers ligament repair for.
Common Symptoms
- Pain and swelling over the front and outside of the ankle within hours of rolling it, with bruising the next day
- Tenderness just in front of and below the outer ankle bone, over the ATFL, rather than on the bone itself
- In a high ankle sprain, pain above the ankle between the two leg bones, worse with push-off and twisting the foot outward
- With chronic instability, a sense the ankle will give way stepping off a curb, and sprains with ever less provocation
Tenderness on the bone itself, or inability to take four steps, raises the question of an ankle fracture. Deep ankle pain and catching that persist beyond 6 to 8 weeks after a sprain suggest an osteochondral lesion of the talus.
Causes & Risk Factors
The ankle rolls inward with the foot pointed down: landing on another player's foot in basketball, a cut on uneven turf, a misstep on a boat deck, a hiking fall. High ankle sprains, which injure the syndesmosis between tibia and fibula, happen when the planted foot is forced outward, typically in football, soccer and skiing. The strongest predictor of a sprain is a previous sprain, particularly one treated with rest alone. Poor balance and an early return to sport raise the risk. Sprains peak between 15 and 35, and repeated sprains in that group produce chronic instability.
How It Is Diagnosed
Dr. O'Donnell applies the Ottawa ankle rules first: tenderness on the back edge of either malleolus, on the base of the fifth metatarsal or the navicular, or inability to bear weight for four steps means an X-ray is needed. The anterior drawer test pulls the heel forward to assess the ATFL, the talar tilt test rocks the heel inward to assess the CFL, and the squeeze and external rotation tests check the syndesmosis. In a swollen ankle these tests are more reliable at 4 to 5 days, so a second look is sometimes scheduled.
X-rays exclude a fracture and, in chronic instability, show bone spurs or loose bodies. MRI is not needed for a typical sprain; it is ordered when pain or swelling persist past 6 weeks, for a suspected high ankle sprain, or before surgery, since it shows the ligaments, talar cartilage and peroneal tendons. Existing imaging can be sent ahead through mymedicalimages.com.
Treatment Options
Non-operative care
Nearly every sprain, including grade III tears, is treated without surgery. The first days are compression, elevation and walking as soon as tolerable in a lace-up brace; a boot is reserved for the most painful grade III injuries and for high ankle sprains, which need 4 to 8 weeks of protection. Rehabilitation starts within the first week: range of motion, calf and peroneal strengthening with bands, and then the part most people skip, balance and proprioception, progressing from single-leg stance to wobble board to hopping. Return to sport is allowed when the ankle can hop and cut without pain and balance matches the other side; a sport brace is worn for 6 to 12 months because it roughly halves the re-sprain rate. Chronic instability gets the same program for 3 months before surgery is discussed.
Lateral ligament repair for chronic instability
When the ankle still gives way after a full course of rehabilitation and the exam and imaging confirm lax ligaments, Dr. O'Donnell performs a Broström repair, tightening the stretched ATFL and CFL back to the fibula, reinforced with adjacent tissue or suture tape. It is outpatient, often combined with arthroscopy to treat any cartilage damage seen on MRI.
Recovery & What to Expect
Pain settles before the ligament heals, and the ligament heals before balance returns. The timeline below is general, for a first-time sprain treated non-operatively; progression is individualized.
| Phase | Timing | What happens |
|---|---|---|
| Protection | Days 0–7 | Compression, elevation, brace; walking as tolerated; gentle ankle motion; grade III and high ankle sprains may use a boot |
| Motion & strength | Weeks 1–3 | Full range of motion; band strengthening in all four directions; calf raises; stationary bike; normal gait |
| Balance & loading | Weeks 3–6 | Single-leg balance progressing to unstable surfaces; hopping; straight-line jogging once pain-free |
| Return to sport | Weeks 6–12 | Cutting, agility and sport drills; brace for sport; cleared on symmetric hop testing and balance |
Grade I sprains return to sport in 1 to 2 weeks, grade II in 3 to 6, grade III and high ankle sprains in 6 to 12. Driving resumes when you can brake hard, usually within 1 to 2 weeks. After Broström repair the ankle is in a boot for 4 to 6 weeks and sport returns at about 4 to 6 months.
Frequently Asked Questions
Should I get an X-ray for a sprained ankle?
Yes if you are tender on the bone at the back of either ankle knob or the outer edge of the midfoot, or cannot take four steps; those are the Ottawa rules and they catch nearly all fractures. Tenderness only over the soft tissue in front of the outer ankle bone does not need one.
How long does a sprained ankle take to heal?
A mild sprain is back to sport in 1 to 2 weeks, a moderate one in 3 to 6 weeks, and a complete tear or high ankle sprain in 6 to 12 weeks. Pain resolves well before the ligament has healed, which is the risk; balance training through week 6 is what prevents the next sprain.
Should I walk on a sprained ankle or rest it?
Walk, in a brace, as soon as it is tolerable. Early movement heals the ligament at the right length and restores balance sooner; rest produces a stiff, weak, unstable joint. The exceptions are a suspected fracture and a high ankle sprain, which need a boot before loading.
Why does my ankle keep giving way?
Because the ligaments healed long and the balance reflexes that protect the ankle never came back. Most are fixed with 3 months of peroneal strengthening and balance training plus a sport brace. If the ankle still rolls after that and the exam confirms lax ligaments, a Broström repair tightens them and restores stability.
Do I need surgery for a torn ankle ligament?
Almost never for the initial injury, even when the ligament is completely torn; rehabilitation and surgery give equivalent results for acute sprains. Surgery is for chronic instability that has failed a proper rehabilitation program, and for a syndesmosis injury that has separated the tibia and fibula on X-ray.
This page is for general education and is not a substitute for a medical evaluation. Treatment recommendations depend on your individual diagnosis and goals. Kevin O'Donnell, MD sees patients from Coral Gables, Miami, Brickell, Pinecrest and Coconut Grove at 475 Biltmore Way, and out-of-town patients by telemedicine.