Understanding Severity of Ankle Sprains & Deciding Next Steps After Injury

Ankle sprains are one of the most common injuries, especially among athletes and active individuals. They occur when the ligaments that support the ankle stretch or tear, usually due to twisting or rolling the foot. Sprains are classified into three grades based on severity: Grade I, Grade II, and Grade III.

Grade I: Mild Sprain

• Slight stretching and microscopic tearing of the ligament fibers.

• Symptoms typically include mild pain, slight swelling, and minimal bruising. The ankle may feel tender, but stability is generally maintained.

• Function/Recovery: Most people can still walk with minimal discomfort, and recovery usually takes a few days to a week with rest, ice, compression, and elevation (R.I.C.E).

Grade II: Moderate Sprain

• A partial tear of the ligament. It is more serious than Grade I.

• Symptoms include moderate pain, noticeable swelling*, bruising*, and some loss of ankle function.

• Function/Recovery: Walking may be painful, and there may be some instability. Treatment may involve a brace or splint, and recovery can take several weeks*.

Grade III: Severe Sprain

• A complete tear or rupture of the ligament.

• Symptoms include severe pain*, significant swelling*, extensive bruising*, and major instability of the ankle*.

• Function/Recovery: Walking is typically very difficult or impossible without assistance. This type of sprain may require immobilization, physical therapy, and in some cases, surgery. Full recovery can take several months.

Deciding Next Steps

The symptoms of the injury and how you score on the Ottawa Ankle Rules dictates next steps the most. The Ottawa Ankle Rules help determine the need for x-ray imaging and likelihood of fracture. If you have 1. Boney Tenderness AND 2. Inability to bear weight on the ankle immediately and within a short period later, an x-ray is required. If you don't have both, you may decide to delay your visit to a medical clinic.

For those with symptoms more characteristic of Grade 1 & 2 Sprains, you may choose to consider a "Wait & See Approach" or 7 Day Rule. If symptoms gradually improve over the course of a week or two, continuing with symptom self-management is often reasonable. If there are signs of a Grade 2 sprain, an 'over the counter' ankle brace can help improve sense of stability, reduce swelling, and minimize use or excessive movement of the healing ankle. Some ankle braces can be uncomfortable if they put pressure on the injured area or may make it difficult to wear shoes so be prepared to try a few. Pursuing manual treatments and return to activity prescriptive programming from a Physical Therapist to resolve symptoms and restore function is incredibly helpful to athletes and active individuals. Doctors of Physical Therapy provide activity guidance and progressions specific to the injury severity, symptoms, function, and sporting demands. Most importantly, PT intervention significantly reduces risk of future ankle sprain injuries - up to 50%.

Grade 2 Ankle Sprain Swelling, Bruising

For those with symptoms more characteristic of Grade 2 & 3 Sprains, seeking evaluation at a medical office or urgent care is more often warranted. A trip to urgent care often results in standard x-rays and/or MRI to rule out fracture or complete ligament rupture is the most important reason to go. If a fracture or complete tear is identified, you'll be immobilized with boot/cast, restricted from putting weight through the ankle, and referred to an orthopedic surgeon for further management. You may additionally get general pain management recommendations including medication, icing recommendations, distribution of a brace or walking aid like crutches, and a referral to Physical Therapy. If you want more specific recommendations for conservative management, don't waste the referral to PT.

Risks from Improper Management

If someone suffers an ankle sprain and does not undergo structured physical therapy, their risk of reinjury is very high (30–70%), with up to 40% developing chronic ankle instability. Physical therapy dramatically reduces this risk by improving strength, balance, and neuromuscular control. Chronic ankle instability can alter natural movement patterns and risk injury further up the leg including knee, hip or back injuries in the future.

If you have any other questions regarding treatment for a new or old ankle sprain, or starting an injury prevention program for you, your athlete, or your team, make an appointment with your trusted, local Physical Therapist.