Lateral Ankle Sprains in Athletes: Why the First Sprain Matters
Kathy Ryan-Ceisel, PT MHS | Algonquin Sports PT
Overhead Throwing Expert-Athletic Edge and Wellness Edge
A lateral ankle sprain is one of the most common injuries in sports. Athletes can sustain an ankle sprain while running, cutting, jumping, landing, sliding, changing direction or simply stepping on another player’s foot.
Because many ankle sprains initially feel better within a few days, athletes often make the mistake of assuming the ankle is “healed” before the ligament, strength, balance and neuromuscular control have fully recovered. That can become a problem.
An inadequately rehabilitated first ankle sprain can lead to recurrent sprains, persistent pain, loss of ankle mobility, weakness and chronic ankle instability (CAI). Research suggests that ankle instability is strongly associated with recurrent ankle sprains, with the relationship becoming stronger as time passes after the original injury. (PubMed)
For athletes—particularly baseball and softball players—an ankle injury can also affect much more than the ankle. Loss of lower-extremity strength and power can interfere with the kinetic chain responsible for transferring force from the ground through the hips and trunk to the throwing arm.
What Is a Lateral Ankle Sprain?
A sprain occurs when a ligament is stretched beyond its normal capacity, resulting in microscopic damage, partial tearing or complete tearing.
What About an Inversion Sprain?
An inversion injury or lateral ankle sprain which occurs when the bottom of the foot turns inward and involves the ligaments on the outside of the ankle.
The three primary lateral ankle ligaments are:
Anterior talofibular ligament (ATFL) – the most commonly injured ligament
Calcaneofibular ligament (CFL) – provides lateral ankle stability, particularly as the ankle moves toward inversion
Posterior talofibular ligament (PTFL) – the strongest of the lateral ligaments and less commonly injured
This is the classic mechanism for a lateral ankle sprain and most commonly stresses the ATFL and, with greater force, the CFL. The lateral ligament complex helps prevent excessive inversion and controls the movement of the talus within the ankle mortise.
An eversion injury occurs when the foot rolls outward. Eversion sprains are less common but can injure the deltoid ligament complex on the inside of the ankle.
An eversion mechanism deserves careful evaluation because a significant force can also produce fractures or syndesmotic injury.
The Three Grades of Ankle Sprain
Ankle sprains are generally classified as Grade I, II or III based on the amount of ligament damage and functional loss.
Grade I: Mild Sprain
A Grade I sprain involves stretching and microscopic tearing of the ligament.
Typical findings include:
Mild swelling
Localized tenderness
Minimal loss of motion
Little or no instability
Ability to walk, although it may be uncomfortable
Minimal loss of strength
Typical recovery: approximately 1–2 weeks, although an athlete may require longer before safely returning to cutting, jumping and competition. (AAFP)
The mistake is assuming that because an athlete can walk, the ankle is ready for sport.
It isn’t necessarily.
Grade II: Moderate Sprain
A Grade II injury involves a partial ligament tear.
The athlete may experience:
Moderate swelling
Bruising
Significant tenderness
Pain with weight bearing
Loss of ankle range of motion
Decreased strength
Difficulty running or cutting
Some mechanical instability
Typical recovery: approximately 2–6 weeks, depending upon the structures involved and the demands of the athlete’s sport. (AAFP)
Grade III: Severe Sprain
A Grade III sprain involves a complete ligament tear and significant functional impairment.
Common findings include:
Significant swelling
Extensive bruising
Difficulty or inability to walk normally
Significant loss of motion
Weakness
Mechanical instability
Difficulty performing a single-leg stance
Typical recovery: approximately 6–8+ weeks, although high-level athletes may require longer before returning to unrestricted competition. (AAFP)
Importantly, these are general timeframes—not clearance dates.
An athlete should progress based on objective recovery rather than simply the number of days since injury.
How Is a Lateral Ankle Sprain Diagnosed?
A good evaluation starts with understanding how the injury occurred.
The clinician should determine:
Was the foot inverted or everted?
Was the athlete running, cutting or landing?
Did the athlete hear or feel a pop?
Could they continue playing?
Could they bear weight immediately?
Where is the pain?
How quickly did swelling develop?
Is there a history of previous ankle sprains?
The physical examination should include:
Palpation
The clinician should assess the lateral ligaments, medial ankle, syndesmosis, base of the fifth metatarsal and other potential areas of injury.
Range of Motion
Particular attention should be paid to:
Dorsiflexion
Plantarflexion
Inversion
Eversion
Loss of dorsiflexion is particularly important because it can alter running, jumping, landing and cutting mechanics.
Stability Testing
Common tests include:
Anterior drawer test
Talar tilt test
Reverse anterolateral drawer
Syndesmotic testing when indicated
Current clinical practice guidelines recommend combining the history and physical examination with specific ligament tests rather than relying on one test alone. (DOI)
Functional Testing
As symptoms allow, the athlete should eventually be assessed with:
Single-leg balance
Heel raises
Squatting
Hopping
Jumping and landing
Running
Cutting
Sport-specific movement
When Are X-Rays Needed?
The Ottawa Ankle Rules can help determine whether radiographs are appropriate after an acute ankle injury. (APTA)
Imaging may be particularly important when there is:
Inability to bear weight
Significant bony tenderness
Suspicion of fracture
Persistent pain that does not follow the expected recovery pattern
Concern for syndesmotic injury or another associated injury
MRI is not routinely required for a straightforward ankle sprain but may be useful when symptoms persist or when there is concern for a more significant ligament, cartilage, tendon or syndesmotic injury.
Treatment: The Goal Is More Than “Getting Rid of the Swelling”
The modern approach to ankle sprains is protection followed by progressive loading and rehabilitation, rather than prolonged immobilization. The 2021 clinical practice guideline recommends external support, progressive weight bearing and structured rehabilitation. For more severe sprains, a short period of immobilization—generally up to approximately 10 days—may be appropriate. (DOI)
Medications
Over-the-counter medications such as NSAIDs may be used to help manage pain and swelling when medically appropriate.
Examples include:
Ibuprofen
Naproxen
Acetaminophen may also be used for pain when appropriate. Medication should be viewed as a tool for symptom management—not as a substitute for rehabilitation. Athletes should consider individual medical history, gastrointestinal, kidney, cardiovascular and other medication-related risks before using NSAIDs.
CAM Boots: When Are They Appropriate?
A CAM walking boot can be useful for a more significant ankle sprain when pain makes normal walking difficult.
A boot may:
Protect the injured ligaments
Reduce painful motion
Allow protected weight bearing
Make walking more comfortable
However, more protection is not always better.
Prolonged immobilization can contribute to:
Stiffness
Calf weakness
Reduced proprioception
Loss of ankle mobility
Delayed return to sport
Clinical guidelines support functional treatment and progressive loading over prolonged immobilization. Severe injuries may warrant short-term immobilization, but extended immobilization should generally be avoided when it is no longer necessary. (DOI)
Bracing and Taping
An ankle brace or athletic tape can provide external support while the ligament heals.
For athletes, bracing is particularly valuable during:
Return-to-running
Cutting
Jumping
Practice
Competition
Research and clinical guidelines support the use of prophylactic bracing following an ankle sprain, particularly in athletes at increased risk of recurrence. (DOI) Importantly, a brace should not replace rehabilitation.
Brace + rehabilitation is far more valuable than bracing alone.
Physical Therapy: The Most Important Part of Recovery
Physical therapy should begin as early as possible and progress according to the severity of the injury. Treatment may include:
Phase 1: Protect and Restore Motion
Early rehabilitation may include:
Protected weight bearing
Compression
Swelling management
Gentle ankle ROM
Calf mobility
Pain-free strengthening
Gait training
Phase 2: Restore Strength
The focus progresses toward:
Calf strengthening
Peroneal strengthening
Tibialis anterior strengthening
Foot intrinsic strengthening
Resisted inversion/eversion
Single-leg strength
Hip and glute strengthening
Phase 3: Restore Balance an
d Neuromuscular Control
This is an often-overlooked component of ankle rehabilitation.
Exercises may include:
Single-leg balance
Single-leg balance with perturbations
Reaching activities
Balance on unstable surfaces
Single-leg squats
Step-downs
Dynamic balance
Hopping
Evidence strongly supports therapeutic exercise, particularly neuromuscular, balance and proprioceptive training, for improving stability and reducing recurrence. (DOI) A 2026 systematic review also found that balance and strength-based interventions can improve proprioception in people with chronic ankle instability. (PubMed)
Why the First Ankle Sprain Should Be Treated Aggressively
This is one of the most important messages for athletes and parents:
Do not ignore the first ankle sprain.
An ankle may feel better long before it has regained:
Full ROM
Strength
Balance
Proprioception
Reaction time
Single-leg control
Jumping ability
Cutting ability
An athlete who returns simply because they can jog without pain may still have substantial deficits. The clinical practice guidelines specifically recommend bracing plus proprioceptive and balance-focused exercise after an initial sprain to reduce the risk of another injury. One meta-analysis cited in the guideline found exercise-based interventions reduced recurrent ankle sprain risk compared with controls. (DOI)
The first sprain is the time to break the cycle.
Chronic Ankle Instability: When Sprains Become a Pattern
Some athletes begin to notice that their ankle simply doesn’t feel normal after the initial injury.
They may describe:
“My ankle keeps giving out.”
“I keep rolling it.”
“It feels loose.”
“I don’t trust it.”
“It swells after practice.”
“It hurts after I run.”
“I’m afraid to cut on it.”
This can represent chronic ankle instability.
CAI can have both:
Mechanical instability
The ligaments may remain elongated or insufficient following the original injury.
Functional instability
The athlete may have deficits in:
Proprioception
Balance
Reaction time
Strength
Neuromuscular control
These problems can persist even when the athlete no longer has significant pain.
Research has demonstrated a strong relationship between ankle instability and recurrent ankle sprains. (PubMed) This is why simply putting a brace on an athlete who repeatedly rolls their ankle is not enough. The underlying deficits need to be addressed.
Return to Play: Don’t Use Time Alone
Returning to sport should be a progression, not a date.
An athlete should demonstrate adequate:
Pain-free ROM
Minimal or no swelling
Strength
Single-leg balance
Calf endurance
Dynamic stability
Hopping ability
Jumping and landing mechanics
Running tolerance
Cutting ability
Sport-specific confidence
Suggested Return-to-Play Progression
Step 1: Walking
Normal walking without significant pain or limp.
Step 2: Jogging
Progress from:
Straight-line jogging
Longer-duration running
Increased speed
Step 3: Acceleration and Deceleration
Introduce:
Short accelerations
Controlled stops
Progressive speed changes
Step 4: Lateral Movement
Progress into:
Lateral shuffles
Carioca
Lateral acceleration
Controlled cutting
Step 5: Plyometrics
Begin with:
Double-leg jumping
Single-leg jumping
Forward hopping
Lateral hopping
Repeated hops
Step 6: Sport-Specific Movement
For a baseball or softball athlete:
Running bases
Defensive movement
Lateral fielding
Sprinting
Sliding progression
Hitting footwork
Pitching-specific lower-extremity movement
Step 7: Practice
The athlete should first tolerate progressively higher practice demands before returning to unrestricted competition.
Step 8: Competition
Return to competition should occur when the athlete demonstrates appropriate physical and psychological readiness.
A recent systematic review emphasized that return to sport after lateral ankle sprain is a continuous process rather than a single clearance event, with injury severity, rehabilitation and objective recovery criteria all influencing the process. (PubMed Central (PMC))
The Ankle and the Overhead Athlete: Why Lower-Extremity Power Matters
This is particularly important for baseball and softball players.
A throwing athlete does not generate throwing velocity exclusively with the arm.
The throwing motion begins with the ground.
The athlete must create force through the:
Foot → ankle → knee → hip → pelvis → trunk → shoulder → elbow → hand
This is the kinetic chain.
The lower extremity and trunk provide the foundation for transferring force toward the upper extremity. Reviews of overhead athletes have emphasized the importance of lower-extremity strength, power, balance and kinetic-chain function in both performance and injury prevention. (PubMed Central (PMC))
A recent systematic review found that throwing performance is associated with lower-extremity power and strength measures. (PubMed)
What happens after an ankle sprain?
An athlete may unconsciously protect the injured ankle.
They may:
Push off less aggressively
Avoid loading the injured side
Reduce ankle dorsiflexion
Reduce plantarflexor force
Change stride mechanics
Shift weight differently
Decrease single-leg stability
The result can be a reduction in lower-extremity power.
For a pitcher, that matters.
If the lower extremity cannot effectively generate and transfer force, the athlete may compensate by asking the trunk and upper extremity to contribute more.
This does not mean that every ankle sprain causes a shoulder or elbow injury.
The relationship is more nuanced.
However, the kinetic-chain literature supports the concept that deficits in lower-extremity strength, power, mobility and coordination can alter the demands placed on the upper extremity. (PubMed)
A 2024 systematic review and meta-analysis also found an association between shoulder pain and ankle/foot pain in overhead athletes, although the certainty of evidence was low and the relationship should not be interpreted as proof that an ankle injury directly causes shoulder injury. (PubMed)
For the overhead athlete, rehabilitating the ankle means restoring the entire kinetic chain—not simply getting rid of ankle pain.
When Is Surgery Necessary?
Fortunately, most lateral ankle sprains do not require surgery.
Even many severe Grade III injuries can be successfully managed with appropriate functional rehabilitation.
Surgery may become appropriate when an athlete has:
Persistent mechanical instability
Recurrent ankle sprains despite comprehensive rehabilitation
Failure of appropriate conservative treatment
Significant ligament insufficiency
Associated cartilage or osteochondral injury
Tendon pathology
Certain fractures or other structural injuries
For chronic lateral ankle instability, the modified Broström procedure is a commonly used anatomic repair technique. The goal is to restore the normal anatomy and stability of the lateral ankle ligaments.
What Are the Outcomes After Ankle Stabilization Surgery?
Surgical outcomes for chronic lateral ankle instability are generally favorable.
A systematic review and meta-analysis of 25 studies involving 1,384 patients found that approximately:
95% returned to some form of sport
83% returned to their preinjury level
87% returned to competitive sport
The mean reported return-to-sport time was approximately 12.5 weeks following anatomic lateral ankle stabilization. (PubMed) However, surgery is not a shortcut around rehabilitation.
Patients still require a structured progression to restore:
ROM
Strength
Balance
Proprioception
Plyometric ability
Running
Cutting
Sport-specific performance
Psychological readiness
Recent literature also suggests that different surgical stabilization techniques—including Broström repair, reconstruction and suture-tape augmentation—can produce good outcomes, with procedure selection depending on the patient’s anatomy, tissue quality, instability pattern, sport and surgeon preference. (ScienceDirect)
The Bottom Line for Athletes
An ankle sprain may seem like a minor injury.
For an athlete, it shouldn’t be treated as one.
A poorly rehabilitated ankle can become a weak link in the kinetic chain and contribute to:
Recurrent ankle sprains
Chronic instability
Loss of mobility
Decreased strength
Reduced lower-extremity power
Altered running and cutting mechanics
Decreased athletic performance
The goal should not simply be:
“Can I play?”
The better question is:
“Is my ankle ready for everything my sport demands?” For athletes, especially overhead athletes, rehabilitation should restore the ankle’s mobility, strength, stability, proprioception and power before unrestricted return to sport.
At Edge 360 Wellness, our approach to sports rehabilitation looks beyond the injured joint. We evaluate how the ankle, knee, hip, pelvis, trunk and upper extremity work together so athletes can return to their sport with confidence—and reduce the likelihood that today’s ankle sprain becomes tomorrow’s chronic problem.
Don’t Ignore Your First Ankle Sprain
If you have recently rolled your ankle, continue to experience swelling or pain, or have a history of recurrent ankle sprains, an individualized sports physical therapy evaluation can help identify the deficits that may be keeping you from fully recovering.
Ready to get back to your sport? Contact Athletic Edge and Wellness to schedule a sports physical therapy evaluation.
☎️224-505-3343
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