An ankle sprain is one of the most common musculoskeletal injuries, particularly among physically active people and those involved in sports. Many patients consider it a minor problem: the ankle becomes swollen, it hurts, walking is difficult for a few days, but eventually the symptoms begin to improve.
And it seems that everything has returned to normal. But has it really?
Throughout my clinical practice, I have met many patients who continued to experience ankle problems months or even years after their original injury. Often, the initial sprain had long been forgotten.
What Actually Happens During an Ankle Sprain?
Most ankle sprains involve the lateral ligament complex, particularly the anterior talofibular ligament (ATFL). However, depending on the mechanism and severity of the injury, other structures may also be affected, including additional ligaments, the joint capsule, tendons and sometimes cartilage or bone. This does not mean, of course, that all these structures are damaged in every ankle sprain.
That is why it is important to establish what type of injury we are actually dealing with. Simply saying that a patient has “sprained their ankle” tells us very little about the extent of the damage.
The Pain Has Gone. Does That Mean the Ankle Has Fully Recovered?
Not necessarily.
A reduction in pain and swelling does not always mean that the injured structures have regained their full function. Following an ankle sprain, patients may continue to experience restricted mobility, impaired neuromuscular control, muscle weakness and reduced balance.
A patient may be able to walk without pain, yet the ankle may still not function adequately during running, jumping or sudden changes of direction. This is where the problem begins. If the decision to return to activity is based solely on the absence of pain, important functional deficits may be overlooked.
The Domino Effect — Can One Ankle Sprain Lead to Further Problems?
Yes, although this is by no means inevitable.
A previous ankle sprain increases the risk of another injury. Some patients develop chronic ankle instability, which may involve a feeling that the ankle is giving way, repeated sprains or difficulty performing sporting activities.
Long-term instability and recurrent injuries may increase the risk of damage to structures within the joint and the development of osteoarthritis. However, this does not mean that everyone who sprains an ankle will eventually develop degenerative changes. Many people recover fully without lasting consequences.
Problems are more likely to arise when the initial injury is underestimated and persistent functional impairments remain unrecognised.
Why the First Ankle Sprain Deserves Particular Attention
Why the first injury? Because appropriate management from the very beginning may help reduce the risk of recurrent sprains and chronic ankle instability. This is particularly important for young athletes, who are often eager to return to training as quickly as possible.
The first step is to assess the extent of the injury and rule out more serious damage. Not every patient needs an X-ray or ultrasound examination. The need for imaging should be determined by the medical history and clinical examination. When a fracture is suspected, the Ottawa Ankle Rules can help guide the decision.
During the first few days, appropriate ankle support, compression and temporary modification of activities that aggravate symptoms may be useful. Ice can provide short-term pain relief, but there is insufficient evidence that it accelerates the healing of injured ligaments. More severe injuries may require a period of immobilisation, depending on medical recommendations.
Rehabilitation Is More Than Reducing Pain and Swelling
This is one of the most important aspects of recovery. In some patients, manual therapy can produce a relatively quick improvement in mobility and a reduction in pain. However, this does not mean that the injured ligaments have already regained their full strength or that the ankle is ready for sporting demands.
Rehabilitation should therefore involve not only manual therapy but also an appropriately designed exercise programme. Exercises aimed at restoring range of motion, muscle strength, balance, proprioception and neuromuscular control are particularly important.
Loading should be increased gradually, according to the patient's tolerance and the stage of tissue healing. This is the practical application of the principle of optimal loading.
Insufficient loading may delay functional recovery, while returning to intensive activity before adequate ankle function has been restored may increase the risk of another injury.
When Is It Safe to Return to Sport?
The decision should not be based solely on how much time has passed since the injury or on the patient's statement that “it doesn't hurt anymore.”
Before returning to full sporting activity, it is important to assess range of motion, strength, balance, lower-limb control and the ability to perform movements specific to the sport. The patient's confidence in loading the previously injured ankle is also important.
If an athlete still experiences instability, is afraid of dynamic movements or has not regained adequate control, returning to full training may be premature.
What Can We Learn from This?
After many years of working with patients, I have become increasingly convinced that an injury should never be assessed solely on the intensity of pain. And this applies not only to the ankle.
Pain may disappear long before the functional impairments caused by an injury have resolved. Therefore, it is not enough to reach a point where the patient no longer experiences pain. We must also establish whether mobility, strength, stability and movement control have been restored.
Not every ankle sprain is a serious injury. But every ankle sprain deserves a proper assessment.
The first sprain is particularly important because appropriate management at this stage can make a meaningful difference to the patient's long-term function and help reduce the risk of future injuries.