As runners, we know the pain of injuries all too well. The dreaded shin splints. Appalling stress fractures. And the surprisingly excruciating plantar fasciitis.

While all those fall under the category of overuse injuries, there are those acute injuries that pop up and put a halt to our running routines in an instant, and those just might be the most heartbreaking ones of all. A great example of one of these injuries? Ankle sprains.

As a runner, especially if you hit the trails, you’ve likely already experienced an ankle sprain. In fact, it’s one of the most common musculoskeletal injuries around, with an estimated 2 million taking place in the United States each year—and those are just the documented cases. Imagine if they counted the people who limped home and nursed it with ice and rest?

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Even though you’ve probably had an ankle sprain (or several) over the years, what is it exactly? And what’s the best way to bounce back from it? Here’s what to know.

What It Means to Sprain Your Ankle

“A sprained ankle is an injury that occurs to the ligaments of the foot and ankle,” says John Nguyen P.T., D.P.T., clinic director at SporTherapy. “The ligaments act as stabilizers for the foot/ankle joint, and when they are stretched or pulled beyond their tensile strength, it can result in tearing of the tissue.”

This can take place as a result of “a sudden and high force inversion injury,” as Alex McDonald, M.D,, a family physician with a specialization in sports medicine, labels it. Think about all those different surfaces you run on (gravel, sidewalks with cracks, trails with roots) that can pose obstacles for your sensitive ankles. Add in the repetitiveness and impact of running, and you’ve got yourself a recipe for an occasional ankle sprain.

Causes of Ankle Sprains

Nguyen says that “acutely and immediately,” you’ll experience swelling, tenderness, and possibly bruising after you experience the trauma if your ankle is sprained.

“Most ankle sprains are a result of sport injuries, but sprains can occur in many different ways,” he adds. “Other common mechanisms of ankle injuries include turning in your ankle while walking on uneven surfaces or stepping off a curb. Ankles commonly get sprained in an inversion [inward] manner, causing injury to the ligaments on the outside of the ankle, but injury to the deltoid ligaments [inside of the ankle] can occur as well.”

How Ankle Sprains Are Diagnosed

Most of the time, ankle sprains are self-diagnosed, something that you’ve likely done at some point throughout your running career. If you consider the severity to be minimal and your ankle responds in a couple days to rest, ice, compression, and elevation, then you’re likely fine to stay home and treat.

But generally, experts recommend you see a doctor to get further examination to rule out more serious injuries, particularly if you’re unable to bear weight on the ankle, you see significant bruising or swelling, or if the pain isn’t improving within a week or so. You’ll want to rule out a fracture or torn muscle tendon, as Nguyen points out.

“Once in a clinic, a healthcare professional can perform orthopedic tests and complete an examination to accurately diagnose the injury,” he says. “If indicated, an MRI can be performed which would reveal soft tissue damage to the ligaments.”

Ankle sprains get classified based on severity level from Grade I to III, with Grade III being the most severe.

McDonald explains: “A Grade I ankle sprain is by far the most common and simply involves a scratching of the lateral ankle ligaments that often will take two to three weeks for a full return to activity with proper treatment. A Grade II ankle sprain is less common and consists of partial or microtears within the ligament. This requires four to six weeks for a full return to activity with proper treatment. A Grade III ankle sprain is a complete tear of the ligament and may require surgery. Recovery is highly variable based on required treatment.”

Your doctor will decide the grade of your injury based on diagnostic tests.

The Best Treatment for Ankle Sprains

You can turn to the acronym “PRICE” as a treatment protocol, which is a twist on the “RICE” acronym you’re likely familiar with. It stands for Protection, Rest, Ice, Compression, and Elevation. “In the rehab circle, the ‘P’ is considered ‘Prevention’ to promote the importance of performing exercises that reduce the risk of injury,” Nguyen details.

Nguyen generally recommends icing anywhere between 15 to 30 minutes every hour for two to three days until the swelling goes down.

“I don’t expect [my patients] to do it every waking hour, but the more frequently they do it, the better they will manage the swelling initially,” he says. “Heat is recommended at that two- to three-day mark once the swelling is reduced, as heat can bring blood flow to the area and promote healing to the damaged ligaments.”

McDonald adds to this, saying, “I recommend NSAIDs and ice only for acute symptoms, followed by heat, daily mobilization, and early strengthening exercises with resistance bands. An ankle brace or support may be used, but only for comfort and only for a few days.”

Nguyen says that many times, especially for more severe sprains, doctors will refer you to physical therapy to work on ankle stabilization and properly progress you through the healing stages to so you can return to full function.

When and How to Return to Running After an Ankle Sprain

First, rest until you’re pain-free

If you’re like most runners, you’re likely wondering: How fast can I get back to running? The answer? Well, it may not be music to your ears, but it involves easing into it and utilizing exercises to help build up ankle strength, so a sprain doesn’t happen again.

Returning to running after an ankle sprain depends on the severity of the sprain as well as other factors, like weekly running mileage and running terrain,” McDonald says. “For the vast majority of ankle sprains, early mobility and strengthening will enable you to start running one to two weeks after the injury with full activity shortly thereafter.”

Add in mobility and strength

How do you know when your ankle is ready for mobility and strength exercises?

“Healing progression depends on the level of severity of the initial injury, but it can be recommended to do ankle alphabets (drawing the alphabet with your foot) as soon as one to two days after injury, following rest,” Nguyen says. “Once you are able to walk and/or stand pain-free and swelling is minimal-to-none, then progressing to standing exercises like heel raises can be implemented.”

As for specific strength and mobility exercises to add to your routine, Nguyen offers some suggestions: “One of my favorites is grabbing a small ball, such as a tennis or lacrosse ball, then squeezing it between the heels and performing a heel raise,” Nguyen says. “This will help to engage both your posterior tibialis muscle [muscle of the lower leg] and gastroc muscles [calf muscles] during your runs.” For this, you should squeeze the ball the entire time as you lift your heels up and down from the floor, starting with two sets of 10 to 15 reps, depending on your strength and exercise tolerance.

Additionally, you can do towel curls to strengthen the bottom of the foot, which will support the ankle. To do them, stand tall and place a towel under foot. Grab the edge of it with your toes, then release, and pull more of the towel in with your toes.

Nguyen also suggests band-resisted motions in the directions of dorsiflexion (up), inversion (in), eversion (out), and plantarflexion (down). “Depending on their impairments, combined motion is an ideal progression for the ankle, such as supination, which is when one brings their foot up and inwards at the same time. Doing these movements with a resistance band will help to strengthen the ankle in all directions,” he says.

Progress to higher impact moves

Nguyen says that he typically doesn’t work his athletes into high-impact movements unless they are healed and ready to return to their sport.

“As a PT, I am continuously assessing their response to dynamic movements including lunging, squatting, and single-leg balance,” he says. “When they can do those movements pain-free, I begin to add small hopping drills (couple inches off the floor) and the agility ladder. If they can get through those with good control and no pain, then I add the high impacts such as running, squat jumps, and hopping off a plyometric box. As mentioned, pain in the end is one of the best gauges to tell how our body is healing.”

“It’s extremely important to work in lateral activity, as well, to promote that ankle stability. Basic hopping drills starting with double-leg and progressing to single-leg is recommended to help strengthen the ankle. In clinic, I’ll tape a line on the floor and have patients do different hopping patterns across it, as long as its pain-free.”

Focus on cardio too

To jumpstart your cardio, McDonald often recommends cycling very early in the process (as soon as you can bike with minimal to no pain within the first week after the injury), followed by elliptical use, then light jogging.

“I suggest a walk/run progression to gradually resume running on a controlled surface like a track or a treadmill. I recommend beginning at 50% of daily and weekly pre-injury running volume and then increase by 10% per week,” he specifies.

What to Know About Future Ankle Sprains

If you take it slow with your running regimen and work in some daily strengthening exercises, the chance of injuring the ankle again is low. But sadly, a sprained ankle is one of those pesky injuries that can reoccur again and again.

“Unfortunately, your risk of suffering ankle sprains again is more likely than someone who never suffered one, and that risk increases with more incidences,” Nguyen says. “Prevention is key to help mitigate that risk, which you can do by incorporating ankle stability exercises [like the ones above] in your daily routine as a runner.”

McDonald says that rehab, whether at home or with a professional, for at least 16 weeks after the injury has occurred will prevent recurrent ankle sprains in the future.

“Ankle sprains, like other injuries, can be extremely frustrating for a runner,” Nguyen says. “Being proactive in prevention and recovery will go a long way to maintain your level of activity. Once an injury has occurred, there are a lot of options for runners to get back on track. Consult a physical therapist or sports medicine doctor to get back to what you love—faster.”

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