John Davis

Written by John Davis

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Ankle Injuries: Pain, Causes, Treatment and How to Return to Running

Have you ever rolled your ankle while out for a run?

Or should we say how many times have you rolled your ankle on a run, walked for a few moments, hoping and praying that the pain will ease away, and you can get back to your training.

It’s a nightmare, especially if you run on trails or other rutted, uneven surfaces. One misstep can sideline you for weeks or leave you with pain that lingers for months.

You hold your breath as your season flashes before your eyes, marathon training schedule out the window.

You’re going to learn about what the various ankle injuries are and how to know which one you have , how treat an ankle sprain to help it return to normal (making it stronger than before), and how to use the best advice there is to return to running as soon as possible. To top it off, you’ll even get a treatment program of exercises to use if you are unable to get to a physical therapist.

We hope you do not ever have to read this post in depth, but if your ankle is throbbing, here is the best advice available.

Rolled your ankle on a run? It HURTS! Is it a sprain? Is it tendon? Am I going to be able to keep running? Once you have one sprain, it is more likely to happen again. Make sure it doesn't with this ultimate guide to ankle sprains, treatment, and how to safely return to running (stronger!).

How Do I Figure Out Which Ankle Injury I Have?

The ankle joint is a magnificently complex anatomic structure; it allows for movement in all three planes of motion, which is what allows you to run adroitly on an uneven surface in the first place.

The downside of the ankle joint’s versatility is that it is also vulnerable to injury if you land in an unexpected way.  An awkward landing or “rolled ankle” can cause a sprain, damaging the ligaments on the outside (or, less commonly, the inside) of the ankle when they’re stretched too far and too strongly.

We can make recommendations of how to trail proof your ankles to limit the possibility of it happening, but unfortunately the ankle is a complex area that even strengthening exercises cannot prevent.

Problematically, there are other injuries that can also cause pain in the same area of your ankle and be mistaken for an ankle sprain.

Ankle sprain?

If you suspect that you’ve rolled your ankle, the first order of business is to make sure you don’t actually have an overuse injury to a tendon instead.

Ankle sprains, as you might guess, always occur after a sudden and jarring impact, landing, or twisting of the ankle.  You might hear or feel a “pop” followed by a sharp pain.

Ankle sprains also cause a good deal of swelling—the joint will be visibly enlarged and swollen fairly soon after sustaining the injury.  You’ll often have throbbing or aching pain in your ankle even when you’re not putting weight on it, and you’ll have a sharp pain if you passively rotate your ankle into inversion or eversion.

Or damaged tendon?

In contrast, tendon injuries like posterior tibial tendonitis (inside of the ankle) and peroneal tendonitis (outside of the ankle) tend to hurt only or mainly during weight-bearing activity, and there is not typically pronounced swelling or throbbing.

Pain from tendon injuries may also extend down into the foot, or up into the lower leg along the course of the tendon.

Now:

If you’re not sure whether you have an ankle sprain or a different ankle injury, it’s best to see a doctor. This is also the correct course of action if you’ve suffered a particularly bad ankle sprain.  A doctor can determine whether you’re dealing with a tendon or ligament problem, and in the case of severe sprains, an x-ray can rule out a broken bone.

 What does the research say about ankle injuries?

According to a study by Bernard Marti and other researchers at the University of Bern in Switzerland, foot and ankle injuries account for 28% of all running injuries.1 Lateral ankle pain accounts for over half of these.

Pain on the inside of the ankle accounts for less, making up only 3.3% of all running injuries.

Marti and colleagues didn’t break down “lateral ankle pain” to distinguish overuse injuries from ankle sprains, but a 2002 paper by scientists at the University of British Columbia found that inversion ankle sprains (the most common type) account for about one percent of all injuries seen at a sports injury clinic, though this might be an underrepresentation of their true incidence, as many people who suffer ankle sprains don’t bother to go to the doctor.2

What Happens When a Runner Sprains Their Ankle?

The complex, multi-plane joint of your ankle is held together by strong, short strips of tissue called ligaments.

In an ankle sprain, these are stretched too hard and damaged.  This causes an almost immediate inflammatory response from the body, and the ankle will visibly swell up.

If you sprain your ankle while running, you may find you’re able to continue to hobble along for a while, but soon, inflammation will set in.

After this, any further running will be extremely painful, if not impossible.

It get’s worse:

One unfortunate result of sustaining an ankle sprain is that it predisposes you to more ankle sprains in the future.

A 2001 study of basketball players published by researchers in Australia found that athletes who had sustained a previous ankle sprain were almost five times more likely to sustain another one.3

A big part of why it’s important to treat an ankle sprain correctly is that proper treatment can help prevent recurrence.  If you rack up too many ankle sprains, you can develop what’s known as chronic ankle instability, a condition where the ligaments of the ankle become ruptured or elongated, and cartilage in the ankle joint sustains damage.

Chronic ankle instability can seriously hamper your ability to run, so avoiding it at all costs should be your top priority!4

How Can I Treat my Ankle Pain?

Once you’ve sustained an ankle sprain, the first thing to do is to cut down on the swelling and pain as quickly as possible.

The best tool for this job is the ice bath.

Using ice (instead of heat) to reduce swelling

A 1982 study published by John Hocutt Jr. and other doctors at the Delaware Rehabilitation and Sports Medicine Center compared icing applied to an ankle sprain immediately following injury (ice applied less than an hour post-injury), or ice applied starting 36 hours post-injury.

The authors found that subjects who initiated icing soon after injury were able to return to sport after an average of 13 days, compared to 30 days for the group who waited 36 hours to start icing.

Although we have recommended not putting ice on your running injuries in the past, in a situation like this, icing an ankle sprain is by far the best way to limit the damage.

You might read other articles on ankle sprains encouraging you to apply heat to the injured area, but Hocutt et al.’s study refutes that idea, too.

The researchers found that applying heat instead of ice resulted in the longest average recovery time: 33 days!

A different study by Debra Coté and colleagues at the University of North Carolina helps build the case against heating for ankle sprains, at least initially.  Coté et al. compared the effects of cold water baths, hot water baths, and contrast baths on swelling following an ankle sprain.6

After using a specially-designed water tank to measure changes in ankle volume, they found that heat and contrast baths led to substantially more ankle swelling than soaking the ankle in a cold water bath.

When it comes to how to ice, a 2006 study published in the British Journal of Sports Medicine suggests that an “intermittent” icing protocol consisting of 10 minutes of icing, 10 minutes of rest, then 10 more minutes of ice produces more rapid reductions in ankle pain when compared to 20 minutes of continuous icing.7

Using a bucket of ice water is also preferable to using an ice pack, since the hydrostatic pressure of the water inside the bucket provides a form of compression, which may help reduce swelling.8

According to Hocutt et al., icing should start as soon as possible following injury, and should occur three times per day for at least the first three days post-injury.5

 Elevating the ankle vs. compression

Research also indicates that elevating the injured leg is a better treatment than applying an elastic wrap like an ACE bandage.

A 1991 study found that patients who elevated their ankle for 30 minutes had less ankle swelling than those who used an elastic wrap, and a 2011 study found no significant benefits of using an elastic wrap for compression when evaluating pain and functioning 10 and 30 days post-sprain.9, 10

Should the ankle be immobilized?

Another busted ankle rehab myth is the idea that you should immobilize your ankle until it is totally healed.

A 2007 review article by Morgan Jones and Annunziato Amendola found that starting rehab exercises as soon as tolerated leads to a more rapid return to sport and a lower reinjury rate when compared to long periods of casting, bracing, or crutching before starting rehab work.11

What rehab do I need to do to get the strength back?

A typical comprehensive rehab program is laid out by Carl Mattacola and Maureen Dwyer at the University of Kentucky.12  Within two or three days following injury, Mattacola and Dwyer encourage initiating calf stretching and basic range-of-motion exercises like writing the “ankle alphabet,” which can be carried out while soaking your foot in an ice bath.

Within a few days, exercises for ankle strength can commence, using an elastic band for resistance.  Once you can walk without pain, you can begin doing single-leg balance work and toe & heel walking.

Single-leg balance work is particularly important because it’s been consistently shown to reduce the risk of future ankle sprains.13

Even once you’ve fully recovered, you should continue to do single-leg balance work on a wobble board as part of your normal strength work, especially if you plan on heading out on the trails again, this is the best way to sprain proof your ankles!

For specifics, it’s easier to lay out the rehab plan on a timeline, as below.  Note that all exercises should be done on both sides, not just on the injured ankle.

Time after injury Treatment
As soon as possible Intermittent ice bath: 10 min of icing, 10 min rest, 10 min of icingAt least 3x per day – continue for at least first 3 days after injury Elevation for 30 minutes several times per day
48-72 hours Gentle Achilles stretching using a towel if weight bearing is painful10×20 seconds, 3-5x per dayAnkle alphabet—write the alphabet using your foot2-3x per hour, 4-5x per day (can do while soaking in ice water) 
72+ hours Inversion, eversion, dorsiflexion, and plantarflexion strengthening with an elastic resistance band: starting with 10 reps each, progressing with resistance and reps3-5x per day 
Once able to walk without pain Toe and heel walking: 3 sets of 10 reps, progressing to more steps as toleratedOnce per day Single-leg balance training on wobble boardStarting with 1 min, progress over time to 5 minStart with standard single-leg balance; increase difficulty over time by adding leg lifts, crossing arms, or keeping eyes closedOnce per day 
Ankle sprain? @Runners_Connect has the ultimate injury guide for runners! Click To Tweet

Achilles stretching with towel

 

Ankle alphabet (A to Z) 

Ankle Alphabet

Ankle inversion with elastic band 

Ankle Inversion with elastic band

Ankle eversion with elastic band

Ankle Eversion with elastic band

Ankle dorsiflexion with elastic band

Ankle dorsi Flexion with elastic band

Ankle plantarflexion with elastic band

Ankle plantar flexion with elastic band

Toe walking
Toe Walking

Heel walking

heel walking image

Single leg balance on wobble board

Single leg balance on wobble board

How can I protect my ankle for the future?

When you return to running, you may find an ankle taping or a brace to be beneficial.

Research has found that taping and bracing can reduce the risk of future injury, but these studies focus on ball-sport players, not runners.12  A taping or a brace can be cumbersome, restricting, or can cause blisters, so you’ll have to see whether it’s worth the hassle for you or not.

If you want to learn more about taping before you decide if it is for you, we created the ultimate what you need to know guide for kinesiology tape.

If your ankle injury does not seem to be responding to treatment, you should definitely see a doctor.

You may need a more individualized physical therapy plan, or you may benefit from a special shoe insert or brace, especially if you’ve had ankle sprains in the past.  There may also be underlying issues that are preventing a speedy recovery; for example, injury to the peroneal tendon can coincide with ankle sprains and ankle instability.14

When can I return to running?

According to Mattacola and Dwyer, you can start running once you can walk an unlimited distance without ankle pain.  You should follow a standard return-to-running plan that uses a walk/jog approach.

For example, your first outing might be six sets of jogging for one minute and walking four minutes. Then, after a day off, you can do six sets of two minutes of jogging and three minutes of walking.

You can keep repeating this process until you are jogging 30 minutes continuously without breaks, then increase your speed and frequency of running (moving from running every other day to running two days in a row and taking one day off, then three “on” and one “off,” and so on) until you are back to your normal running speed and typical training routine.

If you’ve only sustained a mild ankle sprain, you may be able to use a more aggressive return-to-running program if your ankle allows it.

Your initial runs should always be on a flat, stable surface like a road or a track, so there is no chance you’ll roll your ankle again while it’s still vulnerable.

Once you’ve got better ankle strength and balance, you can ease your way back into running on more challenging terrain.

Rolled ankle? Here is how to get back to running quickly. VERY helpful post from @Runners_Connect! Click To Tweet

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References

Marti, B.; Vader, J. P.; Minder, C. E.; Abelin, T., On the epidemiology of running injuries-the 1984 Bern Grand-Prix study. The American Journal of Sports Medicine 1988, 16 (3), 285-294.
Taunton, J.; Ryan, M.; Clement, D.; McKenzie, D.; Lloyd-Smith, D.; Zumbo, B., A retrospective case-control analysis of 2002 running injuries. British Journal of Sports Medicine 2002, 36, 95-101.
McKay, G. D.; Goldie, P.; Payne, W. R.; Oakes, B., Ankle injuries in basketball: injury rate and risk factors. British Journal of Sports Medicine 2001, 35 (2), 103-108.
Hintermann, B.; Boss, A.; Schäfer, D., Arthroscopic findings in patients with chronic ankle instability. The American Journal of Sports Medicine 2002, 30 (3), 402-409.
Hocutt Jr, J. E.; Jaffe, R.; Rylander, C. R.; Beebe, J. K., Cryotherapy in ankle sprains. American Journal of Sports Medicine 1982, 10 (5), 316-319.
Coté, D. J.; Prentice, W. E.; Hooker, D. N.; Shields, E. W., Comparison of three treatment procedures for minimizing ankle sprain swelling. Physical Therapy 1988, 68 (7), 1072-1076.
Bleakley, C. M.; McDonough, S. M.; MacAuley, D. C., Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols. British Journal of Sports Medicine 2006, 40, 700-705.
Bleakley, C.; McDonough, S.; Gardner, E.; Baxter, G.; Hopkins, J.; Davidson, G., Cold water immersion (cryotherapy) for preventing and treating muscle soreness after exercise. Cochrane Database of Systematic Reviews 2012, (2).
Rucinski, T. J.; Hooker, D. N.; Prentice Jr, W. E.; Shields Jr, E. W.; Coté-Murray, D. J., The effects of intermittent compression on edema in postacute ankle sprains. Journal of Orthopaedic & Sports Physical Therapy 1991, 14 (2), 65-69.
O'Connor, G.; Martin, A. J., Acute ankle sprain: is there a best support? European Journal of Emergency Medicine 2011, 18 (4), 225-230.
Jones, M. H.; Amendola, A. S., Acute treatment of inversion ankle sprains: immobilization versus functional treatment. Clinical Orthopaedics and Related Research 2007, 455, 169-172.
Mattacola, C. G.; Dwyer, M. K., Rehabilitation of the ankle after acute sprain or chronic instability. Journal of Athletic Training 2002, 37 (4), 413.
McGuine, T. A., The Effect of a Balance Training Program on the Risk of Ankle Sprains in High School Athletes. American Journal of Sports Medicine 2006, 34 (7), 1103-1111.
Sobel, M.; Geppert, M. J.; Warren, R., Chronic ankle instability as a cause of peroneal tendon injury. Clinical Orthopaedics and Related Research 1993, 296, 187-191.

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