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.

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.⁵ 

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

[bctt tweet=”Ankle sprain? @Runners_Connect has the ultimate injury guide for runners!” via=”no”]

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

Cross Training While Injured and During Recovery

Cross training is recommended while you're injured and as you slowly return to running.

The best form of cross training for this injury is Aqua Jogging. Studies have shown that aqua jogging can enable a well-trained runner to maintain running fitness for up to 4-6 weeks.

Aqua jogging is a form of deep water running that closely mimics the actual running movement.  Your feet don’t actually touch the bottom of the pool, so it is zero impact and safe for almost any type of injury. In my experience, the only time to avoid aqua jogging is when you have a hip flexor injury, which can be aggravated by the increased resistance of the water as you bring your leg up. Because aqua jogging closely mimics natural running form, it provides a neuromuscular workout that, in addition to aerobic benefits, helps keep the running specific muscles active. The same can’t be said for biking and swimming. The only downside to aqua jogging is that you need a pool that is deep enough to run in without touching the bottom. If you’re lucky enough to have access to a pool of this size, aqua jogging should be your first cross training choice.

In one study, a group of ten runners trained exclusively with deep water running for four weeks and compared 5km race times pre deep water running and post deep water running.

The researchers found no statistical difference in 5k time or other markers for performance, such as submaximal oxygen consumption or lactate threshold.

In a second study, researchers measured the effects of aqua jogging over a six week period.

This time, 16 runners were separated into two groups – one who did aqua jogging workouts and the other who did over land running.

Using the same training intensities and durations, the researchers found no difference between the groups in maximal blood glucose, blood lactate, and body composition.

It get’s better:

Research has also demonstrated that aqua jogging can be used as a recovery tool to facilitate the repair of damaged muscles after hard workouts.

These findings make aqua jogging an important recovery tool in addition to being the best cross training method for injuries.

Need one more reason?

The calories burned aqua jogging are even higher than running on land, so if you want to avoid weight gain while you take time off from running, this is definitely the exercise for you!

Aqua Jogging Workouts For Runners

If you're interested in aqua jogging to rehab your injury, then the absolute best way is to use one of my favorite programs, Fluid Running.

First, it comes with an aqua jogging belt and waterpoof bluetooth headphones so you have everything you need to aqua jog effectively.

Second, they have an app that pairs with the headphones so you can get workouts, guided instructions on how to aqua jog properly, and motivation while you're actually pool running.

This has been an absolute game changer for me when I am injured.

I used to dread aqua jogging workouts because they were so boring and it took all my mental energy to stay consistent.

But, with workouts directly in my ear, it's changed the whole experience and I actually look forward to the workouts. So much so that I now use aqua jogging as a cross training activity in the summer, even when I am not injured.

Fluid running is an awesome deal when you consider it comes with the belt (highly recommended for better form), the waterproof headphones (game changer for making pool workouts fun), a tether (to add variety to the workouts you can do) and the guided workout app (to make your cross training structure and a whole lot more interesting).

That's why we've partnered with them to give you 2 additional running-specific workouts you can load into the app when you use the code RTTT .

Check out the product here and then on the checkout page, add the code RTTT in the coupon field and the workouts will be added to your order for free.

If you'd rather do the aqua jogging workouts on your own, here are some great ideas to get you started!

Medium Effort Workouts

The Pyramid

10 minutes easy warm up - 1:00 hard, 30 seconds easy - 1:30 hard, 30 seconds easy - 2:00 hard, 30 seconds easy - 2:30 hard, 30 seconds easy, go to 5:00 in 30 second intervals and then come back down the pyramid (4:30 hard, 30 easy, 4:00 hard, 30 easy etc). Finish with 10 minutes easy cool down.

Wave your hands in the air like you just don’t care

10 minutes easy warm up, 1 minute medium (87-92% of maximum heart rate or what feels like tempo effort), 1 minute sprint (95-100% of maximum heart rate or all out sprint), 30 seconds hands in air (keep moving your legs in the running motion, but put your hand above your head), 1 minute rest, Repeat 10-15 times. 10 minutes easy cool down.

Hard Workouts

One of the difficulties of cross training is replicating those truly lung-busting, difficult workouts.

So, if you’re going to be pool running quite a bit due to injury or limited training volume, invest in a bungee cord designed for sprinters.

Tie one end of the resistance band to a sturdy object (pole, lifeguard stand, pool ladder) and bring the other into the water with you.

Put the strap around your waist and begin aqua jog away from your starting point.

You’ll begin to notice the bungee tighten and resist against you (depending on the length of your pool, you may need to wrap the bungee around the supporting object or tie it in knots to make it shorter to feel resistance).

Spend a few moments testing yourself to see how far you can pull the bungee.

This is a great challenge and a fun way to compete with yourself during an otherwise boring cross training activity.

Now for the hard part:

Pick a point on the pool wall or side of the pool that you feel stretches the bungee to a very hard sprint that you could maintain for 60-90 seconds.

This will be your “sprint” marker that you’ll use on sprint intervals (95-100% of maximum heart rate or all out sprint).

Now:

Find a point that feels like the end of a hard tempo run.

Mark this spot as your “medium” interval distance.

When you complete the hard workouts, you can use these reference points to ensure that you maintain a very hard effort.

The springboard

10 minutes easy warm up, 90 seconds easy (slowly moving out and stretching the bungee), 2 minute medium, 1 minute sprint, 1 min rest (let the bungee pull you back – this is kind of fun). Repeat 10 times. 10 minutes easy cool down.

The race simulation

10 minutes easy warm up, 90 seconds easy (slowly moving out and stretching the bungee), 5 minutes medium (focus and concentrate, just like during the hard part of a race), 30 seconds sprint, 2 minutes rest. Repeat 4 times. 10 minutes easy col down

The lactic acid

10 minutes easy warm up, 90 seconds easy (slowly moving out and stretching the bungee), 2 minutes sprint, 90 seconds rest. Repeat 12 times, 10 minutes easy cool down.

I guarantee that with the bungee, you’ll get your heart rate through the roof.

You can challenge yourself and make aqua jogging more fun by seeing how long you can stay at your maximum stretched distance or seeing how far you can push it.

Likewise, if you have a friend who is injured (or someone willing to be a good sport) you can try pulling each other across the pool for some competitive fun.

Cross training can be tough, especially when you’re injured or want to be increasing your volume faster.

However, I hope that providing a variety of workouts, either through the Fluid Running app (which also makes it easier to keep track of the workout while in the water) or on your own can add a fun challenge in the pool and you can emerge from your injury with minimal fitness loss.

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.

[bctt tweet=”Rolled ankle? Here is how to get back to running quickly. VERY helpful post from @Runners_Connect!” via=”no”]