Ankle Sprain

• Use culturally safe, trauma- and violence-informed care. Explain why questions matter, seek permission before sensitive topics, and adapt communication to the patient’s language, identity, culture, disability and previous health care experiences (Public Health Agency of Canada 2018).
  
• Patient and contextual information: age; sex and gender when clinically relevant; preferred language and communication needs; work or school; caregiving; activity level; footwear or equipment; and the activities, roles and cultural or community connections important to the patient.

Primary concerns

• Injury and symptom course: mechanism and direction of force; date and setting of injury; immediate pain, swelling, bruising, sound or sensation; ability to continue activity and bear weight; care already received; and whether symptoms are improving, stable, fluctuating or worsening.
  
• Location and pattern: lateral, medial, anterior, posterior or pain above the ankle; foot or lower-leg symptoms; pain severity and irritability; swelling, stiffness, locking or catching; numbness, tingling, weakness, colour or temperature change; and the pattern with rest, loading and time of day.
  
• Aggravating and easing factors: walking, stairs, uneven ground, running, jumping, cutting, push-off, footwear, work or sport tasks, rest, support, elevation and self-management.
  
• Previous ankle and lower-limb history: first or recurrent sprain; prior fracture, surgery or rehabilitation; episodes of giving way; persistent instability; previous return to activity; and hip, knee, foot, balance or neurological concerns that may affect assessment or care.
  
• Body systems review: select relevant constitutional or general; eyes, ears, nose and throat; neurological; cardiovascular and vascular; respiratory; gastrointestinal; genitourinary; musculoskeletal and bone health; skin; endocrine or metabolic; haematologic or lymphatic; immune or infectious; mental health; and reproductive questions based on the presentation. Pursue findings that may change safety, the differential diagnosis, care or referral.
  
• Health and safety context: relevant bone health, diabetes or peripheral neuropathy, inflammatory or infectious illness, bleeding risk, medications and supplements, recent antibiotics, systemic corticosteroid or fluoroquinolone exposure, surgery or immobilization, and other factors that may change examination, healing, referral or use of the Ottawa Ankle Rules.
  
• Functioning and participation: effects on sleep, mobility, self-care, work or school, caregiving, recreation, sport, community roles and confidence in the ankle.
  
• Social and access context: ask about relevant work or school demands and supports, caregiving, finances or compensation, housing, transportation, safety, discrimination, social support, access to care and culturally relevant or community supports. Use the information to adapt care when possible (Public Health Agency of Canada 2026).
  
• Previous care and responses: advice, bracing or taping, mobility aids, medication, exercise, hands-on care or other approaches tried; benefits, adverse effects and reasons care was difficult to use or continue.
  
• Patient perspective: understanding of the injury, concerns about damage or reinjury, confidence, expectations, priorities, goals, preferences, cultural approaches and what meaningful recovery would look like.
  
• Flag review: check Red Flags and refer to the separate fixed Orange Flags and Yellow Flags modules when relevant. Reassess relevant features when symptoms or functioning change.

​​Outcomes measures: Choose a small set that reflects the patient’s goals and can be repeated. Record a baseline and reassess often enough to guide decisions.

• Patient-specific functioning: Patient-Specific Functional Scale (PSFS).
• Disability and participation: WHO Disability Assessment Schedule 2.0 (WHODAS 2.0).
• Quality of life: WHOQOL-BREF or another suitable validated measure.
• Foot and ankle ability: Foot and Ankle Ability Measure (FAAM) when a region-specific measure will inform care.
• Perceived ankle instability: Cumberland Ankle Instability Tool (CAIT) when recurrent giving way or instability is a concern.
• Individual goals: agree on patient-defined goals and how progress will be recognized. SMART wording may be used when helpful.

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

• Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
• Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
• Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

• Suicide or self-harm thoughts: thoughts without immediate danger.
• Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
• Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

• Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
• Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
• Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
• Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

• Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
• Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
• Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
• Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
• Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
• Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

• Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
• Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
• Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
• Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
• Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

Select examination elements that answer a clinical question or may change safety, the working diagnosis, care or referral. Adapt timing, positioning, pace and loading to symptom irritability, comfort, consent and abilities.

• Ongoing consent and comfort: explain each step, provide choices, ask permission before touch or exposure, and stop or modify the examination when requested.
  
• Immediate safety and bony assessment: inspect skin and wounds; assess colour, temperature, pulses, capillary refill, sensation and motor function when trauma or neurovascular concern is present; palpate the malleoli, navicular, base of the fifth metatarsal, talus, calcaneus and proximal fibula as indicated; and apply the Ottawa Ankle Rules only when appropriate.
  
• Observation, gait and swelling: compare sides for swelling, bruising, deformity, guarding, antalgic gait, weight-bearing tolerance, footwear or support use and functional movement. Quantify swelling when it will guide progression (Delahunt et al. 2018).
  
• Movement and range of motion: assess active and passive dorsiflexion, plantar flexion, inversion and eversion as tolerated; include a weight-bearing dorsiflexion measure when useful; record pain, apprehension, restriction and movement quality (Delahunt et al. 2018).
  
• Palpation and tissue assessment: examine the lateral and medial ligaments, syndesmosis, Achilles and peroneal tendons, ankle joint line and relevant foot and lower-leg structures. Local tenderness helps shape the differential but does not establish severity or stability alone.
  
• Ligament and syndesmosis tests: use anterior drawer, talar tilt and condition-relevant syndesmosis tests when pain, swelling and guarding allow meaningful interpretation. Cluster findings; no single test confirms the complete injury pattern or syndesmotic stability (Delahunt et al. 2018; Netterström-Wedin and Bleakley 2021).
  
• Strength and motor control: assess ankle and foot strength, endurance and power as tolerated, including plantar flexors and evertors; add hip or lower-limb assessment when it may change rehabilitation (Martin et al. 2021).
  
• Sensorimotor and balance assessment: select static and dynamic balance or proprioceptive tasks that are safe, repeatable and relevant to the patient’s goals (Delahunt et al. 2018).
  
• Functional performance: progress from gait, stairs and single-leg stance to calf raises, hopping, jumping, landing, agility, work or sport tasks only when clinically appropriate. Record pain, quality, confidence and response (Delahunt et al. 2018).
  
• Regional and differential examination: examine the foot, Achilles tendon, calf, proximal fibula, knee, neurological or vascular system, or another region when the history or initial findings indicate.
  
• Imaging: not routine for a presentation that fits an uncomplicated ankle sprain and has a negative, applicable Ottawa rule. Arrange or coordinate imaging when fracture, syndesmotic instability, osteochondral or tendon injury or another diagnosis is suspected, or when persistent symptoms make the result likely to change care. A negative Ottawa rule does not evaluate every soft-tissue injury (American College of Radiology 2019; American College of Radiology 2020).
  
• Reassessment: repeat the findings and functional tasks needed to track recovery, review the clinical impression, detect adverse effects and decide whether further assessment or referral is appropriate.

Use these as working clinical descriptions rather than definitive tissue diagnoses. They can overlap or change as pain, swelling and function evolve (Martin et al. 2021; Delahunt et al. 2018).

• Recent lateral ankle sprain: a twisting injury with lateral pain or tenderness, swelling or bruising, painful or limited weight bearing and reduced ankle motion, strength, balance or confidence. Describe the current impairments and activity limits rather than relying on a grade label alone.
  
• Suspected syndesmotic or other ligament injury: pain above the ankle mortise or a non-inversion mechanism, with tenderness and a cluster of provocative findings. Clinical tests do not by themselves establish stability; use Red Flags and referral when instability or another injury is suspected (Netterström-Wedin and Bleakley 2021).
  
• Recurrent sprain or chronic ankle instability: repeated sprains or episodes of giving way, perceived instability and persistent pain, swelling, stiffness or participation limits after a previous lateral ankle sprain. Common modifiable findings can include reduced dorsiflexion, strength, balance, sensorimotor control or confidence (Martin et al. 2021).
  
• Alternative or overlapping presentation: findings may point to fracture, Achilles or peroneal tendon injury, osteochondral injury, impingement, nerve involvement, inflammatory or infectious disease, referred pain or another foot, ankle or lower-leg condition. Refer or co-manage when assessment or care is needed beyond the clinician’s role.

Develop care with the patient. Base choices on safety, the working presentation, goals, preferences, culture, age, other health conditions, activity demands, access and response. Use adaptable options rather than a fixed sequence, and repeat meaningful outcomes to guide change.

Education, self-management and participation

• Explain the injury, important uncertainty, the expected variable course and the plan for reassessment. Validate the person’s experience, address fear without minimizing the injury, and provide clear advice about safe loading, symptom response and changes that need earlier care (Martin et al. 2021).
• Support continued or gradually resumed daily activity, work, school, caregiving, recreation and community participation. Temporary pacing, task modification, footwear or equipment changes and accommodations can be included when useful and feasible.

Protection and optimal loading

• Progressive weight bearing and early functional loading can be paired with a brace, tape or gait aid selected for injury severity, stage of recovery, comfort, preferences and access. More severe injury can involve brief immobilization and medical coordination before loading progresses (Martin et al. 2021).

Physical activity and exercise

• An individualized exercise program can include protected range of motion, progressive calf and ankle strength and endurance, neuromuscular and proprioceptive training, static and dynamic balance, gait and functional tasks in clinic, at home or both. Adjust type, amount and challenge to symptoms, goals, capacity and response (Martin et al. 2021; Wagemans et al. 2022).
• Return to running, work or sport can progress using task-specific exposure and repeated functional assessment. For sport, the PAASS domains include pain, ankle impairments, athlete perception and readiness, sensorimotor control, and sport or functional performance; the framework does not set one universal clearance threshold (Smith et al. 2021).
• For recurrent-sprain risk, balance or proprioceptive training and external support during higher-risk activity can form part of the plan. A brace or tape is not a stand-alone rehabilitation plan for chronic ankle instability (Martin et al. 2021; Wagemans et al. 2022).

Hands-on and symptom-relieving care

• Soft-tissue techniques and pain-free ankle or foot mobilization can accompany exercise when the intended short-term goal is to reduce swelling, improve comfortable motion, support gait or improve balance. Monitor the response and do not use hands-on care as the only rehabilitation strategy (Martin et al. 2021; de Ruvo et al. 2022).
• Intermittent cold, compression, elevation or a comfortable support can be used for short-term symptom relief when acceptable. Protect skin and circulation, especially when sensation or vascular health is impaired, and use symptom relief to support rather than replace progressive activity (Martin et al. 2021).
• Culturally grounded, traditional, spiritual or community-based approaches identified by the patient can be integrated when they are safe, acceptable and within scope, with coordination across practitioners when needed.

Psychological, social and interdisciplinary support

• When fear of reinjury, low confidence, distress, competing demands or access barriers affect recovery, use supportive communication and graded exposure within competence, adapt the plan and connect the patient with appropriate psychological, occupational, sport, medical, social or community support.
• Coordinated assessment can support persistent instability, complex comorbidity, substantial participation restriction, uncertainty about another injury or return-to-work or return-to-sport decisions beyond one clinician’s role.

Medication

• Medication choices can be coordinated with an authorized prescriber or pharmacist. Review current use, intended benefit, contraindications, interactions and adverse effects, and keep medication decisions connected to functioning and the overall plan.

Monitoring and reassessment

• Agree on a reassessment point based on symptom course, safety, goals, the options being tried, patient needs and access rather than a fixed visit schedule.
• Repeat the small outcome set recorded at baseline and review pain, swelling, ankle motion, strength, balance, gait, functioning, participation, confidence, benefits, adverse effects, treatment burden and progress toward patient-defined goals.
• Continue what is useful and acceptable; adapt or stop what is not; and revisit the working presentation, differential diagnosis, barriers, imaging, referral or shared care when progress differs from expectations or new safety concerns emerge.

• Expected course: for adolescents and adults with a lateral ankle sprain, pain and activity often improve over days to weeks, but the course varies with the injury and the person. Recurrent sprain, giving way or other symptoms can persist at 12 months, so no universal return-to-activity timeline applies (Martin et al. 2021; Michels et al. 2022).
  
• Factors associated with a less favourable course: higher initial pain or swelling, restricted motion, limited weight bearing, a more severe injury, a non-inversion mechanism and lower self-rated recovery have been linked to slower recovery in some studies, but the evidence does not support certain individual prediction. Persistent perceived instability is associated with recurrent sprain (Thompson et al. 2017; Kawabata et al. 2023).
  
• Potential supports for recovery: progressive loading, exercise that addresses identified deficits, balance or proprioceptive training, external support for higher-risk activity, adequate functional preparation, confidence, feasible accommodations and access to care may support recovery and reduce reinjury. These are care considerations, not guarantees (Martin et al. 2021; Wagemans et al. 2022).
  
• Discussing prognosis: describe uncertainty in plain language, ask what the patient wants to know, and update the prognosis using the patient’s goals, repeated outcomes, confidence and response over time rather than treating a grade, risk factor or screening score as a fixed prediction.