Ankle sprain in children
An ankle sprain is an injury to the ligaments that stabilise the joint, usually caused by the foot twisting suddenly. In children it is important to tell it apart from an injury to the bone or the growth plate. Most sprains get better with the right treatment and a gradual recovery, but repeated sprains or a feeling that the ankle gives way need a specialist assessment.
- Also known as
- Twisted ankle · Lateral ankle sprain · Chronic ankle instability · Recurrent ankle sprain
What it is
The ankle is stabilised by several ligaments that connect the bones and limit excessive movement. A sprain happens when the foot turns beyond its normal range and these ligaments are stretched or partly torn. Most sprains affect the ligaments on the outside of the ankle and usually happen when the foot rolls inwards.
It is a common injury in children and adolescents who play sports such as football, basketball, handball or athletics. It can also happen when running on uneven ground, jumping or falling. Severity ranges from a mild stretch to a significant ligament tear.
In childhood, diagnosis needs particular care because the ligaments can be relatively strong compared with some areas of bone that are still growing. A injury that looks like a sprain may therefore actually be a fracture or a growth plate injury. Pain over the bone, difficulty putting weight on the foot and how the symptoms evolve help guide the diagnosis.
Most sprains heal without surgery. However, some children have repeated episodes, a feeling of instability or new sprains when they return to sport. In these cases it is important to look not only at the ligaments but also at the structure of the foot, muscle strength and balance control. Conditions such as cavovarus foot or a tarsal coalition can contribute to recurrent sprains.
Signs parents may notice
The most common symptoms are:
- Ankle pain after a twist or a fall.
- Swelling around the joint, especially on the outside.
- Bruising in the hours after the injury.
- Difficulty putting weight on the foot, walking or climbing stairs.
- Pain when moving the ankle or pressing on the injured area.
- Feeling unsteady when walking or running.
- Repeated sprains or a feeling that the ankle gives way easily.
How much pain or swelling there is does not on its own show how severe the injury is. If the child cannot put weight on the foot or has pain over the bone, a bone injury needs to be ruled out.
When to see a specialist
It is advisable to ask for a medical assessment when pain or swelling is significant, the child has difficulty walking or the symptoms are not gradually improving.
See a doctor especially if:
- The child cannot take several steps on the foot.
- There is very localised pain over the ankle bones or at the base of the fifth metatarsal.
- The swelling is marked or there is extensive bruising.
- The pain persists or recovery is slower than expected.
- Sprains keep happening or the child says the ankle gives way.
- There is deep pain inside the joint, locking or painful clicking.
When is it urgent?
Urgent assessment is needed if there is a visible deformity, an open wound, severe uncontrollable pain, or if the foot is cold, pale, bluish or has lost sensation.
How it is diagnosed
Diagnosis starts with the history of the injury and a careful clinical examination. The specialist asks how the twist happened, where it hurts, whether the child can put weight on the foot and whether there have been previous episodes.
The examination assesses swelling, painful points, ligament stability and ankle movement. The foot and gait are also examined, especially when there is a history of repeated sprains.
When are imaging tests needed?
- X-rays: requested when the examination suggests a fracture or a growth plate injury. Decision criteria should be adapted to the child’s age and the clinical findings.
- Ultrasound: can help assess certain ligaments and soft tissues, depending on the team’s experience.
- MRI: reserved for selected cases, such as persistent pain, a suspected osteochondral lesion of the talus, a significant ligament injury or symptoms not explained by X-rays.
- CT: can be useful when certain bone injuries or a tarsal coalition are suspected and the anatomy needs to be defined more precisely.
With recurrent sprains, the assessment must go beyond the ligaments. It is important to look at hindfoot alignment, the shape of the arch and the movement of the foot joints to rule out predisposing factors such as cavovarus foot or tarsal coalitions.
Treatment
Non-surgical treatment
Most ankle sprains in children are treated without surgery. The aim is to control pain and swelling, restore movement and strength, and prevent new injuries.
1. Protection and activity adjustment
During the first few days, activities that increase the pain should be avoided. An ankle brace, a splint or crutches may be needed for a while, depending on how severe the injury is.
2. Cold packs and elevation
Applying cold, wrapped in a cloth, for about 15–20 minutes can relieve pain. Raising the foot during rest helps reduce swelling. Ice should never be applied directly to the skin.
3. Gradual weight-bearing
For mild and moderate sprains, it is usually recommended to gradually return to weight-bearing as pain allows. If the child cannot put weight on the foot, a bone injury must be ruled out before encouraging weight-bearing.
4. Physiotherapy and rehabilitation
Recovery is not just a matter of waiting for the pain to go. Mobility, strengthening and balance exercises help restore ankle function and reduce the risk of further sprains.
Rehabilitation may include:
- Restoring ankle movement.
- Strengthening the muscles that stabilise the foot and ankle.
- Balance and proprioception exercises.
- Gradual training in running, jumping and changing direction.
5. Preventing further sprains
When there is a history of repeated sprains, it may help to wear an ankle brace for certain sports and keep up a programme of balance and strength exercises.
However, prevention also means identifying possible structural causes. A child with cavovarus foot, a stiff foot or a suspected tarsal coalition may need specific investigation and treatment aimed at the underlying problem.
Surgical treatment
Surgery is rare after a first sprain and is reserved for selected situations.
It may be considered for chronic instability that persists despite proper rehabilitation, especially when repeated episodes limit sport and a significant ligament injury is confirmed.
Depending on the case, the lateral ankle ligaments may be repaired or reconstructed. If an associated structural problem is found, such as certain hindfoot deformities or a symptomatic tarsal coalition, that cause may also need to be treated.
The operation is usually done under anaesthesia and may be day surgery or need a short hospital stay. Afterwards the ankle is protected for a while and rehabilitation begins gradually. The technique, the length of immobilisation and when weight-bearing starts depend on the injury and the procedure.
Outlook and recovery
Most children do well. Recovery time depends on the severity of the sprain, the child’s age, any associated injuries and the quality of rehabilitation.
As a general guide:
- First 2–3 days: protect the ankle, control pain and swelling, and adjust weight-bearing.
- First and second week: gradual recovery of walking and movement in mild sprains, depending on symptoms.
- Between 2 and 6 weeks: many mild or moderate sprains gradually regain function. Severe injuries may take longer.
- Back to school: usually possible early on, adapting walking and physical activity if pain or swelling persist.
- Back to sport: should wait until the child has regained functional movement, strength and balance, and can run, jump and change direction without pain or a feeling of instability.
Significant injuries may need a limited period of immobilisation. Not every sprain needs a cast, and how long protection is needed should be adapted to the type of injury.
The return to sport should not be based only on how much time has passed. If pain, limping or a feeling that the ankle gives way persist, the child should be reassessed before returning to full activity.
Recurrent sprains deserve particular attention: a correct diagnosis, rehabilitation and identifying structural problems help reduce the risk of new injuries and chronic instability.
This page is for general information and does not replace an assessment by a specialist. If you are worried about your child's foot, talk to their paediatrician or book an appointment.