Understanding the pathology, scans, and treatment decisions that shape recovery
Rolled Ankle: What to Do in the Acute Stage
A rolled ankle is one of the most common injuries we see in clinic. While it might look straightforward, it is rarely a simple injury. What happens in the early stages is critical. Accurate assessment and management give the foot and ankle the best chance of recovery. This ensures they can return to their highest level of function — whether that’s elite sport, recreational activity, or simply moving day to day.
Understanding How an Ankle Sprain Occurs
Most rolled ankles occur because of a sudden twist. The classic mechanism is inward (inversion), where the foot turns inwards. This overstretches or tears the ligaments on the outside of the ankle. Less often, the foot turns outwards (eversion). This places strain on the ligaments on the inside of the ankle.
We also consider whether it’s a first-time sprain or a recurring injury. A first sprain may follow a predictable course. Repeat injuries, however, often suggest ligament laxity, joint instability, or incomplete rehabilitation.
The context also matters. Did the ankle roll while changing direction, sprinting, landing from a jump, or stepping off a kerb? Each of these situations places different forces on the joint. These forces help us understand which structures may have been compromised, and to what extent. That detail is important. It changes how we treat the foot and ankle, especially in the acute stage.
Could you keep going on your rolled ankle?
One of the first questions we ask is whether you could continue playing or walking after the rolled ankle injury. Some people can “run it off,” while others can’t take another step. The ability (or inability) to continue often hints at the severity.
Checking for Fracture Risk and Imaging
It’s important not to dismiss every rolled ankle as a simple sprain. We use the Ottawa Ankle Rules—a set of clinical guidelines that help decide if X-rays are needed. These rules direct us to check for tenderness along key bony landmarks, such as the distal tibia, fibula, navicular, and the base of the fifth metatarsal. If a patient has pain in these regions and cannot weight bear, this is what acute hospitals would typically refer for an X-ray to rule out a clear break.
However, while an X-ray can identify a fracture, it does not tell us about the integrity of the ligaments. For this, further imaging may be required. Ultrasound can provide useful information about ligamentous injury, while MRI is often the gold standard: not only can it confirm or rule out fractures, but it also gives us a detailed picture of the ligament complexes and can detect cartilage injuries such as osteochondral (OCD) lesions.
Although a fracture may not be present, OCD lesions can still occur and should be ruled out if there is clinical suspicion. This is particularly important in cases where pain persists, weight-bearing is limited, or mechanical symptoms (like catching or locking) are reported.
So depending on what we think has occurred — guided by history, mechanism of injury, clinical tests, and current function — we will decide whether plain X-ray is sufficient or whether advanced imaging such as ultrasound or MRI is required to ensure nothing important is missed.
Ligament and Joint Assessment
Once fracture is ruled out, we move on to checking the ligament stability of the ankle. The outside ligaments (lateral complex) are most commonly involved, but sometimes the inside (medial) ligaments are affected too. Gentle stress tests help us determine whether there is just a mild stretch, a partial tear, or something more severe.
Balancing Protection and Movement in Ankle Injury Care
This really comes down to the pathology involved. When required, we will immobilise the ankle. For example, using a boot or supportive brace — to allow injured tissues the chance to heal. However, we are also aware that by assisting one problem, we can temporarily create another by immobilising the joint itself.
With periods of immobilisation, we know that contractile tissues such as muscle will decrease in size and capacity, even over a relatively short time. That’s why the decision must be carefully balanced: enough support to protect healing structures, but not so much restriction that we compromise the surrounding muscles or joint function.
As soon as it’s safe to do so, we usually aim for early, guided movement. This helps maintain mobility, stimulate blood flow for healing, and preserve strength — giving the ankle its best chance of returning to full function.
Key Takeaways
Not all rolled ankle injuries are the same. Different pathology is associated with different healing timeframes, which is why a thorough assessment — and, when appropriate, referral for imaging — is so important. The way the injury is managed in the acute stage is vital for setting up the long-term outcome.
Once we have safely navigated the acute stage, the focus shifts to performance metrics and reconditioning. This stage of rehabilitation ensures the foot and ankle not only recover but also regain the strength, stability, and confidence needed to return to full function — from elite sport to everyday activity.
Tania Vascon, B.Pod
Podiatrist
Melbourne CBD Physiotherapy and Sports Medicine Clinic
Tania Vascon, a senior podiatrist, brings over 13 years of clinical experience across sports and general practice. At Melbourne CBD Physiotherapy and Sports Medicine Clinic, she provides expert care for all conditions of the foot and ankle, from complex sporting injuries to everyday concerns such as nail and skin care. With a strong background in biomechanics, Tania integrates evidence-based treatment with modern technology to optimise gait mechanics, relieve pain, and improve long-term function. Her approach is both precise and compassionate, ensuring patients receive tailored strategies that support their goals — whether that’s returning to sport, enhancing mobility, or maintaining foot health for daily life.