Ankle Sprain Return to Play: High vs Lateral Sprains and the Tests That Matter

The swelling is down. Walking feels normal. The athlete wants back in for Friday. This is the moment most ankle sprains go wrong, because an ankle that stops hurting is not the same as an ankle that is ready.

This article walks through what kind of sprain you are dealing with, why the two common types heal on very different timelines, and the simple tests that tell you when an athlete is ready to return.

Two different injuries

Most people say "sprained ankle" as if it is one thing. It is at least two.

Lateral ankle sprain. This is the classic rolled ankle. The foot turns in and the ligaments on the outside of the ankle stretch or tear. The first one to go is usually the ATFL (anterior talofibular ligament), which runs from the front of the fibula to the talus. With more force, the CFL (calcaneofibular ligament), which runs down to the heel bone, can be injured too. Lateral sprains are by far the most common ankle sprain in sport.

High ankle sprain. This one happens higher up, at the syndesmosis, the group of ligaments that hold the tibia and fibula together just above the ankle joint. The usual mechanism is the foot turning out while the leg rotates over it, the kind of thing that happens in a pile-up or a hard plant and cut. Every time the athlete pushes off or cuts, the two shin bones are pried apart a little. That is why these injuries linger.

How long each one takes

Timelines vary with grade and with the athlete, so treat these as ranges, not promises.

• Mild lateral sprain: often days to about 2 weeks before a return to sport.
• High ankle sprain: usually weeks, not days. A common estimate for stable injuries is about 4 to 6 weeks. A systematic review found athletes treated without surgery returned to sport in about 42 days on average, and those who had surgery took longer (Vancolen et al., 2019).

A "low grade" label does not mean quick if the injury is at the syndesmosis. Ask which type it is before you plan a return date.

When an X-ray makes sense

The Ottawa Ankle Rules help decide whether an ankle injury needs an X-ray. Imaging is suggested if there is pain in the ankle area plus any of these:

1. Tenderness at the back edge or tip of the lateral malleolus (the lower 6 cm of the fibula)
2. Tenderness at the back edge or tip of the medial malleolus (the lower 6 cm of the tibia)
3. Unable to take 4 steps both right after the injury and at the evaluation

For the midfoot, the same idea applies to the base of the 5th metatarsal and the navicular. These rules were built to rule out fractures and are highly sensitive (Bachmann et al., 2003). They do not replace an evaluation by an athletic trainer or physician.

Early care

Early on, the goal is to protect the ankle without shutting it down. Gentle, pain-free movement, progressive loading and a plan from your athletic trainer will do more than days of rest. If you want to understand why we move away from rest and ice, read M.E.A.T. vs RICE.

Clinical guidelines for lateral sprains support functional treatment with exercise and bracing as needed, rather than long periods of immobilization (Vuurberg et al., 2018).

Why pain-free is not the test

After a sprain, pain fades fast. Balance, strength and the ankle's sense of position come back much more slowly. If the athlete returns on the pain timeline, they go back to sport with an ankle that still cannot control a landing.

That gap is a big reason sprains come back. A large share of people who sprain an ankle go on to have repeated sprains or lasting symptoms, often called chronic ankle instability (Doherty et al., 2016). The swelling went away, so the rehab stopped.

The return-to-play ladder

Use a simple ladder. The athlete passes each rung without pain or giving way before moving up.

1. Balance. Stand on the injured leg for 30 seconds, eyes open, without hopping or grabbing for support. Then compare to the other side.
2. Hops in place. Two legs, then one leg. Landings should be quiet and controlled.
3. Single-leg hop for distance. The injured leg should reach at least 90% of the healthy leg. This is often called the limb symmetry index.
4. Cutting and sport drills. Change direction at speed, then full practice drills with no limp, no guarding and no swelling the next day.

For a high ankle sprain, rungs 3 and 4 matter most. Hops and hard cuts load the syndesmosis directly. An athlete who can walk without pain but cannot cut hard is not ready, no matter how the ankle looks.

Strength side to side

The ladder works best with a strength check. Calf raises to fatigue, resisted eversion and hip strength can all be compared side to side. The same 90% target is a reasonable bar. Testing both sides on the same surface and at the same time of day keeps the comparison fair.

A sample week-by-week outline

Every athlete is different, so this is an outline, not a prescription.

• Week 1: protect the ankle, use compression, and walk as soon as you can without a limp.
• Weeks 2 to 3: range of motion, then single-leg balance work.
• Week 4 on: hops, then cutting, then sport drills, moving up only when each rung is passed.

A high ankle sprain will usually sit longer in the early weeks. A mild lateral sprain may move through faster.

For students and teachers

The difference between a lateral sprain and a high ankle sprain, the Ottawa Ankle Rules and the anterior drawer test all show up on the BOC exam and in clinical rotations. If you want a one-page study guide that ties the anatomy to the special tests, see Ankle Sprains and Special Tests.

Want to check what you know? Try the free BOC practice quiz.

The short version

• A lateral sprain hits the outside ligaments. A high ankle sprain hits the syndesmosis and takes longer.
• Pain-free is not ready.
• Balance, hops, single-leg hop at 90% or better, then cutting.
• When in doubt, have the ankle evaluated by an athletic trainer or physician.

Jena K Phillips, LAT

This article is for education and does not replace an evaluation by a licensed health care provider.

Sources

• Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003;326(7386):417.
• Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med. 2018;52(15):956.
• Doherty C, Bleakley C, Hertel J, et al. Recovery from a first-time lateral ankle sprain and the predictors of chronic ankle instability. Am J Sports Med. 2016;44(4):995-1003.
• Williams GN, Allen EJ. Rehabilitation of syndesmotic (high) ankle sprains. Sports Health. 2010;2(6):460-470.
• Vancolen SY, Nadeem I, Horner NS, et al. Return to sport after ankle syndesmotic injury: a systematic review. Sports Health. 2019;11(2):116-122.