Broken ankle or sprain? Learn the signs of an ankle fracture, when you may need an X-ray and when to see a foot and ankle specialist.
You step awkwardly off a kerb, roll your ankle playing sport or miss the last stair.
There’s immediate pain, followed fairly quickly by swelling, and perhaps some impressive bruising the following morning.
The obvious question is: have I broken my ankle, or is it just a sprain?
It’s a question I’m asked regularly by patients, and unfortunately the answer isn’t always obvious. A severe ankle sprain can be extremely painful, while some people with an ankle fracture can still put weight through their foot and even walk.
So, what should you look out for, and when is it worth getting your ankle properly assessed?
An ankle sprain is an injury to the ligaments that support the ankle joint. It usually occurs when the ankle twists or rolls beyond its normal range, stretching or tearing one or more ligaments.
The most common injury is a lateral ankle sprain, affecting the ligaments on the outside of the ankle.
An ankle fracture, on the other hand, means that one or more of the bones forming the ankle joint have broken. These include the lower ends of the tibia and fibula and, less commonly, the talus.
The difficulty is that the mechanism of injury can be remarkably similar. The same awkward twist that causes a sprain can also cause a fracture – and occasionally patients have both a fracture and ligament damage.
That’s why I wouldn’t recommend relying on pain alone to decide what has happened.
Both injuries can cause:
There are, however, certain signs that make me more suspicious of a fracture.
Very localised tenderness directly over the ankle bones – particularly the bony prominences on either side of the ankle – can indicate a fracture. Significant swelling, deformity or being unable to take four steps following the injury are also reasons to seek assessment.
Research supports the use of the Ottawa Ankle Rules, a clinical decision tool used to help determine when an X-ray is appropriate following an acute ankle injury. A large systematic review found these rules to be highly sensitive for excluding ankle and midfoot fractures.
They are useful clinical rules, but I certainly wouldn’t suggest trying to use them to diagnose yourself at home.
Yes, and this is another reason why the distinction between a sprain and a fracture isn't always clear-cut.
When you severely twist your ankle, a ligament can sometimes pull so forcefully on the bone where it attaches that it pulls away a small piece of bone.
We call this an avulsion fracture. In other words, you can sustain what feels and looks very much like an ankle sprain, but technically there is also a small fracture.
The reassuring news is that many small, stable avulsion fractures around the ankle are treated in much the same way as a significant sprain, with appropriate support followed by gradual movement and rehabilitation.
However, the exact location and size of the fracture matter, so I would still want to assess the injury properly and review any necessary imaging rather than assume it is simply a bad sprain.
This is probably one of the biggest misconceptions surrounding ankle fractures.
Yes, sometimes you can.
Patients often tell me, “I assumed it couldn't be broken because I could walk on it.”
Some stable or relatively minor fractures still allow you to bear weight. Equally, a severe ligament sprain can make putting your foot on the floor incredibly painful.
Being able to walk is therefore reassuring to a degree, but it doesn't completely rule out a fracture.
If you have significant pain or very localised bony tenderness – or walking simply doesn't feel right – I would advise getting it checked rather than repeatedly testing it.
A mild ankle sprain will often begin to improve over the first few days. The swelling starts settling, walking becomes easier and movement gradually returns.
I'd recommend seeking medical advice sooner if:
An obvious deformity, an open wound around a suspected fracture, or problems with the circulation or sensation in the foot require urgent medical attention.
Another reason to seek advice is if you have what you thought was a straightforward sprain but it is still causing problems several weeks later. Persistent pain after an ankle injury deserves investigation rather than simply assuming you need to give it more time.
An X-ray is usually the first investigation when I suspect an ankle fracture.
It allows us to see whether a bone is broken, where the fracture is and whether it has moved out of its normal position.
However, diagnosis isn't simply about spotting a crack on an X-ray.
With ankle fractures, one of the key questions is whether the ankle joint remains stable and correctly aligned. Stability plays an important role in deciding whether a fracture can be treated without surgery or requires an operation.
For more complex fractures, I may recommend a CT scan to understand the fracture pattern in greater detail and help plan treatment.
MRI is very useful where symptoms persist despite apparently normal X-rays or where I suspect a soft-tissue injury (ankle sprain).
I’m always slightly cautious about the phrase “just a sprain”.
Most ankle sprains recover very well, but a significant ligament injury deserves appropriate rehabilitation. If it isn't managed properly, some patients are left with ongoing pain, weakness or a feeling that the ankle repeatedly “gives way”.
Current clinical guidelines support progressive weight-bearing, structured exercise and rehabilitation for most lateral ankle sprains, rather than simply resting until the pain disappears.
If you repeatedly sprain the same ankle, feel unstable or haven't regained normal movement and confidence, it's worth having it assessed, as there may be more to it that initially thought.
Not all ankle sprains involve the ligaments on the outside of the ankle. A high ankle sprain, also known as a syndesmotic injury, affects the strong ligaments that connect the tibia and fibula just above the ankle joint. These ligaments are important for keeping the ankle joint stable.
High ankle sprains tend to occur with a twisting or external rotation force, often when the foot is planted and the body turns over it. They are particularly associated with sports such as football, rugby and skiing, although they can happen to anyone.
Pain is often felt slightly higher above the ankle than with a typical lateral sprain, and patients may find pushing off, twisting or walking particularly uncomfortable.
These injuries are important to recognise because they can take a lot longer to recover from than a standard ankle sprain, and more severe injuries can cause instability between the tibia and fibula.
Stable injuries can usually be treated without surgery, but significant unstable syndesmotic injuries often require surgical stabilisation.
If the mechanism of injury, examination or symptoms make me suspicious of a high ankle sprain, I usually recommend additional MRI imaging; particularly as a syndesmotic injury is not always obvious on a standard X-ray.
Not every ankle fracture requires an operation.
Stable fractures that remain in a good position can often be managed without surgery, with appropriate protection and progressive weight-bearing. More unstable or displaced fractures may require surgery to restore the alignment and stability of the ankle.
This is where specialist assessment becomes particularly important. I look not only at the fracture itself, but also at the stability of the ankle, associated ligament injuries, your general health and what you need to get back to – whether that's everyday walking, running, skiing or competitive sport.
If you've recently injured your ankle and aren't sure what you've done, don't be embarrassed about getting it checked. Even clinically, fractures and sprains can sometimes look remarkably similar.
Equally, if you've been told you've sprained your ankle but it simply isn't recovering as expected, I would encourage you to seek further assessment.
My job is to establish exactly which structures have been injured and, importantly, how significant that injury is. From there, we can decide on the right treatment and rehabilitation plan to help you recover properly and get confidently back on your feet.
Both can cause pain, swelling and bruising. A fracture is more likely if you have significant tenderness directly over the ankle bones, cannot take four steps, notice deformity or have severe persistent pain. An examination and X-ray may be required to know for certain.
Yes. Some stable ankle fractures still allow people to walk, so being able to put weight through your ankle does not completely rule out a fracture. If walking is painful or you have significant bony tenderness, seek medical assessment.
It can be difficult to tell from symptoms alone because both injuries cause pain, swelling and difficulty walking. The location of tenderness, ability to bear weight, mechanism of injury and an X-ray where appropriate can help distinguish them.
An X-ray may be recommended if you have specific bony tenderness around the ankle or are unable to take four steps. Clinicians commonly use the Ottawa Ankle Rules to help determine whether imaging is necessary.
Recovery depends on the severity of the ligament injury. Mild sprains can improve relatively quickly, while more significant injuries may take several weeks or longer and benefit from structured rehabilitation.
Some small stable fractures heal well with relatively simple treatment, but an unstable or displaced fracture that isn't appropriately treated can heal in a poor position and affect the long-term function of the ankle. Persistent pain following an ankle injury should therefore be assessed.
Martin Klinke is one of the leading ankle surgeons in London. With an impressive background in both Orthopaedics and Sports Medicine, he takes a comprehensive and compassionate approach to your treatment. He’s a trusted, reputable surgeon who can help get you back in the game!
Mr Martin Klinke offers outpatient consultations at the Cleveland Hospital and the Cleveland Clinic in London.
You can find all his patient reviews here.
Bachmann, L.M., Kolb, E., Koller, M.T., Steurer, J. and ter Riet, G. (2003) ‘Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review’, BMJ, 326(7386), p.417. doi:10.1136/bmj.326.7386.417
Martin, R.L. et al. (2021) ‘Ankle stability and movement coordination impairments: lateral ankle ligament sprains revision 2021’, Journal of Orthopaedic & Sports Physical Therapy, 51(4), pp.CPG1–CPG80. doi:10.2519/jospt.2021.0302
Lampridis, V., Gougoulias, N. and Sakellariou, A. (2018) ‘Stability in ankle fractures: diagnosis and treatment’, EFORT Open Reviews, 3. doi:10.1302/2058-5241.3.170057. This is particularly useful for supporting Martin's discussion of why fracture stability, rather than simply the presence of a fracture, is so important when deciding treatment.
Kyriacou, H. et al. (2021) ‘Assessment and management of adult ankle fractures: understanding the evidence’, British Journal of Hospital Medicine. doi:10.12968/hmed.2020.0445. The authors are from King's College Hospital, the Royal National Orthopaedic Hospital and UCLH, making this a particularly relevant UK clinical reference.
