The mechanism is almost always the same: a roll, a stumble, a step off a kerb that was deeper than it looked. The question is whether the ankle in front of you is a sprain (most cases) or a fracture hiding inside a swollen ankle (occasional cases). Australian emergency departments use a validated set of criteria — the Ottawa ankle rules — to make exactly this decision.
First 20 minutes — RICE done properly
- Rest — stop using the joint. No "walking it off."
- Ice — ice or a frozen-vegetable bag wrapped in a tea towel, 15 minutes on, 30 minutes off, for the first 24 hours.
- Compression — a firm crepe or tubular bandage from mid-foot to mid-calf. Not so tight it goes white or numb.
- Elevation — above the heart as much as possible for the first 48 hours.
RICE doesn't fix anything by itself. It controls swelling, which makes the next two weeks much easier.
The Ottawa ankle rules in plain English
You need an X-ray of the ankle if there is bony tenderness over either malleolus (the bony bumps on the inside and outside of your ankle) or you cannot bear weight for four steps either immediately after the injury or in the clinic. You need an X-ray of the foot if there is bony tenderness over the navicular bone or base of the fifth metatarsal (the outside of your midfoot, just behind your little toe). If none of those are positive, you don't need an X-ray — full stop.
The Ottawa ankle rules have been validated in more than 30 studies and miss less than 2% of fractures. They are the same rules used in every Australian ED.
What we'll do in the clinic
- Take a brief history (mechanism, time of injury, prior ankle injuries)
- Examine for swelling, bruising, and the bony tenderness points
- Test weight-bearing
- Check pulses and sensation in the foot
- Apply a soft splint or back-slab if needed
- Provide analgesia (paracetamol and/or ibuprofen, sometimes with a short course of stronger pain relief if severe)
- If an X-ray is indicated, refer you to a local imaging provider for first thing in the morning
- Write a letter to your GP for follow-up
When you need ED instead of urgent care
Go to ED if any of these apply
- Obvious deformity — the ankle is sitting at an unusual angle
- Open fracture — broken skin over the injury
- Numbness, pallor or coldness in the foot — possible vascular injury
- Severe pain not relieved by oral analgesia
- Suspected dislocation — joint clearly out of place
Recovery — what week 1, 2 and 4 actually look like
Week 1 — swelling, bruising peaks at day 3, weight-bearing painful but possible. Use crutches if needed.
Week 2 — bruising starts to fade. Begin gentle ankle range-of-movement exercises (write the alphabet with your toe). Most people back to comfortable walking.
Week 4 — comfortable walking and stairs. Return to running and sport usually around 4–6 weeks for a Grade 2 sprain. Grade 3 sprains and ligament tears can take 8–12 weeks and benefit from physiotherapy.
If you're still in significant pain at 2 weeks, or you have repeated giving-way of the ankle, see your GP for physiotherapy and possible imaging review. Recurrent ankle sprains are a setup for chronic instability — the first injury is worth managing properly.