Broken ankle vs sprained ankle: how to tell the difference

Broken or sprained ankle: the key differences

A sprained ankle is an injury to the ligaments, the tough bands of tissue that hold the ankle bones together. A broken ankle, or ankle fracture, is a crack or break in one of the bones of the ankle joint: the tibia (shin bone), which forms the bump on the inside of your ankle; the fibula, the thinner leg bone that forms the bump on the outside; or the talus, the bone that sits between them, on top of the heel bone.

Both usually happen the same way, by rolling or twisting the ankle, and both cause pain, swelling and bruising. These clues help tell them apart:

These are clues, not a diagnosis. A bad sprain can hurt more than a small fracture, and some people walk around on a broken ankle for days. If you’re not sure, get an X-ray.

Signs of a sprained ankle

Most sprains happen when the foot rolls inward and the ligaments on the outside of the ankle stretch or tear. The one hurt most often, the anterior talofibular ligament, sits just in front of the outer ankle bone. Common signs:

• pain on the outside of the ankle, worst in front of and just below the ankle bone
• swelling that builds over minutes to hours
• bruising that can spread toward the heel and toes over the next few days
• pain when you walk or turn the foot inward
• with a bad sprain, an ankle that feels loose or gives way

Signs of a broken ankle

• severe pain straight away, and pain when you press on the bone
• swelling that comes on fast, often on both sides of the ankle
• bruising that spreads down into the foot over a day or two
• trouble putting any weight on the leg
• an ankle or foot that looks deformed or points the wrong way
• numbness, tingling or a cold foot, which can mean a nerve or blood vessel is affected
• bone showing through a wound, called an open fracture, which is an emergency

What does a broken ankle look like?

A broken ankle is usually swollen, sometimes badly, with bruising that turns blue or purple. Over 1 to 3 days the bruising often spreads toward the heel and toes as blood settles with gravity. A severe sprain can look exactly the same, so photos can’t tell you which injury you have.

An ankle that is clearly misshapen is different. That points to a displaced fracture, where the broken ends have moved apart, or a dislocation, and it needs the emergency room.

Can you walk on a broken ankle?

Sometimes. Being able to walk doesn’t rule out a fracture. Small, stable breaks, such as a hairline crack in the fibula or an avulsion fracture, where a ligament pulls off a chip of bone, can often be walked on with pain.

Walking on an unstable fracture can push the bones further out of place, though. If you can’t walk without a lot of pain, keep weight off the ankle and get an X-ray before you try again.

When do you need an X-ray? The Ottawa ankle rules

Emergency doctors and podiatrists use a checklist called the Ottawa ankle rules to decide who needs an X-ray. An ankle X-ray is needed if you have pain around the ankle bones and any one of these:

1. The outer ankle bone hurts when pressed along its back edge or tip, anywhere in its lowest 6 cm (about 2.5 inches).
2. The inner ankle bone hurts when pressed along its back edge or tip, anywhere in its lowest 6 cm.
3. You couldn’t take 4 steps (2 on each foot, limping is fine) right after the injury, and still can’t.

The same rules check the midfoot. If the bony bump halfway along the outer edge of your foot (the base of the fifth metatarsal) or the bump on the inner side of your midfoot (the navicular) hurts to press, you need a foot X-ray. Our guide to telling a broken foot from a sprain covers those injuries.

When none of the rules apply, a fracture is very unlikely. The rules were designed for adults examined by a clinician. They haven’t been well tested in young children, and they’re less reliable in people with numb feet from diabetes or neuropathy and after drinking alcohol. Use them to judge how quickly to get seen, not as a reason to skip care.

How bad is my sprain? Ankle sprain grades

Recovery times are for getting back to normal activity. Ligaments keep strengthening for months afterward, and stopping rehab too soon is a common reason sprains keep coming back. Our guide to healing a torn ankle ligament goes into more detail.

Injuries that can look like a sprain

Some injuries are called a sprain at first but need different care:

• High ankle sprain. The ligaments that join the tibia and fibula just above the ankle are hurt, usually when the foot twists outward. It’s common in football and soccer. The pain is higher, above the ankle bone, and twisting the foot outward hurts. It usually takes longer to heal than a regular sprain, often 6 weeks or more.
• Avulsion fracture. A ligament pulls off a small chip of bone. It’s often treated much like a sprain, but it shows on an X-ray.
• Fifth metatarsal fracture. Rolling your ankle can break the long bone on the outer edge of your foot. If the side of your foot hurts more than the ankle, get it X-rayed.
• Cartilage injury. A twist can bruise or crack the cartilage on top of the talus. Suspect it if deep ankle pain, swelling, catching or locking is still there weeks after the sprain should have healed. It may need an MRI.
• Tendon injury. The peroneal tendons, which run behind the outer ankle bone, can tear or slip out of place. The Achilles tendon can tear too: you feel a sudden pop at the back of the heel, as if you’d been kicked, and can’t push off properly. A torn Achilles tendon should be seen the same day or the next.

If your “sprain” isn’t clearly better after a week or two, have it checked.

What to do right after you hurt your ankle

For the first 2 to 3 days:

1. Rest. Keep weight off the ankle if walking hurts, and use crutches if you have them.
2. Ice for 15 to 20 minutes every 2 to 3 hours, with a cloth between the ice and your skin.
3. Compress with an elastic bandage, snug but not tight. Loosen it if your toes tingle, go numb, or turn pale or blue.
4. Elevate the ankle above the level of your heart as often as you can.
5. Take a pain reliever such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin), if it’s safe for you. Ask a doctor or pharmacist first if you have kidney disease, stomach ulcers or heart problems, take a blood thinner, or are pregnant.

Skip heat, hot baths, alcohol and massage for the first 2 to 3 days, since they can increase swelling.

If you have diabetes, neuropathy or poor circulation, don’t use ice or a tight wrap before a podiatrist has seen the ankle. You may not feel damage to your skin, and injuries can heal more slowly.

How a sprained ankle is treated

Most sprains heal without surgery. Treatment usually includes:

• Early, protected movement. For mild and moderate sprains, walking as comfort allows with some support, and starting gentle exercises within a few days, leads to a faster recovery than keeping the ankle in a cast.
• Support. Tape, an elastic sleeve or a lace-up brace. A severe sprain may need a walking boot for a short time. Our guide to ankle braces after a sprain explains which type suits which stage.
• Rehab exercises. Range of motion first, such as tracing the alphabet with your toes, then calf and ankle strengthening, then balance work such as standing on one leg. Balance training is one of the best-supported ways to prevent another sprain.
• Physical therapy for moderate and severe sprains, athletes, and ankles that keep giving way. See sports and orthopedic injury rehab.
• Surgery, which is rarely needed. It’s considered when the ankle stays unstable after several months of rehab, or when a sprain comes with a fracture or a torn tendon.

How a broken ankle is treated

Treatment depends on whether the broken bones are still lined up (a stable fracture) or have shifted (an unstable or displaced fracture).

• Stable fractures, such as a small crack in the fibula, are often treated in a walking boot or cast for about 6 weeks. Depending on the break, you may be allowed to put weight on it early, or you may need crutches for a while.
• Unstable fractures, including breaks on both sides of the ankle, usually need surgery to line the bones up and hold them with plates and screws. You’ll usually keep weight off the ankle for several weeks afterward.
• Follow-up X-rays check that the bones stay in place and are healing.
• Physical therapy once the bone has healed, to get back motion, strength and balance.

While you’re in a cast or boot:

• Keep your leg raised as much as you can in the first couple of weeks.
• Call your doctor if the cast feels too tight, the pain keeps getting worse, or your toes go numb, cold or blue.
• Call your doctor about new calf pain or swelling, which can be a sign of a blood clot. Call 911 for chest pain or sudden shortness of breath.
• Don’t drive with your right leg in a boot or cast until your doctor says it’s safe.
• If you smoke, this is a good time to stop. Smoking slows bone healing.

Learn how we treat sprains and fractures.

How long does a broken or sprained ankle take to heal?

Some swelling, stiffness and aching at the end of the day can last several months after a fracture or a bad sprain. That’s normal, and it keeps improving. Healing tends to be slower if you smoke or have diabetes.

Preventing another ankle sprain

The biggest risk factor for spraining an ankle is having sprained it before. To lower the odds:

• Finish your rehab, especially the balance exercises, even after the pain has gone.
• Brace or tape the ankle for sport for up to a year after a sprain.
• Wear shoes that fit and suit the activity, and replace worn-out shoes that tilt your heel.
• Warm up before sport, and take extra care on uneven ground.
• Keep your calves and ankles strong with heel raises and single-leg balance work.

When to see a doctor for an ankle injury

Go to the emergency room if:

• the ankle or foot looks deformed or out of place
• bone is showing, or there’s a deep cut over the injury
• your foot is numb, cold, pale or blue
• the pain is severe and keeps getting worse despite rest, ice and elevation

Get seen the same day or the next day if:

• you can’t take 4 steps, or can’t put any weight on the leg
• pressing on either ankle bone, or on the outer edge of your foot, hurts
• the swelling is severe
• you have diabetes, neuropathy or poor circulation
• a child can’t walk normally on the ankle, since the growth plates near a child’s ankle can be injured

Book a visit if:

• a sprain isn’t clearly better after 5 to 7 days
• the ankle still feels loose or keeps giving way after a few weeks
• you keep spraining the same ankle
• pain, swelling, catching or locking is still there 4 to 6 weeks after the injury

Getting your ankle checked

A podiatrist can examine the ankle, test the ligaments and tell a sprain from a fracture. Evolve Health podiatrists have digital X-ray on site, so you can usually have an X-ray and get a diagnosis at the same visit. Our guide to what happens at a podiatrist appointment after an injury walks you through it. You can find a podiatrist near you and book online.