Sprained ankles are the most common ankle injuries sustained in both the general population and athletic population and can lead to severe pain. These injuries are highly treatable with conservative care such as physiotherapy. Nevertheless, they can be quite distressing, especially in the acute and sub-acute phases of injury.

One very common complaint associated with a sprained ankle is the sensation of throbbing at night. This can be associated with numerous factors, including, but not limited to, overuse during the day, increased swelling, inflammation, secondary injury, and even an increased metabolic rate.

While it is best to check in with your local doctor or physiotherapist if you are experiencing throbbing in the ankle, this article will attempt to shed light on this symptom in the hopes that this knowledge will allow for a more informed decision when it comes to seeking care for a sprained ankle throbbing at night.

What can you do about a sprained ankle throbbing at night?

Early Stage

*** This stage may last approximately 1-3 weeks, but that could vary depending on the extent of injury.

During the week following injury, the injured ligaments in the ankle will be undergoing the inflammatory phase of healing. While this is a necessary stage of healing, it can be quite uncomfortable, sometimes producing a throbbing pain that increases at night after activity.

The main goal is to provide an optimal environment for healing so that the ankle can get through this phase of healing quickly and smoothly. During this phase, one may be able to minimize or prevent the ankle from throbbing at night by incorporating the following strategies:

R.I.C.E. Principle: Rest/Ice/Compression/Elevation. We cover this in more detail in our section on swelling below. Application of ice, gentle compression provided by something like an ankle sleeve, and elevating the ankle above heart level while lying down, can all assist in the reduction of swelling and inflammation. For elevation, using a stack of pillows in bed is usually the most comfortable, and this can be done at the same time as ice, compression, or even while wearing something like a walking boot (see below).

Positioning: If sleeping on your back, avoid having the sheets or blankets resting on your feet. Even if they aren’t heavy, the additional weight can place the ankle in a higher degree of plantarflexion, and if this is sustained throughout the night, it can increase the chances of producing throbbing pain in the ankle. This can happen because the prolonged plantarflexion position can keep the healing ligaments and nerves on stretch, which can increase pain and disrupt proper healing.

Medication: Consult with a doctor or pharmacist regarding the suitability of anti-inflammatories, such as Advil, or pain medications, such as Tylenol. While inflammation is necessary after injury, prolonged or excessive inflammation can cause undue throbbing pain, so it may be possible to strike a balance of allowing the ankle to heal while preventing excessive inflammation via anti-inflammatories, but consulting with a doctor or pharmacist will be extremely important to ensure safety and effectiveness.

Pacing: This sounds like the easiest strategy, but can be a little tricky due to the requirement of planning ahead. During the day, it’s important to pace your activity during the early and middle stages of an ankle sprain. This means taking “mini-breaks” throughout the day to avoid overuse of the ankle while it’s in the acute stages of healing.

Overuse throughout the day can predispose one to developing throbbing pain at night, so by pacing activities throughout the day and taking breaks to unload the ankle when possible, one can be a little more confident in minimizing throbbing pain at night.

Gait Aids: Depending on the extent of injury, your doctor or physiotherapist may recommend using gait aids, such as crutches, a cane, or a knee scooter. In the case of crutches, they may be to help offload the ankle altogether, thereby walking in a non-weight bearing fashion, or the may just help take some of the stress off the ankle by using them in a partial weight bearing fashion.

Not everyone will need a gait aid for an ankle sprain, but if it is recommended by your physiotherapist, being diligent with their instructions may save you some pain in the moment, later on in the day, or at night.

Air Cast: Similar to gait aids, an air cast, also known as a walking boot, is typically reserved for high ankle sprains, or for more severe medial and lateral ankle sprains.

The Air Select walking boot is the Honda Civic of walking boots. This model is so popular that practitioners will often interchange “Air Cast’ with Walking Boot.

This can really help protect the ankle, as it provides physical protection through padding and an air cushion, and also helps immobilize the ankle in a neutral position, which is ideal for ligament healing. In addition to healing, this may also help prevent flaring up the ankle, which in turn can help prevent throbbing pain at night.

Middle Stage

*** This stage is associated with basic restoration of ankle range of motion, strength, and balance/proprioception. As such, the timeline for this phase is undefined and will be guided by the healthcare professional involved in your care.

As the ankle healing process moves out of the inflammatory phase, it enters the proliferative phase, whereby the new tissue is being deposited in the injured area to help repair the damage. This new tissue is not organized well enough to keep up with normal demands on the ankle, which is why sticking with your physiotherapy treatment and still being cautious with the ankle is highly recommended. This will help prevent or minimize throbbing pain at night, which can be achieved through the following strategies:

Range of Motion: Your physiotherapist will be able to guide you on what movements to perform with your ankle, including how often, how far to move, and what directions to focus on. Just as importantly, they can also provide guidance on what movements to be cautious with.

Restoring ankle range of motion will allow for more proper function and load distribution throughout the ankle during functional movements, such as walking, climbing or descending stairs, or picking up objects from the ground. So while it may not be intuitive to move the ankle to prevent pain, this represents a more long term strategy to bring down the throbbing pain over time.

In terms of where to take caution, let’s consider the common lateral ankle sprain. Ankle inversion may be pain-provoking while the ligaments are still healing, and forcing the ligaments to constantly be placed on stretch while the ankle is in an inverted position may compromise healing and lead to throbbing pain at night. Your physiotherapist can guide you more specifically on what movements to avoid.

Strength: Strength is very important to help improve ankle stability, and thus reduce the amount of undue stress on the healing ankle ligaments. For example, with a lateral ankle sprain, strengthening the peroneal muscles as soon as it’s safe can build the necessary support for the lateral ankle ligaments over time. Not only will this help support the healing ligaments themselves, but this will translate to function in the sense that the muscle will now take a lot of the load for the ankle joint, potentially reducing any occurrences of throbbing pain at night.

Balance and Proprioception: This may rely heavily on strength, so these two strategies can work together in tandem. Improving joint proprioception (joint position awareness) through range of motion and balance exercises, an individual can continue to build stability around the ankle, which will help prevent any secondary injuries to the healing ankle ligaments.

Given the ankle is inherently unstable after a sprain, taking range of motion and strength exercises and putting them into action in the form of balance training can help improve overall stability. While this may be challenging and uncomfortable in the moment, this will help reduce undue stress placed on the ankle over time during day-to-day activities like walking on uneven ground, which can subsequently reduce the chance of experiencing throbbing pain at night. It will also help prevent any slips or falls, which helps minimize the risk of re-injury.

Late Stage

*** This stage typically represents returning to your most demanding activities, whether that be return to sport, return to work, or simply keeping up with a hectic family life.

Functional Strength, Mobility, and Balance: During this stage, the ankle is likely feeling a lot better, maybe even feeling back to normal, but lingering throbbing pain may still occasionally occur. By improving your functional strength and mobility through specific advanced exercises prescribed by your physiotherapist, you can continue to give the ankle the support it needs to keep up with your task demands throughout life.

This will help eliminate that last little bit of throbbing pain that may occur intermittently in the ankle, as well as reduce the chances of experiencing a similar injury again. Those who do not keep up their rehab during this later stage may find that their ankle sprain becomes a “nagging injury”.

Lace-Up Ankle Brace: When first getting back to highly demanding activities, it can be quite effective to wear a lace-up ankle brace, such as the EVO Ankle Stabilizing Orthosis (ASO brace).

This helps add an extra layer of security by providing substantial lateral stability to the ankle while still fitting in a shoe and allowing you to move properly. These are common items for volleyball players, basketball players, and soccer players when returning to sport.

What causes a sprained ankle to throb at night?

The following factors, either in isolation or in combination, may result in the uncomfortable and/or painful throbbing of the ankle at night.

Inflammation

Inflammation is a necessary phase of tissue healing that occurs immediately after acute ankle sprains. The expected timeline of the inflammatory phase of healing for a mild to moderate ankle sprain is approximately 1-10 days.

So why does inflammation get a bad rap? The problem occurs when inflammation lasts longer than it should, especially if it is causing severe pain. This is a sign that a conducive environment for healing has not been provided, or the injured tissue has been stressed too much during this phase. Other systemic inflammatory conditions, such as rheumatoid arthritis, may also contribute to prolonging the inflammatory phase of healing.

So what can we do about this? Given inflammation is a necessary component to healing, we don’t want to try and stop it altogether, but rather, provide an optimal environment for healing to facilitate completion of this phase as efficiently as possible, or reducing excessive inflammation for purposes of symptom reduction.

One very common method of addressing inflammation after ankle sprains is the use of non-steroidal anti-inflammatories, also known as NSAID’s. Advil is probably the most common brand name of over-the-counter anti-inflammatory on the market. In order to determine if this is a suitable treatment method, it’s highly recommended to discuss with your doctor or pharmacist about the suitability and potential adverse effects of these types of medication before consumption.

Other more conservative methods include the application of ice to the inflamed area in order to reduce pain. The effectiveness of applying ice to reduce swelling and inflammation for an acute ankle sprain is controversial (Miranda et al, 2021), but anecdotally, many patients find this helpful for reducing symptoms like painful throbbing.

Swelling

Swelling can also cause the ankle to throb at night, especially if the individual has been on their feet all day. Gravity has a mechanical effect on swelling in the sense that if someone is on their feet, gravity will tend to pull the swelling towards the ground into the feet, which can lead to pressure being exerted on damaged or sensitive tissues.

Swelling is commonly associated with inflammation, especially in the acute stage of an ankle sprain, so there may be a combination of the two. However, technically, they should not be considered the exact same thing, as inflammation includes a variety of cellular processes and pathways, and while this is somewhat similar for swelling, the latter is more specific to fluid accumulation.

We have previously discussed using ice for reducing pain and swelling following an ankle sprain, including the controversial evidence behind it, but nevertheless, this is a common method of symptoms reduction that many people find helpful.

Another effective treatment method to reduce ankle swelling is elevation, which involves keeping the ankle above heart level, allowing for the swelling to drain out of the ankle and ultimately alleviating the discomfort associated with excessive swelling. One of the easiest ways to do this at night is to lie on your back with your leg and ankle up on a stack of pillows above chest height.

Other methods include compression, for example, via the use of graded compression stockings. Graded compression stockings provide the greatest amount of pressure in the foot and ankle and gradually decrease pressure up the leg, which ultimately prevents and minimizes the accumulation of swelling in the ankle joints (Sultan et al, 2014).

Overuse

“Overuse” doesn’t necessarily mean using the ankle to the point of structural tissue damage (although that can be the case sometimes), but more often, indicates an increase in inflammation. Therefore, this often occurs in the sub-acute phase of healing when the person has started to challenge the ankle more on their feet, whether through therapeutic exercise or simply trying to hold up to the demands of every day life.

Once out of the inflammatory phase of healing, we progress to the proliferative phase of healing. In simple terms, this phase of healing involves the deposition of new cellular tissue, formation of new blood vessels, and initial repair of the structurally damaged tissue (e.g. ligament, tendon, muscle, etc). One can think of it has bringing all the new materials to a construction site and laying the foundation.

Since the new tissue isn’t optimally organized (this reorganization occurs later in the remodelling phase), it’s easy to over-stress the tissue, thus restarting an inflammatory process, albeit typically less intense than during the acute stage of injury.

Additionally, new blood vessels start forming at this time due to a low oxygen concentration in the area local to the injury. If there is a lack of oxygen, the surrounding muscles and tissue may not be able to keep up with the demands of physical activity, which may cause an ischemic type of pain, often felt as an aching or throbbing pain.

For treatment, rest may be indicated, but more often than not, one can still keep progressing their rehab in a strategic manner while avoiding possible overuse symptoms. This would involve a careful selection of activities and exercises along with guidance on pacing daily activities.

This typically comes in the form of controlled ankle movement with low load in order to continue restoring overall function to the ankle, while also being cognizant that their may still be some residual inflammation or swelling to be careful of. This can be really tricky to sort out if you don’t have specific knowledge regarding injury rehabilitation, and as such, consulting with a physiotherapist is highly recommended in order to safely optimize this phase of your recovery.

Positioning

Keeping the ankle in a static position for a prolonged amount of time may also increase ankle pain and discomfort during the night, particularly after an acute ankle injury. For example, following an acute lateral ankle sprain, pain may be brought on when the ankle is in an inverted and/or plantarflexed position, as the lateral ankle ligaments will be on stretch in this case. Spending a lot of time in this position may lead to increased pain and discomfort.

Furthermore, we’re largely unaware of body movements that occur during sleep. With tossing and turning, the ankle may move into positions it doesn’t like, and over time this can add up to then increase pain and discomfort.

Peripheral Nerve Entrapment

Peripheral nerves are the nerves that provide the ability to move and detect sensation in the limbs of the body. These nerves can become entrapped during injury, meaning something is causing excessive pressure on them, thus eliciting pain which can often be described as throbbing.

Peripheral nerve entrapment can be caused by direct trauma to the nerve tissue that occurred at the same time as the ankle sprain itself, traction due to ligamentous instability from the ankle sprain, increased pressure from excessive swelling, or direct contact such as wearing shoes that are too tight (Hirose and McGarvey, 2004).

Patients often report increased throbbing pain at night from peripheral nerve entrapment. While we aren’t sure exactly why this is the case, and it may vary between individuals, it likely involves a combination of positioning and physiological processes.

We briefly mentioned that keeping the foot in a plantarflexed position (“pressing the gas pedal”) can place the injured ligaments on stretch; however, this can be the same for certain nerves in the foot and ankle as well, especially nerves that pass over the top of the foot in the area of the talonavicular joint.

Another reason this pain may be heightened at night is increased microvascular perfusion that is not present in the day due to increased activity. In other words, nighttime changes to the blood vessels in and around the nerves may alter blood flow and fluid transport, which can lead to the sensation of pain.

Treatment for a peripheral nerve entrapment that is associated with a sprained ankle will typically involve standard physiotherapy care for an ankle sprain, but may also include more advice from a doctor or pharmacist to assist in the prescription of anti-inflammatories or other medications that may ease neuropathic pain. Reducing swelling, restoring ankle range of motion, and improving the stability of the ankle are all ways to reduce pressure on nerves, thus helping to alleviate symptoms while also restoring function.

Secondary Injury or Chronic Conditions

Secondary injuries to ankle sprains, such as fractures (broken ankle bones) or muscle strains (“torn” or “pulled” muscle), can compound the symptoms associated with a sprained ankle. In this case, one can expect to feel more aches and pains, particularly if a fracture is present, and this may require more caution when preparing for sleep. In some cases, a physiotherapist may recommend that you sleep with a walking boot on, or some form of stabilizing support, such as an ankle brace, to ensure maximum protection of the ankle at night.

Another chronic condition to watch out for is Complex Regional Pain Syndrome, also known more simply as CRPS. This condition can occur after injuries to the ankle, and the primary symptoms is a hugely disproportionate amount of pain relative to what would be expected for the sustained injury. This pain is often worse at night, but will be present pretty much all the time, both at rest and with any sort of movement.

The nervous system is highly involved in this condition and those with psychological conditions may be more prone to developing CRPS. As such, treatment for CRPS resulting from an ankle sprain may include a stronger emphasis on the biopsychosocial approach to treatment, often with collaboration between physiotherapists and chronic pain specialists (Renström, 1994).

Additionally, those who suffer from more systemic inflammatory conditions, such as rheumatoid arthritis or gout, are also more prone to feeling their sprained ankle throbbing at night. These types of conditions can prolong the inflammatory phase of healing, and may also bring on inflammation in later stages of recovery, especially when introducing new forms of loading through the ankle joint and surrounding soft tissue (DiStefano and Pinney, 2010).

This is part of the reason why physiotherapists will inquire about your medical history. Some people do not feel comfortable disclosing other medical conditions, which is completely understandable; however, the more context a physiotherapist has about your general health, the more likely they will be to develop an optimal treatment plan for your recovery. Moreover, the physiotherapist may then be able to identify issues requiring referral or collaboration, which can ultimately prevent undue distress and maximize the safety and effectiveness of your rehab.

Summary

Many factors can lead to the sensation of a throbbing ankle at night after sustaining a sprain, and more often than not, it’s a combination of factors that create this symptoms. In most cases, this isn’t something to be too worried about, but would still be worth mentioning to your doctor or physiotherapist so they can make appropriate adjustments to the treatment plan, especially if it is causing severe ankle pain.

References

DiStefano, J. G., & Pinney, S. (2010, December). Ankle arthritis: etiology and epidemiology. In Seminars in Arthroplasty (Vol. 21, No. 4, pp. 218-222). WB Saunders.

Hirose, C. B., & McGarvey, W. C. (2004). Peripheral nerve entrapments. Foot and ankle clinics, 9(2), 255-269.

Miranda, J. P., Silva, W. T., Silva, H. J., Mascarenhas, R. O., & Oliveira, V. C. (2021). Effectiveness of cryotherapy on pain intensity, swelling, range of motion, function and recurrence in acute ankle sprain: a systematic review of randomized controlled trials. Physical Therapy in Sport, 49, 243-249.

Renström, P. A. (1994). Persistently painful sprained ankle. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 2(5), 270-280.

Sultan, M. J., Zhing, T., Morris, J., Kurdy, N., & McCollum, C. N. (2014). Compression stockings in the management of fractures of the ankle: a randomised controlled trial. The Bone & Joint Journal, 96(8), 1062-1069.