It Went on the Push Off, Not the Landing: Understanding Tennis Ankle Sprains and How Physical Therapy Can Help

If you have ever pushed off hard for a wide forehand, felt your foot roll under you as you turned, heard something that was more of a crunch than a pop, finished the game anyway, and taken your shoe off two hours later to find the outside of your ankle puffed up, you have had a tennis ankle sprain.

Here is the part that surprises people. The ankle is the most commonly injured lower-limb site in tennis. In a study of 600 German league players covering 1,012 injuries, 56 percent of the acute ones were in the lower limb, the ankle led the list, and ligaments were the most commonly damaged structure at 36.4 percent. Everyone worries about the shoulder and the elbow. The ankle is the one that actually happens.

The good news? A well-run rehabilitation plan measurably lowers the odds of doing it again, and that finding comes from randomized trials rather than from gym folklore.

At Rooted Motion Physical Therapy, we believe the injury that keeps happening deserves more attention than the one that sounds dramatic. Let us look at what a tennis ankle sprain is, why it happens at the moment it does, and what has to be true before you go back on court.

What Happens in a Tennis Ankle Sprain?

In most cases the foot rolls inward while the ankle points down, and the ligaments on the outside of the joint are stretched beyond what they tolerate. Sometimes they partly tear. The swelling, the bruising that shows up a day later in a surprising place, and the tenderness below the bony bump all come from that.

What matters clinically is that the ligament is not the only casualty. Those ligaments are full of sensors telling your brain where the joint is and how fast it is moving. A sprain damages the reporting as well as the rope.

The ligaments on the outside of the ankle, and where the tenderness usually sits.

Why Does It Go on the Push Off and Not the Landing?

Because tennis is a game of stopping and turning, not jumping and landing.

The clearest data comes from American high school tennis, where 176 injuries were logged across four seasons. The ankle was the most-injured site at 25.6 percent, ahead of the knee and wrist. And 28.7 percent of all injuries came from rotation around a planted foot or the foot turning inward. Not contact. Not landing. Turning on a foot already down.

Small sample, younger population than most club players, so hold the percentages loosely. The pattern matches what happens on court: you plant to change direction, your body keeps going, and the ankle has to control a rotation it did not expect.

Ankle first, and rotation on a planted foot is the commonest mechanism of all.

Imagine a Rug on a Polished Floor

Stand on a rug on a wood floor and nothing happens. It holds your weight all day. Now pivot on it quickly, and it slides out from under you.

The rug was never weak. It was fine at the thing you were testing, and failed at a completely different demand.

The key idea: an ankle rarely fails standing still. It fails at the moment you change direction on it—which is why “it does not hurt any more” and “it is ready for a match” are two different questions with two different answers.

Common Symptoms

• Swelling on the outside of the ankle, often within the first hour.

• Bruising that appears a day or two later, sometimes down into the foot.

• Tenderness in front of and just below the bony bump on the outside.

• Pain turning the foot inward, and often none turning it outward.

• A sense that the ankle might give way on uneven ground or in a quick change of direction.

• Feeling fine walking in a straight line and unconvinced the moment you try to pivot.

Some ankle injuries need imaging rather than rehabilitation, and that is not a judgement to make from a website. Get it assessed promptly if you cannot put weight through it, if there is bone tenderness at the back edge or tip of either ankle bone, if the foot looks misshapen, or if swelling was severe and immediate.

Why “It Stopped Hurting” Is Not the Same as Ready

“It was fine after two weeks, so I went back and did it again.” We hear that more than any other sentence in this injury.

Pain and swelling settle first, on their own timeline. The sensing and the control take longer, and walking around pain-free does not test them. The current clinical practice guideline for lateral ankle ligament sprains, revised in 2021, treats a first sprain and ongoing instability as related presentations precisely because so many people move from one to the other.

So the question at the end of rehabilitation is not whether it hurts. It is whether the ankle controls a fast change of direction under load, on ground that is not perfectly flat, when you are tired.

What Does the Research Recommend?

Balance and proprioceptive training, and on one point the evidence is unusually clear.

A meta-analysis of seven moderate-to-high quality randomized trials with 3,726 participants found proprioceptive training cut ankle sprain rates, relative risk 0.65 — and 0.64 in the group that matters most here, people who had already sprained one. Roughly a third fewer.

The same review is careful about the other half. For people who had never sprained an ankle, the pooled estimate rested on two trials that were individually not significant, and the authors call that evidence inconclusive. The 2021 guideline reaches the same conclusion, describing a lack of evidence for balance training as a first-sprain preventive while rating the recurrence evidence as strong. That distinction gets dropped in a lot of summaries. It should not be.

What Balance Training Does and Does Not Do

A 2026 umbrella review pulled together 27 systematic reviews on balance training for ongoing ankle instability. For dynamic postural control—staying controlled while moving—it found a solid effect with moderate certainty.

For pain, ankle range of motion, muscle strength and quality of life, it found no poolable evidence at all. Not evidence of no effect. Simply not enough consistent data to combine.

That shapes what rehabilitation is for. Balance work is well supported for the thing that actually causes re-injury, which is control. It is not a general-purpose fix for a sore ankle, and anyone who says otherwise is ahead of the evidence.

Getting Back on Court

Progress on what you can do rather than how many weeks have passed. Full weight-bearing and range first, then loading the calf and the muscles down the outside of the shin, then single-leg control on a stable surface and then an unstable one, then the thing that hurt you: a pivot, a plant-and-push, side-to-side at pace, and the same again when you are tired.

A few practical points that make a difference:

• Train the pivot deliberately. Straight-line running back to fitness does not prepare an ankle for a change of direction.

• Do the balance work often and briefly. Short daily sessions beat one long session a week.

• Test it tired. Ankles give way at the end of the third set, not in the warm-up.

• A brace or tape is worth using early, and for preventing another sprain. The guideline advises against relying on one by itself once instability is the problem.

• If it has gone more than once, treat that as information rather than bad luck.

The Rooted Motion Difference

We provide one-on-one mobile care throughout Richmond, Henrico, Chesterfield and Midlothian, which means the later stages of an ankle rehabilitation happen where they matter:

• A full assessment of the ankle, and of the hip and knee that share the work of a plant-and-push.

• Balance and control retested objectively rather than by how it feels.

• Progression driven by criteria you meet, not by a number of weeks.

• Change-of-direction work rebuilt in real conditions instead of on a clinic mat.

• Honest separation of what the evidence supports from what is clinical judgement.

• Guidance on bracing and taping, and on when they are worth using.

• Convenient concierge mobile physical therapy delivered where you are.

Because recovery is not just about a joint that has stopped swelling—it is about trusting your footing when the ball is out wide.

Ready to Trust That Ankle Again?

If your ankle went on a plant-and-push and you have been favouring it ever since, or if this is not the first time, you do not have to guess your way back onto the court alone.

Schedule a one-on-one evaluation and we will find out what your ankle can control, and build the plan from there.

Ready to move better and live rooted? Contact Rooted Motion Physical Therapy to schedule a one-on-one evaluation and begin a personalized plan built around the change of direction your game actually asks for.

Research Used for This Article

1. Martin RL, Davenport TE, Fraser JJ, et al. Ankle stability and movement coordination impairments: lateral ankle ligament sprains revision 2021. Journal of Orthopaedic & Sports Physical Therapy. 2021;51(4):CPG1-CPG80. DOI

2. Krueckel J, Szymski D, Lenz J, et al. Tennis injuries among German league players: investigating patterns and epidemiology of acute and chronic injuries. Open Access Journal of Sports Medicine. 2024;15:67-75. DOI

3. Llanes AC, Deckey DG, Zhang N, Curley KL, Curley ND, Chhabra A, Neal MT. Lower-extremity injuries predominate in American high school tennis players. Arthroscopy, Sports Medicine, and Rehabilitation. 2023;5(6):100811. DOI

4. Schiftan GS, Ross LA, Hahne AJ. The effectiveness of proprioceptive training in preventing ankle sprains in sporting populations: a systematic review and meta-analysis. Journal of Science and Medicine in Sport. 2015;18(3):238-244. DOI

5. Martinez-Lozano P, Sanchez-Romero EA, Martinez-Pozas O, Sillevis R, Selva-Sarzo F, Cuenca-Zaldivar JN. Effectiveness of balance training in people with chronic ankle instability: an umbrella review with meta-meta-analysis. Journal of Back and Musculoskeletal Rehabilitation. 2026;39(4):1318-1339. DOI

Educational disclaimer: This article is for general education and is not a substitute for an individualized evaluation. Seek prompt medical care if you cannot put weight through the ankle; if there is bone tenderness at the back edge or tip of either ankle bone; if the foot or ankle looks misshapen; or if swelling was severe and immediate.