How to manage a twisted ankle even when you have to keep rucking: A first aid guide

If you’ve served in the military, there’s a decent chance you’ve twisted an ankle (or two)

Ever twisted an ankle when you were rucking out in the field? The standard injury advice of rest and ice are generally incompatible with that environment.  

Military members sustain up to five times as many ankle injuries as the general population due to the physical demands of the job.1 Combat boots and incomplete injury recovery (leading to re-injury) add to the risk profile.

The problem? Just one ankle injury, such as a ligament sprain, sets a person up for more long-term issues such as instability, weakness, knee pain, or back pain. 

While you might not be able to prevent a twisted ankle – and it’s unlikely you can stop to care for it properly in the field – there are steps you can take to minimize injury and future complications.   

In this article we’ll go over three topics: 

  1. First aid you can do for a twisted ankle while you are out in the field (PACE program)
  2. Key signs to help you judge the urgency of seeking professional care
  3. Lessons we’ve learned over the years about injured ankles

Remember: good judgment is your responsibility. No article can replace the advice of a healthcare professional who has examined you and knows your situation. While some injuries will heal on their own, many others will require additional attention. Consider this info as a starting point, not a treatment plan.

Part 1: First aid for a twisted ankle in the field: PACE yourself

PACE is a self-care first aid method to mitigate further damage and prepare for rapid recovery following an injury: 

  • Protection – prevent further injury so healing can begin.
  • Activity Modification – encourage the repair process while staying active.
  • Comfort – manage pain and circulation to promote normal healing.
  • Exercise – maintain nutrition and circulation while preventing a loss of motion.

Protection: boot lacing, add compression wrap or a brace

A simple variation in boot lacing called a double overhand knot can help you lock your ankle more securely into your boot. This quick technique helps to avoid excessive movement of the ankle inside the boot, especially if boot fit is less than ideal (Starting at 0:45 in this video):

If you can add an elastic compression wrap (aka ACE wrap), do it! A 2 or 4-inch wide bandage is ideal. Start at the mid-foot and wrap up the ankle to the mid-shin. Wrap at least to the top of your boot, so the wrap doesn’t slide down. Pull the bandage to approximately 50% stretch and overlap each layer by 50% coverage. Secure with tape or pins while you are standing on the injured ankle, to avoid securing it too tightly (and forcing blood to pool in the foot).

In an optimal situation, exchange the compression wrap for a lace-up ankle brace used for rucking and other weight-bearing activity. This video shows how to apply a cloth lace-up brace to an injured ankle: 

Activity modification: foot flat weight-bearing 

While it may be a habit to place only the ball of your foot on uneven or rocky terrain (as opposed to a flat foot), this position “unlocks” the ankle, making it more prone to buckle after a twisting injury. 

As much as you can think about it, anticipate your foot placement of the injured ankle when out in the field, placing your entire foot (heel and ball) on the ground for better stability.  

Comfort: elevation, compression, ice 

Use gravity to your advantage during rest breaks and before you go to sleep. Elevate the injured leg as high as comfortable up a wall or tree, keeping your knee bent slightly. If you elevate both legs, keep your ankles uncrossed. This recovery position, borrowed from yoga and known as “legs up the wall,” assists circulation and drains fluid build-up. Try to get in 5-10 minutes per session, 3 times per day as able. 

If you’ve been using a compression wrap, use this recovery period to check its application. Remove and re-wrap the ankle if the fabric has developed wrinkles or has bunched up in your boot. Keep the wrap on while you sleep.

Cold packs or ice, if available, can provide substantial pain relief and reduce painful muscle spams. Ice application also controls excessive inflammatory “heat” that can injure healthy tissues alongside the already damaged ones. Up to 10 minutes submersion in cold water (50-60 degrees Fahrenheit) is best, as the hydrostatic pressure of the water helps control internal swelling.

A bag of ice or a cold pack can be applied to the injured area for 15 minutes.  Use a damp cloth to create a barrier between the pack and your skin (to avoid skin burns). Then, attach the pack to the injured ankle with the compression wrap if available, and elevate the ankle as high as practical for the duration of the treatment. Again, 3 sessions per day are optimal, but at a minimum, try to apply cold immediately after activity or before bed. 

Exercise: rope-assisted ankle pumps 

During your recovery periods, perform a set of 25 assisted ankle pumps. Loop a rope or jacket around the middle of your foot with leg outstretched. Keeping your toes pointed upward, slowly move your ankle by bending your feet backward and forward. Try to reach the limits of your motion in each direction. Use your ankle muscles to supply 50% of the effort, and use your arms and rope for the remaining 50% assistance. 

Part 2: When should you get help? 

Twisted ankles can cause several injuries, including bone fractures, ligament sprains, and blood vessel or nerve injuries. Seek guidance from a physical therapist, physician, medic, or athletic trainer: 

Urgently (today) if you notice: 

  • Numbness, tingling, or paleness in your foot or ankle
  • Visible deformity of your foot or ankle
  • Deep, open wounds
  • Severe pain when you touch bony areas of the foot or ankle 
  • Inability to bear weight or walk on the injured side

Promptly (within a few days) if you notice:

  • Deep bruises developing
  • An intense pain on the inner (big toe side) of the ankle
  • Severe or sharp pain at the front side of the ankle, or lowest part of the shin, that worsens when you walk or climb stairs 

Schedule an appointment soon if you notice: 

  • Inability to stand on the injured leg for 10 seconds with eyes closed after 2 weeks 
  • Difficulty or pain with single-leg activities such as going up and down stairs after 3 weeks
  • Inability to tolerate impact such as hiking an incline or running after 4 weeks

Part 3: Lessons we’ve learned about twisted ankles 

Twisted ankles are likely to cause problems months or even years after the initial injury due to incomplete recovery early on. 

Unresolved ankle stiffness or weakness results in poor feedback to the brain about your ankle position, causing stress on the knees, back, and opposite ankle to compensate. 

To reduce your chances of long-term problems, know that you may need additional treatment or rehab advice after the pain and swelling resolve.


Twisted ankles are common and frequently cause long-term problems. To manage an injury in the field, PACE yourself.  If you have signs of a severe injury or lingering pain, look for an athletic trainer or physical therapist who can help you get back to 100%. 

Questions about ankle pain or repeated injuries? Send us your question. We answer every question. 

If you have a friend, teammate, or co-worker who could use this information, please share it with them.


  1. Cameron KL, Owens BD, DeBerardino TM. Incidence of ankle sprains among active-duty members of the United States Armed Services from 1998 through 2008. J Athl Train. 2010; 45(1): 29-38

-Related articles- 

Leave a Reply

Your email address will not be published. Required fields are marked *