"It's just a twisted ankle": the ankle is the most common injury in youth female athletes

The ankle accounts for 23% of injuries in youth female athletes — more than the knee (16%). Yet it is the injury we describe with a shrug: among athletes aged 14-18, 20% live with chronic ankle instability, and among girls that figure rises to 23.6%. In youth sport, prevention programmes cut ankle injuries by about 26%. The data, the limits of the data, and what changes in twenty minutes a week.

In a club's calendar, the ankle sprain is the injury that never makes news. It doesn't end a season like an ACL tear, it has no written protocol like concussion, it doesn't frighten parents like a fracture. It gets described in five words — "it's just a twisted ankle" — and filed away with an ice pack. Then you look at the numbers on what happens to those athletes in the years that follow, and those five words turn out to be one of the worst bets in youth sport.

In brief

  • In youth female athletes the ankle is the most affected location: 23% of all injuries, ahead of the knee (16%) and thigh (13%); 67% of injuries involve the lower limb (Beech et al., 2024; 32 studies, 15,908 athletes aged ≤19).
  • Ankle sprain incidence is higher in females (13.6 versus 6.94 per 1,000 exposures) and higher in the young (Doherty et al., 2014; 181 prospective studies, highly heterogeneous values).
  • Among athletes aged 14-18, 20.0% have chronic ankle instability: 23.6% among girls, 16.3% among boys — with lower sport function and lower perceived quality of life (Donovan et al., 2020; 1,002 athletes).
  • In youth sport, prevention programmes cut ankle injuries by roughly 26% (IRR 0.74; 95% CI 0.60-0.91), at 15-20 minutes twice a week for 3-6 months (Berkey et al., 2024; 10 RCTs, ages 13-19).
  • The problem isn't only biomechanical: in a historical snapshot of young athletes, no medical attention was sought in more than half of cases (55%) (Smith and Reischl, 1986 — 84 male athletes, study from 1986).

What really is the most common injury in youth female athletes?

The ankle, and it isn't close. The largest systematic review and meta-analysis of the injury profile in youth female sport pooled 32 studies and 15,908 athletes aged 19 and under. The result is clear: overall incidence is 4.4 injuries per 1,000 hours (95% CI 3.3-5.9), 40% of athletes sustain at least one time-loss injury, and the anatomical distribution puts 67% of injuries in the lower limb, with the ankle at 23%, the knee at 16% and the thigh at 13% (Beech et al., 2024).

That comparison is worth pausing on, because it inverts the usual order of concern. The ACL is the injury we talk about — rightly, because it is the one most likely to end a career. But statistically the ankle is hit almost one and a half times as often as the knee, and receives a fraction of the attention. The same goes for stress fractures and patellofemoral pain: those topics have a name, while the ankle only gets a shrug.

One honesty note on the figure: the authors themselves flag that each anatomical category rests on a variable number of studies (three to 15) and that injury definitions differ across sources. The 23% is an estimate, not a constant.

Do girls sprain their ankles more than boys?

The data say yes, by a wide margin — with an equally wide caveat about the numbers. The reference meta-analysis examined 181 prospective studies on the incidence and prevalence of ankle sprain. Comparing subgroups, incidence is higher in females than males (13.6 versus 6.94 per 1,000 exposures), higher in children than adolescents (2.85 versus 1.94) and in adolescents than adults (1.94 versus 0.72) (Doherty et al., 2014).

Two things need saying immediately. First: the absolute values are not comparable across subgroups, because they come from different sets of studies with different sports, definitions and denominators — the literature here is notoriously heterogeneous. Second, and more important: what is documented is the direction, not the mechanism. Why female athletes sprain their ankles more often has no settled explanation of the kind that exists for the knee.

We would rather be explicit here than plausible. For the ACL there is longitudinal evidence that after puberty girls land with greater dynamic knee valgus than boys (Ford et al., 2010, cited in our article on the ACL); hypothesising that the same change in landing control also loads the ankle is reasonable, but it stays a hypothesis, not a finding. The solid, actionable fact is a different one: the age band where sprains are most frequent is exactly the age band of youth sport.

What happens next: the 20% living with an ankle that gives way

Here is the number that should change how "just a twisted ankle" is heard.

A study of 1,002 high school athletes aged 14-18 (mean age 15.6, 50.4% girls) measured the prevalence of chronic ankle instability — the condition in which, after one or more sprains, the ankle keeps giving way, hurting or feeling unreliable well beyond tissue healing. The result: 20.0% overall, 23.6% among girls versus 16.3% among boys. Almost one girl in four (Donovan et al., 2020).

The most instructive detail, though, is elsewhere. Only 26.1% of participants reported having sustained at least one ankle sprain. Put the two percentages side by side and the problem appears: the share of athletes with an unstable ankle is nearly equal to the share who remember getting hurt. In other words, the sprain is an event that gets forgotten; the instability it leaves behind does not.

And that instability carries a measurable cost. Those affected reported markedly lower sport-related ankle function (FAAM-Sport 87.0 versus 97.7) and lower perceived quality of life (total PedsQL 89.8 versus 93.5) than those without it. With one detail that makes the picture worse, not better: physical activity levels did not differ between the groups. They are not dropping out. They are carrying on playing with an ankle that doesn't work properly and a lower quality of life, and none of it shows up in any club record.

On the clinical side, the reference epidemiological review reports that up to 70% of people who sustain an acute sprain may develop residual physical disability, and cites a study estimating a 40% prevalence of chronic instability one year after a first lateral ankle sprain (Herzog et al., 2019). It is a narrative review focused on the US context, not a meta-analysis: the value is in the order of magnitude, not the exact figure.

"It's just a twisted ankle": why the clinician step gets skipped

There is one study that, despite its age, describes this better than any other. Across 84 high school basketball players, 70% had a history of ankle sprain; of those, 80% had sustained more than one; in 32% of cases the injury meant more than two weeks out. And the figure that matters: in 55% of cases no medical attention was sought at all. Around half reported residual symptoms, and 15% felt those symptoms compromised their performance (Smith and Reischl, 1986).

This must be said plainly: that sample was entirely male and the study dates from 1986. It is not a valid estimate today, and it is not an estimate about girls. We cite it for what it is — the clearest description in the literature of a cultural behaviour that anyone who spends time in a gym still recognises: the ankle sprain is the injury people self-manage.

The thing is, that self-management isn't irrational. A sprained ankle stops hurting quickly enough to look healed. The problem is that "it doesn't hurt any more" and "it works again" are not the same thing, and the gap between them only becomes visible months later — in the proportion of 15-year-olds living with an ankle that gives way.

The dynamic closely resembles what we described for urinary leakage and for knee pain that lasts months: a very common symptom which, precisely because it is common, gets mistaken for normal, and which nobody discusses enough because it never seems serious enough to deserve it.

Does prevention work? Yes — and there is youth-specific evidence

Yes, with an estimated effect of around 26% — and this time the data cover exactly the right age band.

A systematic review and meta-analysis pooled 10 randomised trials in high school athletes aged 13-19 (four in girls only, two in boys only, four mixed), across soccer, basketball, handball and other team sports. The pooled estimate is an ankle injury incidence rate ratio of 0.74 (95% CI 0.60-0.91): about a quarter fewer. The authors add the practical part, which is the most useful: the trials with statistically significant results all combined strengthening exercises, agility exercises and a multicomponent approach, in sessions of 15-20 minutes, twice a week, for 3-6 months, with compliance above 62% (Berkey et al., 2024).

Those numbers sit alongside two more specific reference points:

The practical message is the same one we found writing about neuromuscular prevention training: protection doesn't come from a piece of equipment or an isolated drill, but from a structured warm-up done for months. And, as with the ACL, the variable that collapses the effect is adherence — not intensity.

And afterwards? The rehab that reduces recurrence (with an age caveat)

The ankle sprain has one feature that sets it apart from almost every other youth injury: the best-documented risk factor for a sprain is having had one already. That is why the recurrence numbers matter more than the first-event numbers.

A systematic review and meta-analysis of 14 randomised trials with 2,182 participants compared exercise-based rehabilitation with usual care after an acute lateral sprain, finding a significant reduction in re-injury at 12 months (OR 0.60; 95% CI 0.36-0.99) (Wagemans et al., 2022).

Mind the age: those participants are adults. For adolescent female athletes specifically the evidence is thinner, and presenting an adult result as if it held for a fourteen-year-old would be exactly the shortcut this blog tries to avoid. What can honestly be said is this: in the population where it has been studied, exercise-based rehabilitation reduces recurrence compared with letting it pass; and in youth sport, where exercise-based prevention works (Berkey et al., 2024), the direction is consistent.

A paediatric assumption that has been revised

For years, in a child or adolescent still growing, a painful lateral ankle with no fracture visible on X-ray was managed as a Salter-Harris type I fracture of the distal fibula — an injury to the growth plate — on the basis that, in an immature skeleton, the growth plate is mechanically weaker than the ligament.

MRI has cut that assumption down to size. In a prospective study of 31 children with clinical suspicion of that lesion, none had it on imaging: what they had were ligament injuries, bone contusions and joint effusions (Hofsli et al., 2016). The same result emerged in an earlier study of 18 children (Boutis et al., 2010).

Two limits are worth keeping in view, both important. The samples are small (31 and 18 patients). And mean age is around 9-10 years, lower than the athletes discussed here: in a thirteen- or fourteen-year-old, skeletal maturity is different, and with it the balance between the strength of growing bone and that of ligaments — a theme we also touch on when writing about the growth spurt. So what this line of research tells a coach is not "it isn't a fracture": it is that what exactly that ankle is, is for a healthcare professional to establish, and that the idea that in young athletes "it's always the bone" no longer holds as an automatic rule.

What changes in the gym, concretely

This is not a clinical protocol — that is written by whoever assesses the athlete. These are the points on which the sources above converge.

Where BAB fits

BAB does not diagnose an ankle and does not write return-to-play protocols. It does the thing systematically missing from the data above: it gives the athlete a way to note privately what she feels — pain, giving way, uncertainty on landing, energy, recovery — and gives the club aggregated, anonymous signals, never an individual's health data.

Because the real problem these studies describe isn't that athletes sprain their ankles. It is that between the sprain and the chronic instability there are months in which nobody asks anything else, and the only thing on record is a phrase: "it was just a twisted ankle".

Sources

This article is for information only and is not medical advice or a clinical assessment. After an ankle sprain — especially if pain does not improve, if swelling is significant, if weight-bearing is not possible, or if the ankle keeps giving way — consult a healthcare professional.

What is the most common injury in youth female athletes?

The ankle. In a systematic review and meta-analysis of 32 studies covering 15,908 female athletes aged 19 and under, 67% of injuries involved the lower limb, and the ankle alone was the single most affected location at 23%, ahead of the knee (16%) and thigh (13%). In the same review the overall incidence was 4.4 injuries per 1,000 hours, and 40% of athletes sustained at least one time-loss injury (Beech et al., 2024).

Do girls sprain their ankles more often than boys?

The available data say yes, but they need careful reading. The reference meta-analysis of 181 prospective studies on ankle sprain incidence reports a higher incidence in females than males (13.6 versus 6.94 per 1,000 exposures), in children than adolescents (2.85 versus 1.94) and in adolescents than adults (1.94 versus 0.72) (Doherty et al., 2014). Absolute values vary widely across studies because sports, injury definitions and exposure counting all differ: what holds is the direction, not the precise number.

What is chronic ankle instability?

It is the condition in which, after one or more sprains, the ankle keeps giving way and hurting beyond tissue healing, with repeated episodes of instability. In a study of 1,002 high school athletes aged 14-18, prevalence was 20.0% overall, 23.6% among girls versus 16.3% among boys. Those affected reported markedly lower sport-related ankle function (FAAM-Sport 87.0 versus 97.7) and lower perceived quality of life (PedsQL 89.8 versus 93.5) — while doing the same amount of physical activity (Donovan et al., 2020).

Should you see a clinician after an ankle sprain?

This article is educational and does not replace clinical assessment: that decision belongs to a healthcare professional, and pain that does not improve, significant swelling or an inability to bear weight are all good reasons to seek one. It is worth knowing how often that step is skipped: in a historical study of young basketball players, 70% had a history of ankle sprain, 80% of those had sustained more than one, and in 55% of cases no medical attention was sought at all; around half reported residual symptoms (Smith and Reischl, 1986). Note: that sample was 84 MALE athletes and the study dates from 1986 — it is useful as a portrait of the "it's just a twisted ankle" culture, not as a current estimate for girls.

Can ankle sprains be prevented?

Partly, and youth-specific evidence exists. A systematic review and meta-analysis of 10 randomised trials in high school athletes aged 13-19 estimated an incidence rate ratio of 0.74 (95% CI 0.60-0.91) for ankle injuries with prevention programmes — roughly 26% fewer. The programmes that worked combined strengthening, agility and a multicomponent approach, in 15-20 minute sessions twice a week for 3-6 months, with compliance above 62% (Berkey et al., 2024).

How long does a balance programme need to run to work?

The available studies talk about minutes, not hours — but sustained over months. In a randomised trial of 765 high school soccer and basketball athletes (523 girls and 242 boys), the balance training group recorded 1.13 sprains per 1,000 exposures versus 1.87 in the control group (6.1% versus 9.9% of athletes; p=.04) (McGuine and Keene, 2006). In the under-19 meta-analysis, effective programmes ran 15-20 minutes, twice weekly, for 3-6 months (Berkey et al., 2024). The recurring variable is not intensity: it is consistency.

Does rehabilitation after a sprain actually reduce recurrence?

The evidence points that way, but the population studied is not thirteen-year-olds. A systematic review and meta-analysis of 14 randomised trials with 2,182 ADULT participants found that exercise-based rehabilitation reduced re-injury at 12 months compared with usual care (OR 0.60; 95% CI 0.36-0.99) (Wagemans et al., 2022). For adolescent female athletes specifically the data are thinner: the bridge is reasonable, but it should be declared as one.

In a growing girl, is a swollen ankle always a growth plate fracture?

That used to be the assumption, and it has been revised. In a prospective MRI study of 31 children with a clinical suspicion of Salter-Harris type I distal fibula fracture, none had that lesion on imaging: what they had were ligament injuries, bone contusions or joint effusions (Hofsli et al., 2016); the same result had emerged in 18 children in an earlier study (Boutis et al., 2010). Two important caveats: the samples are small and mean age is 9-10 years, lower than the 13-14-year-old athletes discussed here, and the distinction remains a clinical assessment — not something decided pitch-side.