High Ankle Sprain

High Ankle Sprain

Article by John Miller

What is a High Ankle Sprain?

A high ankle sprain is an injury to the upper ankle ligaments located above the ankle joint.

A high ankle injury may also involve the syndesmosis between the tibia (thick shin bone) and fibula (thin outer shin bone) just above the ankle joint.

high ankle sprain

Your syndesmosis is a fibrous structure where the two leg bones are connected. Ligaments or connective tissue keep the bones together with very little excessive mobility.

High ankle sprains are less common but are much more disabling than your traditional lower ankle sprain. Early diagnosis is vital. Appropriate high ankle sprain treatment does differ from a more moderate lower ankle sprain. Please seek the professional advice of your physiotherapist or foot doctor.

High Ankle Sprain. What Happens?

High ankle or syndesmotic injuries can be troublesome to treat. They do not heal as well as more common lower ankle sprains. The main issue seems to relate to a lack of passive ankle stability in weight-bearing. Long-term functional instability is why your physiotherapist or sports doctor are often concerned about high ankle sprains. It is crucial to determine whether your high ankle injury is stable or unstable.

Stable high ankle sprains are usually conservatively treated. Often this is with a moon boot or immobilisation cast. Please consult your physiotherapist or doctor for more advice.

Do High Ankle Sprains Require Surgery?

Whereas stable high ankle sprains can often avoid surgery, unstable high ankle sprains usually require surgical fixation. Based upon this, an ankle sprain suspected to be a high ankle sprain requires professional assessment. Only then will your physiotherapist or doctor determine the best treatment course.

What Causes a High Ankle Sprain?

High ankle sprains most commonly occur when you plant your foot on the ground, and then an excessive outwards twisting of your foot occurs.

High ankle ligaments can also sprain when your ankle is loaded severely and pushed into excessive dorsiflexion. This injury often occurs in football tackles.

What are the Symptoms of a High Ankle Sprain?

High ankle sprains occur following a traumatic ankle injury.

Patients often report:

  • The pain felt above the ankle increases with the outward rotation of the foot.
  • Pain with walking and often significant bruising and swelling across the higher ankle rather than around the malleolus.
  • Unable to perform a single leg calf raise.

Your severity of symptoms will depend on the grade of ankle sprain: mild, moderate, severe.

Patients with a high ankle sprain without fracture may be able to bear weight but will have pain over the junction between the tibia and fibula just above the ankle’s level. This pain region is higher than the more traditional sprains. Pain over the ankle’s posterior aspect is of particular concern and may be associated with an avulsion fracture or bone bruising.

How is a High Ankle Sprain Diagnosed?

Your physiotherapist, sports doctor or ankle surgeon will clinically assess your ankle ligaments integrity. If they suspect a high ankle sprain or syndesmosis injury, they may recommend a weight-bearing X-ray, CT scan or MRI to confirm the diagnosis.

The radiologist will check for a gapping in the inferior tibiofibular joint, as shown in this X-ray. A gap >2mm can become unstable. It is the “unstable” group that may require surgical stabilisation. For specific advice, please get in touch with your trusted healthcare practitioner.


What’s the Treatment for High Ankle Sprain?

It is vital to have stability between the tibia and fibula because a tremendous amount of force passes through this area when walking and running. These ligaments permit some rotation of the fibula to the tibia.

Once you rupture or overstretch these high ankle ligaments, the bones of your lower leg move apart with every step causing pain and loss of your passive ankle stability. You will often require crutches or a walking boot during this phase. While “unstable” injuries usually require surgery, “stable” injuries can regularly undertake conservative treatment. Surgeons recommend high-quality physiotherapy in both conventional and post-operative rehabilitation.

Physiotherapy Treatment Aims:

Researchers have concluded that multiple goals need to be covered to effectively rehabilitate your sprained ankle and prevent a recurrence, or even worse, premature ankle arthritis, which can result in permanent ankle fusion surgery. These include:

  1. Injury Protection, Pain Relief & Control Inflammation
  2. Regain Full Range of Motion
  3. Strengthen your Ankle and Calf Muscles
  4. Restore Joint Proprioception & Balance
  5. Restore Normal Function
  6. Walking
  7. Running
  8. Jumping & Landing
  9. Speed & Agility
  10. Sport-Specific Skills
  11. Resume Sport

High Ankle Sprain Treatment Progressions

There is no specific time frame for when to progress from each stage to the next. Many factors will determine your injury rehabilitation during your physiotherapist’s clinical assessment.

In most cases, you’ll find that your physiotherapist will seamlessly progress between the rehabilitation phases as your clinical assessment and function improve. It is also important to note that your physiotherapist will carefully monitor each progression, as attempting to progress too soon to the next level can lead to re-injury and the frustration of a delay in your recovery.

Phase 1 – Injury Protection: Pain Relief & Anti-inflammatory Tips

As with most soft tissue injuries, the initial treatment is RICE – Rest, Ice, Compression and Elevation.

(Active) Rest: In the early phase, you’ll most likely be unable to walk on your sprained ankle. Our first aim is to provide you with some active rest from pain-provoking postures and movements. Active rest means that you should stop doing the action or activity that provokes ankle pain. In most cases, you will need to be non-weight bearing. You may need to be placed in an ankle walking boot, a supportive ankle brace or utilise crutches.

Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot.

Compression: A compression bandage, Tubigrip compression stocking or kinesiology supportive taping will help support the injured soft tissue and reduce excessive swelling.

Elevation: Elevating your injured ankle above your heart will assist gravity in reducing excessive swelling around your ankle.

Your physiotherapist will utilise a range of helpful tricks, including pain-relieving techniques, joint mobilisations, massage, strapping and acupuncture to assist you during this painful phase.

Anti-inflammatory medication and natural creams such as arnica may help reduce your pain and swelling. However, it is best to avoid anti-inflammatory drugs during the first 48 to 72 hours to encourage additional bleeding. Most people can tolerate paracetamol as a pain reliever.

Phase 2: Regain Full Range of Motion

If you protect your injured ankle ligaments appropriately, the torn ligaments will successfully reattach and heal at a reasonable functional length. Mature scar formation takes at least six weeks.

During this time, it is important to lengthen and orientate your healing scar tissue via massage and exercises designed to address your joint range of motion, muscle length and normal neural tissue motion.

Just as importantly, you should not overstretch ligaments and soft tissue, or you may develop a passively unstable ankle. Your physiotherapist will prescribe the exercises that are best suited to your needs.

Phase 3: Restore Muscle Strength

Your calf, ankle and foot muscles will require strengthening after a high ankle sprain. It is essential to regain normal muscle strength to provide reasonable dynamic ankle control and function.

Your physiotherapist will progress your strength and power from non-weight-bear to partial, and then full weight bear and resistance loaded exercises. Your physiotherapist will guide you.

Phase 4: Normalise Foot Biomechanics

Your physiotherapist should assess your foot arch and its control. In some instances, you may require a foot orthotic (shoe insert), or you may be a candidate for the Active Foot Posture Stabilisation program.

Your physiotherapist will happily discuss the pros and cons of both options with you.

Phase 5: Restore High Speed, Power, Proprioception and Agility

Most sprained ankle injuries occur during high-speed activities, which place enormous forces on your ankle and adjacent structures.

Balance and proprioception are both known to be adversely affected by injuries such as a sprained ankle. Both aspects need assessment and re-training to minimise the re-injury risk.

To prevent a recurrence as you return to your sport, your physiotherapist will guide you through exercises to address these critical components of rehabilitation to avoid repeat injury and improve your sporting performance.

Depending on what your sport or lifestyle entails, a customised speed, agility, proprioception and power program will prepare you for light sport-specific training.

Phase 6: Return to Sport

Suppose you play sport and depending on the demands of your chosen sport. In that case, you may require specific sport-specific exercises and a progressed training regime to enable a safe and injury-free return to your chosen sport. You must be able to hop at least 15 to 20 times pain-free before even considering returning to light training.

Your physiotherapist will discuss your goals, time frames and training schedules with you to optimise you for a complete and safe return to sport. The perfect outcome will have you performing at full speed, power, agility and function with the added knowledge that a thorough rehabilitation program has minimised your chance of future injury.

What is the Recovery Time from a High Ankle Sprain?

High ankle sprains are more severe than the more common lower ankle sprain and typically take longer to heal. Suspected high ankle sprains must seek early and appropriate diagnosis and treatment, which differ from a more moderate lower ankle sprain.

Syndesmotic injuries heal slower than the more common low ankle sprain, which is why health professionals are often more concerned about “high ankle sprains.” Your physiotherapist, sports doctor or orthopaedic surgeon will first determine if the injury is stable or unstable. If the damage is “stable”, the high ankle sprain can be treated in a cast or walking boot, usually for six or more weeks.

Grade 1 – Mild

In mild cases, you can expect complete ligament healing at approximately six weeks, but it may take longer to prepare you for functional sport again.

Despite the common practice of advising most people to only “rest” and recover, we find that these mild sprains often result in joint stiffness, ligament laxity, muscle weakness or tightness, plus reduced proprioception (balance and joint awareness).

These often cause your ankle and foot joints to compensate movement at adjacent joints if not adequately treated, leading to several other injuries months or years down the track.

Grade 2 – Moderate

Grade 2 injuries occur when you have a significant ligament injury that allows the ligament to excessively stretch. In most cases, these injuries result in a recovery period of 6 to 12 weeks. With increasing injury severity, the rehabilitation process becomes more complex and extensive. Grade 2 injuries can be stable or unstable. “Unstable” high ankle injuries will require surgery.

All Grade 2 injuries will require thorough rehabilitation to enable:

  • full range of motion
  • full strength
  • full proprioception
  • full power and agility
  • total return to sport-specific drills

Grade 3 – Severe

Grade 3 ligament injuries are when the ligament is completely ruptured. More severe high ankle sprain injuries can also include fractures of the bones or high ankle sprains, which will require additional rehabilitation time to a simple ankle sprain.

If the injury is “unstable”, then Your surgeon can place a “syndesmotic screw” or a “tightrope” between the tibia and fibula. These procedures hold the bones in proper position while the syndesmotic ligament heals.

Patients will have the screw in place for about three months while the syndesmotic ligament heals. Patients should understand that if they walk on the leg while the syndesmotic screw is in their leg (even after the ligament has healed), the screw can break. The reason for this is that there usually is some motion between these bones when people walk.

A Grade 3 ankle sprain’s rehabilitation takes typically 3 to 6 months but is quite variable depending on your specific injury. Your physiotherapist or surgeon will be able to provide you with more specific guidelines and advice.