Entire Podiatry


High Ankle Sprain

High ankle sprain – How does it differ to a traditional ankle sprain?

High ankle sprains are much less common than a traditional ankle sprain.  But what is the difference between a traditional ankle sprain and a high ankle sprain?  In addition, why must an athlete who suffers a high ankle sprain have to cease sporting activity for an extended period of time compared with traditional ankle sprains? The reason is the lies in the anatomy of the injured ligaments in a traditional compared to a high ankle sprain. 

The ankle joint is made up of three bones in the lower leg: the tibia (thick shin bone), the fibula (the outer shin bone) and the talus. These bones work together to form the ankle joint, which may sustain loads of up to three times a person’s body weight during activities. The soft tissues that support the ankle joint allow it to move in all directions and provide stability. The ligaments, in particular, secure the ankle.

What is a traditional ankle sprain?

The traditional ankle sprain ranges is severity from a strain to a partial or complete tear of the anterior talofibular ligament (ATFL) on the outer side of the ankle. This ligament runs between the end of the fibula to the talus bone on the outside of the ankle. The ATFL is one of the principal stabilizers of the ankle and is commonly injured when an athlete “rolls” the ankle with extreme force.

Athletes often will have pain, swelling and bruising in more severe sprains. These symptoms can be experienced on the outside of the foot, just below the ankle joint. There is usually an area of maximal tenderness. Depending on the severity of injury and symptoms, athletes are able to gradually return to activity as pain permits. Frequently, when returning to vigorous sports activity, the athlete wears a wrap or ankle brace to support the ankle. This helps compensate for the injured ligament and protects the ankle from another sprain.

What is a high ankle sprain?

A high ankle sprain is an injury to the upper ankle ligaments which is a different set of ligaments than in the traditional ankle sprain. These ligaments are located above the ankle joint and between the tibia and fibula. They form what is known as the syndesmosis (pronounced “SIN-des-MO-sis”).

When you bear weight on the leg, the tibia and fibula experience great forces that spread them apart. The ligaments of the syndesmosis serve as shock absorbers, preventing the tibia and fibula from spreading too far apart. When you run, and especially when you run and quickly change direction, these ligaments of the syndesmosis experience very high forces.

What causes a high ankle sprain?

A high ankle sprain is caused when you plant your foot to the ground and then an excessive outwards twisting of your foot which causes trauma to the syndesmosis.  High ankle ligament injuries can also occur when your ankle is loaded severely and pushed into excessive dorsiflexion.  (Dorsiflexion of your ankle is when the top of your foot comes towards your shins.)  This usually results from a sudden twisting or turning motion while a person is running or jumping. They are most common in high-impact running sports like football, rugby and basketball.  The best way to avoid this injury is frequent performance exercises for strength and flexibility, including suitable stretching exercises.

How is a high ankle sprain diagnosed?

Your podiatrist will ask you what motion you were performing when your injury took place, assess your symptoms, and clinically assess your ankle ligaments integrity.  The exam may include a fibular compression test (also sometimes called a “high ankle sprain test” or “syndesmosis squeeze test”). For this test, the podiatrist will place hands on each side of your lower leg and squeeze the tibia and fibula together.  If this causes pain that radiates down your leg, this suggests a high ankle sprain. However, additional tests such as an x-ray, CT scan or MRI may be required to check if you have a fracture.

The podiatrist will check for a gapping in the inferior tibiofibular joint.  A gap of greater than 2mm can become unstable and may require surgery.

What are the symptoms of a high ankle sprain?

High ankle sprains occur following a traumatic ankle injury.  Patients often report the following:

  • Pain radiates up the leg from the ankle.
  • Each step may be quite painful, and the pain is usually even worse if you move your foot in the same way as when the injury occurred
  • Often, but not always, there is significant bruising across the higher ankle rather than around the malleolus.  The malleolus is the bony projection either side of the ankle.
  • Unable to achieve a single leg calf raise.

Patients with a high ankle sprain may be able to weight bear but will have pain just above the ankle which is higher than the more common ankle sprains.  Pain at the back of the ankle is more concerning at it may suggest a fracture.

If surgery is required the typical procedure is to insert a screw between the tibia and fibula to hold the two bones together.  This relieves pressure on the ligaments and allows them to scar and heal. High ankle sprain recovery time varies.  With a mild strain some people are able to return to their sports within six weeks, but about 50% will experience symptoms for as much as six months.

There is no typical time frame for how long a high ankle sprain will take to heal.  Many factors will determine your injury rehabilitation including patient demographics, goals and individuals progress.  Below is a general guideline for the treatment for high ankle sprains.   

What is the treatment for high ankle sprain?

Phase 1 – Acute Phase : Injury Protection and Pain Relief

Weeks 0-2 

The acute phase high ankle sprain treatment is the same “RICE” protocol used for the common ankle sprain:

  • Rest – Studies have shown the fastest recovery comes with wearing a walking boot within the first couple of weeks after the sprain.  It is vital to have stability through the high ankle ligaments and keep your weight off the affected leg.  The walking boot can be measured and fitted by a podiatrist.  The amount of rest required to permit healing is usually much longer than for the common ankle sprain – nearly twice as long, according to most studies.  
  • Ice – Applying ice for approximately 20 minutes every few hours is a simple and effective modality to reduce the inflammation and soreness.  When you notice that your injury is warm or hot then use the ice for the first couple of days.
  • Compression – Wrap the lower leg with a compression bandage to support the injured ligaments and minimize swelling.
  • Elevation – Sit or lie down with your injured ankle elevated to a position above the level of your heart to reduce swelling.

Phase 2 – Intermediate Phase :  Regain Full Range of Motion

Week 2-5 

If you protect the injured ankle ligaments correctly, the torn ligaments will successfully reattach and heal.  Mature scar formation takes at least 6 weeks.

During this time is important to continue to avoid forceful external rotation and dorsiflexion of the ankle.  Massage and basic exercises will be prescribed to strengthen and improve the range of motion and balance.  

Phase 3 – Restore Muscle Strength

Week 4-8 

It is recommended at this stage to use a lace-up ankle brace or a double upright hinged ankle brace to support the joint.  The calf will require strengthening and the podiatrist will prescribe exercises.  In the beginning the exercises should be in a single direction and then progressively becoming more quick, intense and dynamic.  Starting with both feet and then to one foot with emphasise on good form and technique.  At the end of this stage you can start doing some short runs in a straight line. 

Phase 4 – Normalise Foot Biomechanics and Return to Full Activity

Week 6-8

Your podiatrist will examine your foot biomechanics.  There have been extensive studies which demonstrate that many patients with instability of the ankle also have instability of the joint directly beneath the ankle which is called the sub-talar joint.  This is the joint at which your foot rolls in and out (or pronates and supinates).  Correctly prescribed custom functional orthotics act to stabilize the sub-talar joint and consequently help avoid ankle sprains.

The most effective recovery occurs when you are able to wear your orthotics before you start back to activity without wearing your ankle brace. Assessment for the orthotics should therefore take place approximately 6 -8 weeks after the injury.  By this stage normal walking is likely to have returned and swelling should have decreased substantially.

Phase 5 – Restore power, high speed, balance and agility

Weeks 6 – 10

Most ankle injuries occur during high-speed impact sports.  It is important that the ligaments and structures around the ankle are rehabilitated correctly to avoid re-injury.

Depending upon your sport there will be specific exercises and drills required at this stage to improve speed, power, agility and proprioception.  Your podiatrist will guide you through exercises to address these components to prepare you.

Phase 6 – Return to Sport     

Weeks 10 – 12

For severe high ankle sprains, or in cases where a ligament is torn through completely, surgery may be appropriate. The standard procedure is to insert a screw between the tibia and fibula to hold the two bones together, which relieves pressure on the ligaments and allows them to scar and heal. High ankle sprain recovery time varies. Some people are able to return to their sports within six weeks, but about 50% will experience symptoms for as much as six months.

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