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High Ankle Sprain

What is a high ankle sprain?

A high ankle sprain is also known as a syndesmotic sprain is a unique injury that differs greatly from a traditional “low” ankle sprain. This injury specifically involves the ligaments that connect the fibula to the tibia, and those ligaments are also known as syndesmosis. The difference between a high ankle sprain and low ankle sprain is not just the location, but is also the mechanism of injury.

How does the high ankle sprain occur?

High ankle sprains are very common in sports such as downhill skiing, rugby, soccer, football, and basketball. When the leg is loaded the tibia, and fibula experience forces that cause them to be pushed apart. The ligaments that form the syndesmosis bind the tibia/fibula together, and help absorb some force. When a high ankle sprain occurs, it is usually caused by forceful or extreme external rotation paired with dorsiflexion. Examples of how this occurs would be an impact to the outside of the knee while the athlete’s foot is planted causing an extreme external rotation due to the rotating mass of the torso in response to the blow. Some common risk factors for high ankle sprains are participation in collision sports, a flat foot, history of injury to the foot/ankle, history of ankle instability, and wearing rigid footwear(boots like in skiing/hockey).

What ligaments and structures are involved in a high ankle sprain?

There are several ligaments involved in a High Ankle Spain that can be stretched, partially torn, or completely torn. The interosseous membrane rests between the tibia, and fibula, which allows it to provide stabilization to those two bones. In addition, the anterior inferior tibiofibular ligament, superficial posterior inferior tibiofibular ligament, transverse tibiofibular ligament, and inferior transverse ligaments are all at risk of injury. Beyond ligamentous damage, there is risk of fractures of either malleolus, or spiral fracture of the fibula. Seeing a qualified health provider is key to identifying the severity and anatomical involvement of a high ankle sprain. These differences can impact the intervention needs, rehabilitation needs, and recovery time.

What are high ankle sprain symptoms?

Individuals who have a high ankle sprain often have far less swelling than a lateral or low ankle sprain. This can cause some individuals to not understand the significance of their injury initially. Bruising, if there even is any, often takes several days to become visible. A lost of a portion of the patient’s plantarflexion, and an inability to bear weight. Patients will also notice they are unable to walk on their toes, and struggle climbing stairs.

How are high ankle sprains diagnosed?

The first step to successful management of a high ankle sprain is accurate diagnosis of the ankle sprain. This is done through identification of the mechanism of injury, physical examination, and possibly imaging. During the physical examination the provider will perform several tests to assess for the tension or pain in the ligaments that could be involved. They will also palpate specific structures that could have implications on clinical presentation. If imaging is required a radiograph will be used to rule out other pathologies, and an MRI is often utilized to assess for the high ankle sprain. Often the imaging is not required due to the specificity, and sensitivity of the tests used during the physical examination.

How are high ankle sprains treated?

Treatment will again vary depending on the involved structures, severity of the injury, and the individual themselves. Additionally, some high ankle sprains can require surgical intervention if severe enough, but most do not. However, the general flow of non-operative rehabilitation can be plotted out in phases of recovery. This is based on standard tissue healing times and the grade of injury. Phase 1 would be best described as a protection/immobilization phase. The goals of this phase is to avoid excessive forces places on the damaged tissue and often involves reduced weight bearing, bracing, heel splints, and P.O.L.I.C.E. Early open chain exercise is key to retaining mobility throughout the early phase of rehabilitation. Training the joints and tissue above the injured ankle is also beneficial. The second phase would be focused around increasing the loading of the ankle, and re-establishing neuromuscular control. This phase often has an increasing amount of close chain strength exercises, and appropriate balance tasks through graded exposure. The final phase is often a focused on plyometric, impact, running, cutting, and return to sport transitionary exercises. The rate at which someone progresses through these exercises is entirely dependent on the level of tissue involvement. A ballpark estimate is that individuals with grade 1 injuries will return to sports within 6-8 weeks, but someone with a grade 3 injury can take 10-14 weeks.

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