A high ankle sprain, also known as a syndesmotic sprain or syndesmosis injury, is a specific type of ankle sprain that affects the ligaments connecting the long bones of the lower leg together.1 These bones are commonly known as the tibia and fibula, and the joint where they connect is referred to as the syndesmotic joint with the ligaments connecting them – syndesmotic ligaments. Unlike traditional ankle sprains, a high ankle sprain occurs when there is damage to the syndesmotic ligaments. There are three syndesmotic ligaments between your tibia and fibula: the anterior tibiofibular ligament, posterior tibiofibular ligament, and interosseous ligament. The role of these ligaments is to provide stability to the ankle joint and help maintain the alignment between the tibia and fibula bones. When these ligaments are stretched or torn, it results in a high ankle sprain. High ankle sprains are often caused by excessive rotation of the foot outwards or forceful twisting motion of the ankle. This type of injury is commonly seen in sports such as football, netball, volleyball and basketball, where athletes frequently change direction or experience sudden rotational forces on the ankle.2
This article will explore the signs and symptoms, diagnosis and management of a high ankle sprain.
Signs and symptoms of a high ankle sprain
The signs and symptoms of a high ankle sprain can vary depending on the severity of the injury. Below are detailed descriptions of the common signs and symptoms associated with a high ankle sprain:1
- Pain and tenderness:
A high ankle sprain typically causes pain and tenderness directly above the ankle joint in between the two bones. The pain may be sharp or dull and can be exacerbated by weight-bearing or movement.
- Swelling and bruising:
Swelling is a common symptom of a high ankle sprain due to the natural inflammatory response of the body to injury. The injured area may appear swollen and feel puffy to the touch. Additionally, bruising (discolouration of the skin) may develop mid-shin, which can track down to the ankle because of gravity.
- Difficulty bearing weight or walking:
Due to the pain and instability that can be caused by a high ankle sprain, it can be challenging to stand on the affected leg. Walking may be painful or limited, and individuals may experience a feeling of instability or weakness in the ankle.
- Increased pain with ankle rotation or movement:
High ankle sprains can cause pain and discomfort when the ankle joint is moved or rotated. Activities such as twisting the foot, turning the ankle, or pivoting can exacerbate the pain. Athletes may struggle with continuing to play their sport or train on the affected leg.
- Stiffness and limited range of motion:
This stiffness may be accompanied by a reduced range of motion, making it difficult to flex (bend) or extend (straighten) the ankle fully.
It's important to note that the severity of these signs and symptoms can vary depending on the grade or degree of the high ankle sprain:3
Grade 1: Mild sprain with stretching or minimal tearing of the syndesmotic ligaments. You may feel mild pain and swelling and are able to carry on with your everyday activities with minimal difficulty.
Grade 2: Moderate sprain with partial tearing of the syndesmotic ligaments. You’ll probably feel a bit more pain, swelling, and bruising, and you may find it difficult to put your full weight on that leg. You will find the range of movement of the ankle is less than usual, which is usually because of the swelling.
Grade 3: Severe sprain with complete tearing of the syndesmotic ligaments. You’ll notice significant pain, swelling, and bruising and have difficulty or be unable to walk or stand on that leg. You may also find that the ankle feels a little unstable, with a noticeable reduction in range of movement.
The diagnosis of a high ankle sprain involves a combination of patient history, thorough physical examination by a healthcare professional and, in some cases, imaging studies.
- Patient history:
The healthcare professional, such as a physiotherapist, will ask questions about the circumstances surrounding the injury, such as the mechanism of injury (e.g., a sudden twisting motion, a fall, or a direct impact), the onset of symptoms, and any previous ankle injuries. This information helps in understanding the nature and potential severity of the injury.5
- Physical Examination:
A physical examination of the ankle and lower leg will be conducted. This will assess the area for pain, tenderness, swelling, and bruising. Specific tests will be performed to evaluate the stability of the ankle. These tests help determine the integrity of the syndesmotic ligaments and assess the severity of the injury.1,5
- Imaging studies: While physical examination and patient history are crucial, imaging studies are often used to confirm the diagnosis and assess the extent of the injury. The following imaging modalities may be used:6
- X-rays are commonly used to rule out fractures or other bone injuries. While they may not directly show ligament damage, they can provide information about the alignment of the tibia and fibula bones as well as any associated fractures or bony abnormalities.
- In some cases, ultrasound imaging may be used to assess the syndesmotic ligaments. It can provide real-time information and help evaluate the integrity of the ligaments.
- An MRI scan can provide detailed images of the ligaments, tendons, and soft tissues surrounding the ankle joint. It is the most reliable imaging modality for visualising syndesmotic ligament injuries. An MRI can help determine the extent of ligament damage, differentiate between a high ankle sprain and other ankle injuries, and guide treatment decisions.
It's important to note that imaging studies may not be necessary for all cases of high ankle sprains, especially when the injury is mild, and there are no signs of severe ligament damage. However, in moderate to severe cases or when there is suspicion of associated fractures or other injuries, imaging studies are usually recommended to guide treatment decisions.
The management of high ankle sprains depends on the severity of the injury and can range from conservative measures like rest to surgical interventions. Some treatment options for a high ankle sprain are:
- Protect, Optimally Load, Ice, Compression, Elevation (POLICE):12 The POLICE principles are a commonly used first aid technique, formally known as RICE or PRICE.
- Protect: Emphasises the importance of avoiding further tissue damage but does not imply indefinite immobilisation as this is not always necessary (for mild cases, for instance). This could mean using crutches to limit the amount of weight you put through the limb, or it could be ensuring you rest to allow tissue healing.
- Optimally load: This helps stimulate tissue healing (bones, tendons, muscles, ligaments). It can also stimulate the body’s lymphatic system to help move fluid away from the affected area and improve the range of movement. For example, contracting the calf muscle can help move fluid against gravity so that it moves away from the ankle. There is a careful balance to ensure you don’t overdo it - your health professional will be able to guide you.
- Ice: Apply ice packs or cold compresses to the affected area for 15-20 minutes every 2-3 hours in the first few days to help reduce pain, swelling, and inflammation.
- Compression: Use an elastic compression bandage or brace to provide support and compression to the ankle, which can help control swelling and provide stability.
- Elevation: Elevate the injured leg above heart level whenever possible to help reduce swelling.
- Non-steroidal anti-inflammatory drugs (NSAIDs):
Over-the-counter NSAIDs, such as ibuprofen or naproxen, may be recommended to manage pain and reduce inflammation. However, it's important to follow the recommended dosage and consult with a healthcare professional before taking any medication.8
Reducing or eliminating movement of the ankle joint is often necessary, especially in moderate to severe high ankle sprains. This can be achieved using a walking boot, cast, or ankle brace. Immobilisation helps protect the injured ligaments and allows for healing to occur.8
- Functional bracing:
After a period of immobilisation, a functional brace may be used to provide additional support and stability during the recovery phase. Functional braces are designed to allow controlled ankle movement while offering protection to the healing ligaments. They are not recommended for long-term use unless guided by a healthcare professional.
- Physical therapy:
Physical therapy (or physiotherapy) aims to restore ankle joint strength, stability, range of motion and proprioception. This will usually occur once the initial pain and swelling subside. Therapists may use various exercises, stretching techniques, manual therapy and balance training to aid in the recovery process. They can also guide the gradual return to activities and sports.4
- Surgical intervention: In severe cases of high ankle sprains where there is significant ligament disruption or associated fractures, surgery may be necessary.9 Surgical options may include:
- Syndesmotic screw fixation: This procedure involves placing screws across the tibia and fibula bones to stabilise the syndesmosis and promote ligament healing.
- Suture button fixation: In this technique, a device consisting of a button and sutures is used to stabilise the syndesmotic ligaments.
- Ligament repair or reconstruction: In severe ligament damage, surgical repair or reconstruction of the damaged ligaments may be performed.
The choice of treatment depends on several factors, including the severity of the injury, the individual's activity level and the goals of treatment. Recovery time for a high ankle sprain can vary significantly depending on the severity of the injury and the individual's response to treatment. Mild sprains may heal within a few weeks (usually 6), while more severe cases may require several months of rehabilitation before returning to full activity.10
How can I prevent a high ankle sprain?
Strengthening exercises targeting the ankle and lower leg muscles, along with balance and proprioception training, help improve ankle stability. Choosing appropriate footwear, engaging in proper warm-up and stretching routines, and gradually progressing in activities can also reduce the risk. Employing proper technique and body mechanics, being aware of hazards, allowing for rest and recovery, maintaining overall physical conditioning, and seeking professional guidance when needed are additional key strategies for prevention.1
How common is a high ankle sprain?
High ankle sprains are less common than traditional ankle sprains and are more frequently seen in sports that involve rapid changes in direction, pivoting, or twisting motions, such as football, basketball and skiing. While the exact prevalence in the general population is not well-documented, high ankle sprains can be significant injuries that require proper diagnosis, treatment, and rehabilitation to ensure optimal recovery and prevent long-term complications.11 Therefore, if you suspect you may have injured the syndesmosis, it is worth speaking to a qualified healthcare professional such as a physiotherapist.
Who is at risk of a high ankle sprain?
Athletes participating in sports with rapid changes in direction or physical contact, those with a history of ankle sprains or instability, and individuals with improper technique or inadequate conditioning are at higher risk. Certain anatomical features can also contribute to an increased stability.9
When should I see a doctor?
It is advisable to consult a healthcare professional if you’re experiencing severe pain; you’re struggling to walk or put weight through your leg; you have significant swelling or bruising; persistent or worsening symptoms; limited range of motion; a history of ankle instability; or suspicion of a high ankle sprain. Seeking timely medical attention ensures an accurate diagnosis, appropriate treatment, and prevention of potential complications.1
In summary, a thorough understanding of high ankle sprains is essential for their effective management and prevention. High ankle sprains are characterised by damage to the ligaments connecting the tibia and fibula bones and can cause significant pain and impairment. Recognising the causes and symptoms of high ankle sprains is crucial for early diagnosis. Diagnosing high ankle sprains involves a combination of physical examination and imaging studies, such as X-rays or MRI scans. Treatment options range from conservative measures like POLICE to immobilisation, physical therapy, and in severe cases, surgical intervention. Appropriate and timely management is key to promoting optimal healing and preventing long-term complications.
Prevention strategies play a vital role in reducing the risk of high ankle sprains and recognising when to seek medical attention is important. By adopting preventive measures and seeking professional guidance, individuals can significantly reduce the occurrence of high ankle sprains and maintain an active lifestyle. Remember, each individual's situation is unique, and consulting with a healthcare professional is crucial for personalised advice and optimal management of high ankle sprains. With proper care and attention, individuals can effectively understand, manage, and prevent high ankle sprains for better ankle health and overall well-being.
- A Patient’s Guide to Ankle Syndesmosis Injuries (2003). Lafayette, LA: Orthopedic and Sports Physical Therapy. https://ospt.net/wp-content/uploads/2017/03/ankle_syndesmosis.pdf
- Del Buono A, Florio A, Boccanera MS, Maffulli N. Syndesmosis injuries of the ankle. Curr Rev Musculoskelet Med. 2013 Dec;6(4):313-9. doi: 10.1007/s12178-013-9183-x. PMID: 23943273; PMCID: PMC4094094. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4094094/
- Hunt KJ. Syndesmosis injuries. Curr Rev Musculoskelet Med. 2013 Dec;6(4):304-12. doi: 10.1007/s12178-013-9184-9. PMID: 23949902; PMCID: PMC4094093. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4094093/#:~:text=Clinical%20diagnosis,squeeze%20and%20external%20rotation%20tests.
- Tampere, T., D’Hooghe, P. The ankle syndesmosis pivot shift “Are we reviving the ACL story?”. Knee Surg Sports Traumatol Arthrosc 29, 3508–3511 (2021). https://doi.org/10.1007/s00167-020-06008-2
- Yu, GS., Lin, YB., Xiong, GS. et al. Diagnosis and treatment of ankle syndesmosis injuries with associated interosseous membrane injury: a current concept review. International Orthopaedics (SICOT) 43, 2539–2547 (2019). https://doi.org/10.1007/s00264-019-04396-w
- Beumer A, van Hemert WL, Niesing R, Entius CA, Ginai AZ, Mulder PG, Swierstra BA. Radiographic measurement of the distal tibiofibular syndesmosis has limited use. Clin Orthop Relat Res. 2004 Jun;(423):227-34. doi: 10.1097/01.blo.0000129152.81015.ad. PMID: 15232454. https://pubmed.ncbi.nlm.nih.gov/15232454/.
- de-Las-Heras Romero J, Alvarez AML, Sanchez FM, Garcia AP, Porcel PAG, Sarabia RV, Torralba MH. Management of syndesmotic injuries of the ankle. EFORT Open Rev. 2017 Sep 21;2(9):403-409. doi: 10.1302/2058-5241.2.160084. PMID: 29071125; PMCID: PMC5644422. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5644422/.
- Dubin JC, Comeau D, McClelland RI, Dubin RA, Ferrel E. Lateral and syndesmotic ankle sprain injuries: a narrative literature review. Journal of Chiropractic Medicine. 2011 Sep;10(3):204-219. DOI: 10.1016/j.jcm.2011.02.001. PMID: 22014912; PMCID: PMC3259913. https://europepmc.org/article/MED/22014912.
- Hunt KJ, Phisitkul P, Pirolo J, Amendola A. High Ankle Sprains and Syndesmotic Injuries in Athletes. J Am Acad Orthop Surg. 2015 Nov;23(11):661-73. doi: 10.5435/JAAOS-D-13-00135. PMID: 26498585. https://pubmed.ncbi.nlm.nih.gov/26498585/.
- Matava (no date) High ankle sprain Q&A -- causes, diagnosing, treatment, Washington University Orthopedics. Available at: https://www.ortho.wustl.edu/content/Education/3636/Patient-Education/Educational-Materials/High-Ankle-Sprain-Dr-Matava.aspx (Accessed: 12 July 2023). https://www.ortho.wustl.edu/content/Education/3636/Patient-Education/Educational-Materials/High-Ankle-Sprain-Dr-Matava.aspx.
- Lin CF, Gross ML, Weinhold P. Ankle syndesmosis injuries: anatomy, biomechanics, mechanism of injury, and clinical guidelines for diagnosis and intervention. J Orthop Sports Phys Ther. 2006 Jun;36(6):372-84. doi: 10.2519/jospt.2006.2195. PMID: 16776487. https://pubmed.ncbi.nlm.nih.gov/16776487/.12. Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine [Internet]. 2012 Sep 7;46(4):220–1. Available from: https://bjsm.bmj.com/content/46/4/220