High Ankle Sprain (Syndesmotic Ankle Sprain): What's the Difference vs. a Regular Sprain?
Ankle sprains are one of the most common injuries in the United States. But what is the difference between a common ankle sprain and a high ankle sprain? Why must athletes who sustain high ankle sprains stop playing sports for a longer period than those with common ankle sprains? The reason lies in the anatomy of the leg and ankle and the different ligaments injured in a high ankle sprain.
Ankle and lower leg anatomy
The ankle joint is formed by three bones in the lower leg: the tibia (shin bone), the fibula (the bone next to and parallel to the tibia in the outer calf), and the talus (a dome shaped bone in the foot below the tibia). These bones act together to form the ankle joint, which may sustain loads of up to three times a person’s body weight during normal daily activities.
The bony prominences on the inside and outside of the ankle are called malleoli. The malleoli on the outside of the ankle are formed by the fibula. Ligaments connect bone to bone and help stabilize the ankle. Tendons connect muscle to bone and allow for movement and dynamic stabilization.
Anatomy of the Ankle (courtesy of the Journal of Musculoskeletal Medicine. © Todd Buck, CMI 2008).
What is a common ankle sprain?
The common ankle sprain ranges in severity and usually involves an injury to the anterior talofibular ligament (ATFL). Injury can also involve other tendons or ligaments and can range from a partial tear to a complete tear. The ATFL is one of the primary stabilizers of the ankle and is frequently injured when an athlete internally inverts or “rolls” the ankle with excessive force.
After an ankle sprain, athletes will often have swelling and bruising that may spread to the foot. It is important to be evaluated by a healthcare provider to ensure there is no fracture or more severe injury. It often takes 6 to 12 weeks for return to full sports participation after an ankle sprain.
Prior to returning to sport, it is important for an athlete to have full range of motion and full strength in the injured ankle. Balance and coordination are equally important to prevent reinjury and a rehab program is beneficial to optimize full return to sport and prevent reinjury. During the early return to sport period it is often recommended that an athlete wear an ankle brace to help prevent reinjury.
What is a high ankle sprain?
A high ankle sprain (syndesmotic ankle sprain) involves different ligaments than in the common 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"). Injury to the syndesmotic ligaments account for only about 14% of ankle sprains.
When you bear weight on the leg, the tibia and fibula experience high 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 syndesmotic ligaments experience very high forces.
What causes a high ankle sprain?
A high ankle sprain is caused by an external rotation and/or dorsiflexion (foot bending toward the shin) trauma to the ankle, usually resulting from a sudden twisting, turning or cutting motion while a person is running, jumping or falling. This syndesmotic injury is most common in athletes who play high-impact running sports like football, soccer, basketball and lacrosse.
How can you prevent a high ankle sprain?
Some warm-ups that involve neuromuscular training − movements focused both balance and coordination − may decrease injury rate. In one study of young basketball players, a warm-up reduced the rate of ankle and knee injuries by 35% (SHRed study). Unfortunately, there is no high ankle sprain brace that has been shown to prevent these injuries.
The best way to avoid this injury is continual performance training for strength, balance and performing a dynamic warmup that engages all the major muscle groups prior to practice and competition. Adequate sleep and good nutrition are also important for performance and injury prevention.
What are the symptoms of a high ankle sprain?
You will typically feel pain that radiates up your leg from the ankle. Pain is often worse with weightbearing or when pivoting on your foot.
High ankle sprains do not typically cause a great degree of swelling or bruising. This can be frustrating to athletes and coaches, because a high ankle sprain generally does not “look that bad.” For this reason, many people can be unaware of how severely they have injured themselves and may not rest and rehabilitate as necessary for complete healing.
How is a high ankle sprain diagnosed?
Your doctor will ask you what motion you were performing when your injury took place, assess your symptoms, and conduct a physical exam. The exam may include a fibular compression test (also sometimes called a "high ankle sprain test" or "syndesmosis squeeze test"). For this test, your doctor will place hands on each side of your lower leg and squeeze the tibia and fibula together in a few different spots. If this causes pain that radiates down your leg, this suggests a high ankle sprain. However, additional tests (for example, X-rays) may also need to be conducted to be sure you do not have a fractured fibula or compartment syndrome.
What is the treatment for a high ankle sprain?
High ankle sprains can be serious and have a long-term impact on pain and function. You should see a doctor to guide management for a high ankle sprain. Basic concepts can be helpful in treating a high ankle sprain. The acronym RICE protocol (Rest, Icing Compression and Elevation) is a helpful reminder for many injuries. However, unlike the early mobilization that is beneficial for a lateral ankle sprain, many high ankle sprains require a short period of limited weightbearing and may need more substantial bracing. Surgery may be needed for severe injuries with notable instability.
RICE protocol
- Rest – Keep your weight off the affected leg. 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.
- Icing – During the first couple of days after the injury, apply ice for about 15 minutes every few hours to reduce inflammation and swelling.
- Compression – Wrap the lower leg with an elastic bandage to minimize swelling, but not tight enough to cut off circulation.
- Elevation – Sit or lie down with your foot elevated to a position above the level of your heart to reduce swelling and pain.
How do you rehab a high ankle sprain?
After the initial two weeks of protected weightbearing and RICE protocol, your physician will often recommend you start physical therapy to regain strength, range of motion and proprioceptive training.
Proprioception training has been shown to reduce the rate of recurrent injury. (Proprioception is your body’s ability to sense the position of your foot and ankle.) It is also recommended that you use an ankle brace for a period when returning to sports participation.
What is the surgery for a high ankle sprain?
Most high ankle sprains do not require surgery. However, in severe cases or if a ligament has been completely torn, the standard surgical 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 in place and heal.
What is the recovery time for a high ankle sprain?
High ankle sprain healing and recovery times vary. Some people are able to return to their sports within six weeks, but about 50% will experience symptoms for as much as six months.
Do sprains take longer to heal than breaks?
A sprain is an injury to a ligament. The ligaments are stabilizing tissues between bones. A strain is an injury to a muscle or tendon. A tendon connects the muscle to the bone. A fracture is a break in the bone itself. Every sprain and fracture requires a different amount of time to heal. Factors that affect healing include quality of blood supply, nutrition, rest, and the overall health of the patient.
Some sprains may take longer to heal than some fractures and pain can persist well past the initial healing phase for both of these injuries. You should see a doctor if you are ever injured and unable to move a joint appropriately or put weight on the joint.
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Dr. Nicholas Sgrignoli is a sports medicine doctor at Hospital for Special Surgery (HSS) with offices in Stamford and Westport in Fairfield County, Connecticut. He treats patients of all ages and especially enjoys working with youth athletes. An athlete himself, Dr. Sgrignoli plays volleyball, soccer, Gaelic football, and is an avid snowboarder who is well versed in managing ski and snowboarding injuries.
Updated: 6/13/2022
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