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High Ankle Sprain: Injury and Recovery

A high ankle sprain or syndesmotic sprain affects the shin, fibula, and talus joint located on the outside of the leg. This type of sprain is the consequence of contact trauma. Strong dorsiflexion and external rotation of the foot lead to this kind of injury. The rehabilitation process and duration depend on the severity of the injury.

Key takeaways:

Most of us have experienced a twisted ankle or minor sprain with a bit of swelling and even a more serious injury with pain and swelling where it is difficult to walk. Ankle sprains can be divided into three categories:

  1. Lateral ligament complex sprains. These sprains are the most common on the outside of the ankle. The recovery time is about eight days.
  2. Medial ligament complex sprains. This injury occurs in the inner side of the ankle. The recovery takes about 11 days.
  3. Distal tibiofibular joint sprains. These are the high ankle sprains on the outside of the ankle. This type of sprain has the longest recovery compared with other ankle sprains. These take about 14 days to heal.

The high ankle joint consists of the shin-bone, fibula, and talus. These three bones are connected by ligaments, such as the syndesmosis, which stabilizes them. When this ligament is affected, it's called a syndesmotic sprain. In the general population, high ankle sprains make up 1–17% of ankle sprains; in the athlete population, that number soars to about 30%.

How does a high ankle sprain occur?

Most high ankle sprains happen from contact with another person. The most common motions during a high ankle sprain are ankle dorsiflexion, which means the foot flexion in an upward direction, and external rotation.

As a result, high ankle sprains occur most often in athletes during contact sports, such as football, basketball, ice hockey, volleyball, and soccer. Although there are cases when high ankle sprains happen in noncontact situations or surface contact, the dominant injury mechanism is player contact.

First AID for an ankle sprain

A simple acronym — R.I.C.E. — helps medical attendants remember how to treat ankle sprains:

  • Rest. Avoid putting weight on the injured area.
  • Ice. Application decreases pain and slows down blood flow to the injured area.
  • Compression. Bandaging the injury immobilizes the joint and provides support.
  • Elevation. Keeping the foot up decreases swelling and helps to reduce pain in the ankle.

Classifications for an ankle sprain

The table below represents classification of ankle sprain types.

Injury typeSymptomsEffectsJoint stability
Partial tear of a ligamentSwelling and tendernessNo function loss. A person is able to bear weight on the injured legMechanically stable joint
Incomplete tear of a ligament
Pain and swellingLoss of function. Pain with weight bearingModerate instability of the joint
Complete tear
Severe swelling and painLoss of function. A person cannot bear weight on an injured legMechanical instability

High ankle sprain rehab and recovery

A person with a high ankle sprain can be treated without surgery if they have no other side injuries, fractures, or dynamic instability during weight-bearing. In such a case, rehabilitation starts immediately by progressing through the following three phases.

Acute rehabilitation phase

The acute rehabilitation phase lasts days from 1 to 4. During this phase, the primary goals are pain management, joint protection, and inflammation management. Manual resistance and passive and active motion exercises are important during acute rehabilitation. Moreover, a removable controlled ankle motion boot should be worn during this stage to control swelling and pain. Furthermore, non-weight-bearing crutches or knee scooters should be used.

Subacute phase

The subacute phase typically occurs around days 4–7. In this phase, restoring joint mobility, muscle strength, and gait is important. One goal of this stage is to break the reliance on crutches. Active motion, strengthening, resistance training, and weight-bearing exercises are recommended during this phase. Additionally, the person should begin light-intensity step-by-step activation of proprioception.

Integration into sports/activities

Integration into sports/activities lasts at least a week. This phase consists of neuromuscular control, strength training, and sports-specific tasks. A physical therapist will encourage weight-bearing on the injured leg, active motion, strengthening, resistance, and proprioception exercises. During this phase, functional exercises such as heel rise in standing, hops, single leg heel rise and hops, jogging, running, and jumping begin. If necessary, the use of an ankle brace and/or tapping to return to sports activities should be implemented during this time.

It is important to mention that rehabilitation plans are individualized based on the patient’s pain level, inflammatory response, joint stability, and response to exercises.

This rehabilitation plan helps to heal injuries relatively quickly in the event of a ligament-only injury. However, a ligament injury with fractures, such as fibular fracture with syndesmotic injury, is more common. Therefore, if surgery is needed to fix the syndesmosis or for other related medical issues, the time to heal, rehabilitate, and strengthen the ankle is significantly longer. For instance, with more severe injuries, the non-weight-bearing period alone often lasts from 4 to 6 weeks.

The long-term effect on ankle sprains

The long-term effect of high ankle sprains is chronic ankle instability. If the ankle joint did not properly heal and strengthen during rehabilitation, it would not have the proper stability and proprioception. For example, the ankle tends to be more sensitive to unstable or uneven surfaces. The proprioception and static and dynamic balance are statistically significant deficits after ankle sprains.

Moreover, another negative aspect of this kind of damage is that these types of injuries have a tendency to re-injury. For instance, the recurrence of injury rate in ice hockey is almost 17%. With a high-ankle injury, the joint becomes unstable, losing some neuromuscular control and function. This increases the chances of re-injury — especially if the joint is not properly rehabilitated. For example, a person who had an ankle sprain increases the risk of injury recurrence by 3.5 times.

Rest, ice, compression, and elevation are primary care regimens for the trauma of a high ankle sprain. The injured person should heed and follow the R.I.C.E advice and guidelines for five or more days. Additionally, non-weight-bearing rehab is vital for the first few days or weeks, depending on the severity of the injury. Adhering to a regular exercise schedule is important for quicker and better healing.

Following a doctor's or physiotherapist's instructions during rehabilitation is essential because every case is different. The exercises, brace recommendations, and weight-bearing exercises on the injured leg are prescribed individually to facilitate healing.

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