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High Ankle Sprain

The high ankle sprain occurs when the high ankle ligaments are torn or damaged and the lower leg and foot rotate externally. It is also known as a syndesmotic sprain, as the high ankle ligaments (located high above the ankle) are also known as syndesmotic ligaments. These connect the tibia to the fibula and they sustain a lot of the pressure in the lower limb that appears when walking or running. If these ligaments are torn or damaged and the leg twists out, then the high ankle sprain occurs. This kind of sprain is less common than the traditional ankle sprain and it accounts for 15% of all the cases of ankle sprains.

Even though the high ankle sprain is less common than the traditional one, it can cause more severe symptoms and the recovery period is considerably longer. Apart from the damage done to the actual ligaments, the interosseous membrane might also be affected by the sprain. Both the severity of the injury and the recovery duration depend on how many structures and tissues were affected by the sprain. This is why it is important to make the diagnosis as soon as possible, so as to guarantee the fastest recovery.

Signs and symptoms of High Ankle Sprain

These are the most common signs and symptoms of the high ankle sprain:

  • The high ankle sprain may appear on its own or alongside a fracture
  • If the high ankle sprain appears as a solitary problem, the patient might be able to bear weight on the affected leg
  • The patient will experience pain just above the ankle
  • The pain is aggravated if the patient tries to rotate the foot outward
  • Walking may be possible but with significant pain
  • High above the ankle, it is possible for swelling and bruising to appear
  • The symptoms can range in severity, according to the number of structures and soft tissues involved in the actual sprain (from mild to moderate and severe).

Actually, there are three grades for the high ankle sprain:

Grade one

  • Mild pain
  • Stretched ligaments
  • Minor tearing
  • Minimal joint pain
  • Walking is difficult

Grade two

  • More intense pain
  • Joint instability
  • Bruising
  • Minor swelling
  • Walking is more difficult

Grade three

  • Most severe type
  • Really intense pain
  • Moderate to severe swelling
  • Extensive bruising
  • Ligaments are 100% ruptured
  • Major joint instability.

Causes of High Ankle Sprain

These are the main causes that can lead to the appearance of high ankle sprain:

  • Rotational injuries
    • Ankle fractures
  • Impact sports
    • Football tackles
    • Falling or being pushed forward
    • Side-to-side running
    • Starting and stopping feet in a repetitive manner
    • Turning while moving
    • Other sports: hockey, wrestling, soccer
  • Mechanism
    • Foot is planted on the ground
    • Foot is then twisted outward (excessively)
    • Bones pull away from each other and the syndesmotic ligaments that connect them are torn
  • Increased risk
    • Severe load on the ankle
    • Excessive dorsiflexion of the foot – toes go beyond their normal range of motion, towards the shin
    • When a person is tangled under another person.


These are the most common methods used for the diagnosis of the high ankle sprain:

Physical examination

  • Pain above the ankle
  • Tenderness over the deltoid ligament (this occurs in case a fracture accompanies the high ankle sprain)
  • Physical examination is essential in order to determine whether this is a high ankle sprain or a traditional ankle sprain (according to the area in which the pain and tenderness are experienced)
  • Squeeze test – the leg is squeezed just below the knee. If the patient has a high ankle sprain, then the pain will radiate to the high ankle ligament area.
  • External rotation test – the knee is bent and the ankle is placed in a position that it forms a 90 degree angle with the foot. The next step of the test will be to perform an outward rotation of the foot. If pain appears in the high ankle ligaments, then the patient might have a high ankle sprain.
  • Dorsiflexion and compression test – in this test the patient performs the dorsiflexion of the foot. As the same time, the doctor will apply pressure to the internal and external malleolus, observing the exact location of the pain.

Imaging studies

  • X-rays
    • Important to determine the existence of an additional fracture
    • Three views of the ankle will be taken (different plans)
    • Tibia fractures can be accompanied by high ankle sprains
    • Increased space between tibia and fibula suggest injury to the high ankle ligaments
  • MRI
    • Used for the confirmation of the diagnosis
  • CT
    • Used to determine the distance between the tibia and fibula as well.


These are the most common courses of treatment undertaken for the high ankle sprain:

  • The treatment recommended for simple high ankle sprains, without additional bone fractures, includes:
    • Leg rest
    • Ice applications – it is recommended that ice packs wrapped in something (to avoid circulatory problems) should be applied to the affected area for a period of twenty minutes. The ice-pack should be reapplied every two or three hours.
    • Leg compression – ACE wrap is recommended for such purposes.
    • Leg elevation – the toes should be in a higher position than the nose.
    • Removal walking boot
  • The RICE technique is generally applied for all high ankle sprains:
    • R – rest
    • I – ice
    • C – compression
    • E – elevation
  • The compression can be enforced with the help of different types of wraps but also with specially-made casts or splints.
  • Surgery
    • Surgery might be indicated for the internal fixation of an unstable ankle
  • H.E.M treatment
    • Increase healthy blood flow to the ankle
    • Eliminate swelling
    • Increase mobility of the ankle
  • Physical therapy
    • Reduce swelling and pain
    • Improve stability of the ankle
    • Improve weight bearing
    • Add strength of the lower leg muscles
    • Prevents muscle atrophy.

Recovery time

The recovery period depends from one patient to the other, the severity of the sprain, the structured affected, the age of the patient and the actual cause that led to the appearance of the sprain in the first place. On average, the mobility in the ankle is improved after a period of six weeks. The hopping test is performed in order to determine whether the patient can resume his or her normal physical activities (for example, those who play professional sport). If the patient is able to hop on that leg fifteen times, then the recovery process is completed and the patient can return to full, regular physical activity.

However, it is important to understand that the recovery period for the high ankle sprain is considerably longer than the one for the traditional sprain. If the sprain has been accompanied by a fracture as well, then the patient will most likely be recommended to wear a protective walk boot for three months or more. Starting physical therapy as soon as possible after the surgery for ankle fixation is essential, especially if you want to recovery period to be reduced. The exercises performed in the physical therapy clinic will help you achieve weight bearing and they will also prevent the muscle atrophy or weakness.

Healing time

The healing time depends on the grade of the high ankle sprain:

Grade one

  • Full ligament healing in approximately six weeks
  • If you are going to play professional sports, it is recommended that you extend that period, in order to strengthen both the tendons and the muscles. By doing that, you will reduce the risk of further similar injuries.

Grade two

  • The healing time in case of moderate high ankle sprain ranges from six to twelve weeks
  • These patients from a complex rehabilitation process

Grade three

  • The healing time in case of severe high ankle sprains, with full ligament rupture, can be about three months and even more, depending on how severe the rupture was
  • The rehabilitation process can extend as far as six months, because the patient will require several physical therapy programs
  • It is very important to follow a complete physical therapy program as soon as the screws have been removed
  • Weight bearing should be avoided during the period in which the ankle is kept stable with the help of screws

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