How To Rehab a High Ankle Sprain

Prevalence of High Ankle Sprains

High ankle sprains can be a challenging injury to overcome. Sometimes difficult to diagnose accurately, if initially mismanaged, it may lead to chronic issues, including persistent pain, instability, and prolonged recovery. These ankle sprains account for roughly 11-17% of all ankle sprains within the athletic population, and about 10% of all ankle sprains in the general population. These tend to be more common in collision sports, such as lacrosse, rugby, American football, wrestling, and ice hockey. There has been a growing interest in these injuries over the past few years as numbers are trending upwards.

In just 2020 alone, there have been a number of high ankle sprains in the NFL, including All-Pro Players Michael Thomas, Zach Ertz, and Christian McCaffery. These are some of the best athletes in the world, and yes, they are able to overcome these injuries, but this is no walk in the park compared to other injuries. To give you some perspective, these athletes missed about 6-8 weeks of playing time, which is up to one half of the entire regular season! A study by Miller et. al on time to return to play demonstrated that professional football players with high ankle sprains lost significantly more time (2.5 vs. 1.25 weeks), practices (11.7 vs 3.5), and games (1.4 vs 0.3) than those with lateral ankle sprains.

Where At The Ankle Does This Occur?

In contrast to a lateral ankle sprain, high ankle sprains occur higher up the foot, above the ankle joint. The distal tibiofibular syndesmosis is an area of connective tissues that enhances the stability of the talocrural (ankle) joint. Syndesmosis refers to a fibrous joint between two bones that are held together by strong ligaments, with very little to no movement. In contrast to our shoulder for example is extremely mobile, the distal tibiofibular joint is the complete opposite, with very little motion!

This is why when there is an injury to this area of the ankle, it usually requires a high amount of energy, force, and/or trauma.

Why The Longer Healing Times Than Lateral Ankle Sprains?

So why the longer healing and return to play/function time in comparison to a lateral ankle sprain? There are a couple of reasons. The first being is there usually is a longer, more frequent period of immobilization for high ankle sprains to respect the healing process. However, if someone has a low-grade high ankle sprain, one can start weight-bearing immediately, thus quickening recovery. Moreover, there are often concerns about stability after a high ankle sprain. In some instances, a return to adequate stability for high ankle sprains can take longer, with more rehab time needed.

High Ankle Sprains: Mechanism of Injury and Risk Factors

Forced External Rotation: Twisting outwards of the ankle is the most common mechanism of injury for a high ankle sprain. What happens during this external rotation motion coupled with a high amount of force is that the talus (ankle bone) causes a separation of the distal tibia and fibula.

In the case of athletics, there are 3 common instances of how this can occur:

• A rapid pivoting motion internally (turning inwards) off of a foot that is planted in an externally rotated position

• When one player applies a valgus force (outwards to inwards force) to another player while the leg is in a planted position

• When there is a direct blow to the outside portion of the heel, which forces the foot and ankle of a fallen or kneeling athlete into external rotation (towards the ground)

Grades of High Ankle Sprains

Depending on the severity of a high ankle sprain, it will dictate prognosis as well as treatment approaches.

• Grade 1: Involvement of the anterior deltoid ligament and the distal interosseous ligament but without tearing of the more proximal syndesmosis or the deep deltoid ligament. ATIFL usually is tender upon palpation, but due to no diastasis (separation), the injury is stable

• Grade 2: Involvement of the anterior and deep deltoid ligaments as well as a tear in a significant portion of the syndesmosis resulting in an unstable ankle that is still normally aligned on non-stress radiographs.

• Grade 3: Complete disruption of the medial ligaments and severe disruption of the ankle syndesmosis, frequently accompanied by a fracture. These injuries demonstrate a lot of ankle instability.

High Ankle Sprain: The Role of Imaging in Proper Diagnosis

There is a combination of clinical examination tests that can be performed by a practitioner, in addition to specific imaging of the foot/ankle when deemed medically necessary. The American College of Radiology has constructed thorough guidelines for musculoskeletal conditions that allow practitioners to decipher which image may be most appropriate at what time depending on a patient's clinical presentation.

High Ankle Sprain Signs and Symptoms

Some of the common signs and symptoms of a high ankle sprain include:

• Difficulty with weight-bearing

• Point tenderness over higher ankle ligaments (ATIFL, PTIFL)
  • There also may be tenderness higher up the leg at the interosseous membrane or at the deltoid ligament on the inside of the ankle, depending on the severity of the injury

• Variable edema (swelling) of the foot and ankle
  • Swelling is more common higher up the ankle versus lateral ankle sprain which is lower
  • If the sprain is more severe such as a tear to the interosseous ligament and/or deltoid ligament, swelling will be more significant, that can be seen on the inside portion of the ankle

• Decreased ability to push off the toes while walking

So I Have A High Ankle Sprain...Now What?

You now are diagnosed with a high ankle sprain. What happens now? Can I walk? When can I get back on the field? Generally speaking, if someone has a high ankle sprain without significant diastasis (separation) or dynamic instability exemplified on weight-bearing or stress X-rays, that person can be treated non-surgically. Yet in cases of significant instability and associated fractures, surgery will be required.

The Early Phase

• Immobilize and Protect: There usually is a period of immobilization and protection of the injured site. As with any tissue injury, you will want to avoid directions of movement that could strain soft tissue, which is external rotation and excessive dorsiflexion after this injury. There are a variety of orthoses that can be used, such as a walking boot, an ankle stirrup, or a cast in more severe cases. 

• Weight Bearing: Difficulty tolerating weight-bearing is a common complaint after this type of injury, which is why relative restrictions are usually indicated in the early phase. The amount of restriction in weight-bearing is based on the severity of the injury and the patient's symptoms. For instance, if someone had a minor, Grade I high ankle sprain, that individual may be able to tolerate weight bearing right away. However, someone who had a more severe Grade II high ankle sprain might need to be placed in a boot with crutches with a partial weight bearing (PWB) or weight-bearing as tolerated (WBAT) restriction for 1-2 weeks.

• Heel Splints: Sometimes practitioners will want to limit ankle dorsiflexion (toes towards nose motion of the ankle) with a heel splint in the back of a boot for example, but there have been some arguments against this. The rationale to oppose this notion is that the distal tibiofibular joint needs to accept the front portion of the talus (ankle bone) moving into dorsiflexion in order for a normal range of motion to occur. Therefore, if ankle dorsiflexion is strictly prohibited, it can negatively affect the full return in the range of motion.

Because it is common for there to be a period of immobilization after a high ankle sprain, prolonged stiffness of the foot and ankle is common, especially into dorsiflexion. Once you are able to bear weight, restoring dorsiflexion in the closed chain (foot on the ground) is crucial for optimal function. Below we have a podcast dedicated to this topic. We also have an Ankle Dorsiflexion Mobility Overhaul Program that will give you access to a plethora of exercises to optimize your ankle mobility!

Early Phase Exercises

As with any other injury, it is important to stay moving in any way that you can to avoid the negative effects of bed rest. The ankle usually has a difficult time combating swelling, but early, open-chain exercises and the method we often praise, POLICE can get you ahead of the game! Here we are showing some ankle and foot exercises, but always remember, you still should train above the injury, such as strengthening in the open chain for the hips. Read our article on how to stay strong after surgery!

Note: An article by Knapik et. al discusses while early range of motion after lateral ankle sprains is commonly prescribed to promote early return to function, early motion after a high ankle sprain may place unwanted stress on the syndesmosis, potentially contributing to heterotopic ossificans formation (abnormal growth of bone) by increasing the zone of secondary injury. This is why there usually is a period of immobilization in a boot before progressing to specific exercises.

High Ankle Sprains: Middle Phase

At this point, you have achieved some great milestones. The range of motion is returning, you are able to fully weight bear, the swelling has gone down, and pain is reducing! In this phase, exercise will start to get more progressive at an appropriate rate, with some movements that will continue to load structures surrounding the ankle, further facilitating the healing process. Here are some examples of progressive exercises in this phase.

Late Phase

Time to add on the final touches. If you are returning to sport, it is making sure you can complete all the specific movements optimally. This phase will consist of a return to plyometric movements, cutting, running, and activity-specific re-integration!

Plyometric training is often a missing link between strength training and return to sport for athletes. Read below in our article as we detail plyometric progressions during rehab!

Closing Thoughts

High ankle sprains are difficult injuries to manage, yet the prognosis is often good! Return to play or full activity can vary depending on the severity of the injury. In a comprehensive review by D'Hooge et. al, the authors discussed that grade I injuries have about a 6-8 week timeline post-injury, but grade III injuries may take 10-14 weeks on average. After a specific injury to the ankle, a differential diagnosis is important to decipher exactly what part of the ankle was injured. Imaging may be a part of the clustering during diagnosis, but paying attention to the history, patient's presentation, and all other variables is crucial. These injuries are less common than your typical lateral ankle sprain, yet sometimes if more severe, they may take more time to recover from. All in all, put in the work with focused rehab and you will be back to your activities better than ever!