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The High Ankle Sprain: What's the Difference?

Ankle sprains are common injuries. In fact, they 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? In addition, why must athletes who sustain high ankle sprains stop playing sports for a longer period of time than those with common ankle sprains? The reason lies in the anatomy of the leg and ankle and the different ligaments injured in a common versus a high ankle sprain.

Illustration of the anatomy of the ankle for an article about High Ankle Sprains.
Anatomy of the Ankle (Illustration courtesy of the Journal of Musculoskeletal Medicine. © Todd Buck, CMI 2008.)

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. 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 soft tissues that support the ankle joint allow it to move in all directions and provide stability. The ligaments, in particular, stabilize the ankle.

What is a common ankle sprain?

The common ankle sprain ranges is severity from a strain to a partial or complete tear of the anterior talofibular ligament (ATFL) on the outer side of the ankle. This ligament runs between the end of the fibula to the talus bone on the outside of the ankle. 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.

Athletes frequently will have pain, swelling and even bruising in more severe sprains. These symptoms can be experienced on the outside of the foot, just below the ankle joint. There is usually an area of maximal tenderness. Depending on the severity of injury and symptoms, athletes are able to gradually return to sports as comfort permits. Commonly, when returning to vigorous sports activity, the athlete wears an elastic wrap or an ankle brace to support the ankle. This helps compensate for the injured ligament and protects the ankle from another sprain.

What is a high ankle sprain?

A high ankle sprain is an injury that involves a different set of 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").

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 ligaments of the syndesmosis experience very high forces.

What causes a high ankle sprain?

A high ankle sprain is caused by an inversion or dorsiflexion trauma to the syndesmosis, usually resulting from a sudden twisting, turning or cutting motion while a person is running or jumping. They are most common in athletes who play high-impact running sports like football, soccer, basketball and lacrosse. 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 and flexibility, including appropriate stretching exercises (especially just prior to playing sports).

What are the symptoms of a high ankle sprain?

You will typically feel pain that radiates up your leg from the ankle. Each step you take may be quite painful, and the pain is usually even worse if you move your foot in the same way as when the injury occurred. For example, if you sprained syndesmosis ligaments by running and then quickly turning left using your right foot, repeating that motion later will be very painful.

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 and recovery time of a high ankle sprain?

The standard high ankle sprain treatment is the same "RICE" protocol used for the common ankle sprain:

  • 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.
  • Ice – 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.

For severe high ankle sprains, or in cases where a ligament is torn through completely, surgery may be appropriate. The standard procedure is to insert a screw between the tibia and fibula to hold the two bones together, which relieves pressure on the ligaments and allows them to scar and heal. High ankle sprain recovery time varies. Some people are able to return to their sports within six weeks, but about 50% will experience symptoms for as much as six months.

Authors

Eric Chehab, MD
2006 Sports Medicine and Shoulder Fellow
Hospital for Special Surgery

Reviewed and updated May 2019 by
Edward C. Jones, MD, MA
Assistant Attending Orthopedic Surgeon, Hospital for Special Surgery
Chairman, Institutional Review Board, Hospital for Special Surgery

 

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