The High Ankle Sprain.

Most players view an ankle sprain as a nuisance — a few days off then back to play. I always say that a traditional ankle sprain needs to be treated with greater respect by players, as the consequences of returning to play too early can be considerable.

Most ankle sprains that are incompletely rehabilitated lead to another sprain (or something else far more serious), usually within the same season. The injured ankle can use support for six months or more.

There are other ligamentous injuries to the ankle and we seem to be hearing more about something called a ‘high ankle sprain.’

A typical ankle sprain happens when a player rolls the sole of the foot toward the other foot and damages the ligaments on the outside of the ankle. Like coming down from a jump and landing on someone else’s foot and rolling the foot inward.

The tibia and fibula of the leg are parallel bones that connect with each other at both ends. In between the bones is a special type of ligament (a syndesmostic ligament) that, among other duties, helps hold the two bones in parallel with each other. This seems to be the prime ligament that gets injured.

How this gets damaged can be hard to picture. The most likely cause is when the foot is fixed to the ground while the body above it is internally rotated over the planted foot. This then externally twists the uppermost bone of the ankle (the talus, which sits ‘pinched’ between the tibia and fibula) in comparison with the rest of the foot.

This pries the tibia and fibula apart out of parallel damaging that syndesmotic ligament in the lower part of the leg. If the force is strong enough, damage can happen to the medial side of the ankle, opposite that of a traditional ankle sprain.

The greater the force and the longer the force is applied can damage the ligament further up the leg meaning a more serious injury. Imagine running to the right, planting for a cut to the left and the opponent steps on your foot while you are twisting to the left.

This is not a common injury. We hear about these injuries mostly in sports with rigid ankle support like downhill skiing and ice hockey, but we are seeing reports in other ballistic cutting sports like football, basketball and soccer. When looking at all sports, this unique sprain makes up about only about 10-20% of all ankle sprains.

Players will complain about pain between the bones just above the level of the joint, either on the front or back of the ankle. Usually there is pain with weight bearing and pushing off during movement that can be lessened with specialized diagnostic taping (this taping method is not effective for play) .

The ‘tenderness length’ up the leg is indicative of injury severity. A doctor may perform a series of tests including a squeeze test (just what it sounds like), or externally rotate the foot under the leg, or others that evaluate the position of the fibula in relation to the tibia and foot.

There are others, but outside of the external rotation test, there is no definitive test or image that can be taken to clearly identify the injury. Most imaging is looking for possible fractures or changed relationship of the tibia to the fibula. Some recent MRI imaging methods have shown promise.

The time lost to this injury is very unpredictable. Some studies report only two and a half weeks out while others report two months or more. Many players report symptoms for a long time after the injury. Estimating time lost to this injury is very difficult. For most players and leagues, two months off effectively ends that season.

There is good data showing how to treat a common lateral ankle sprain. Not so for the high ankle sprain. No one can state with any degree of assurance if: the ankle needs immobilization, for how long, in what position, when to allow weight bearing, when to return to sport-specific movement, what specific sporting activities to be used and at what time in the rehab process and many more questions.

There are only 3-4 published papers on rehabbing this injury. Surgery may be required to improve stability of severe injuries. And the sports medicine community is not united in its opinion on early surgery versus non-operative rehabilitation.

The injury is not without the potential for complications, either from surgery or non-operative rehabilitation.

There is much known about this injury…how it happens, the incidence, and how to diagnose it. After that, things get complicated because the best course of treatment continues to evolve.

A player with an unstable ankle who tries to cut and avoid an opponent may be unable to evade contact and suffer a serious, high impact collision injury. For this reason, no player should return to play before the ankle is fully rehabilitated.

As always, never use columns like this to self-diagnose or treat. Always see a qualified sports medicine physician…they are the real professionals.

If you have access to a medical library, a recent detailed summary of this injury can be found in Williams GN. Syndesmotic ankle sprains in athletes. American Journal Of Sports Medicine, vol 35, pg 1198-1207, 2007.

Copyright 2007 Donald T. Kirkendall

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