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Dr. Matt Matava-Associate Professor of Orthopaedic Surgery Washington University School of Medicine

   
High Ankle Sprains
 
What is a High Ankle Sprain?
The ankle joint is composed of a complex hinge with both bone and ligamentous structures playing a role in stability. Ligaments are soft-tissue bands that connect bones to bones. The ligaments of the ankle allow a wide range of motion while providing stability throughout the range of motion. These ligaments are divided into two groups – the lateral ligaments located on the outside of the ankle, and the medial ligaments located on the inside of the ankle.
 
The most common ankle sprain (a low ankle sprain) occurs when the foot is turned inward which stretches and tears the ligaments on the outside part of the ankle complex. Low ankle sprains represent 90% of all ligament injuries to the ankle. The term “high ankle sprain” refers to an injury involving the ligaments on the inside of the ankle joint that occurs when the foot is forcibly turned outward from either a contact or non-contact injury. If the force is great enough, there is also damage to the ligaments spanning the lower leg bones – the tibia and fibula. These injuries represent only 10% of all ankle sprains, yet they are increasingly seen in football players of all levels. In addition, these sprains result in significantly more lost time from sports due to the nature of the damage that occurs. High ankle sprains have been theorized to occur, at least in part, as a result of the increased traction provided by artificial turf fields as well as the lighter, more flexible cleats that players now use.
 
How is a High Ankle Sprain Diagnosed?
High ankle sprains are reliably diagnosed by sports medicine specialists through careful attention to the history, examination, and imaging studies. The player’s history of injury and a review of game film showing the specific direction the ankle was twisted can be extremely helpful in diagnosing this injury. A thorough physical examination specifically isolating the ligaments suspected of being injured is imperative. Unfortunately, the physical examination is often non-specific, especially immediately following the injury. Radiographic studies, such as plain x-rays, are usually normal in terms of showing the normal relationship between the tibia and fibula (Figure 1). However, if the injuring force is great enough, there may be separation of these bones which allows an abnormal shift of the ankle joint (Figure 2). This can lead to chronic stiffness, pain, and ultimately arthritis of the ankle joint. Plain x-rays are also necessary to rule out other injuries such as fractures of the ankle and/or foot. Magnetic resonance imaging (MRI) may also be used to show more subtle signs of injury as well as to rule out other damaged soft-tissue structures such as ligaments, tendons, and cartilage.
 
What is the Usual Treatment for a High Ankle Sprain?
The vast majority of high ankle sprains are treated conservatively (non-operatively) with splinting of the ankle to reduce motion of the painful joint. Elevation and icing to the ankle is helpful to reduce swelling. Icing should not be applied for any longer than 20 minutes as this may result in an increase in the amount of ankle swelling. Non-steroidal anti-inflammatory medications are usually prescribed to aid in pain control and swelling, though there is limited scientific evidence of the effectiveness of these drugs. Crutches may be necessary to assist with ambulation.
 
Once the acute inflammatory phase is over, physical therapy is prescribed. Gentle range of motion exercises are begun as tolerated. This is followed by strengthening exercises to the muscles of the lower leg. Graduated, sport-specific exercises are then initiated with the goal to return the athlete to sports when he or she is able to run, jump, cut, and pivot without pain. An ankle brace or taping of the ankle may help reduce the risk for recurrent injury once the athlete returns to sports.
 
Surgery is rarely necessary for high ankle sprains and is indicated only if there is significant injury to the ligaments around the ankle resulting visible separation of the tibia and fibula bones. In this situation, an orthopedic surgeon will place one or two screws across the two bones to restore their normal anatomic relationship.
 
When Can Athletes Return to Sports Following a High Ankle Sprain?
Despite the fact that most athletes who experience a low ankle sprain can return to sports within one to three weeks following the injury, those players who sustain a high ankle sprain are often out of sports for four to six weeks depending upon the injury severity. Sports that involve cutting and pivoting, such as football, are especially difficult to play in the setting of a high ankle sprain. The player’s position may also dictate the length of recuperation as running backs or linebackers who have to quickly change direction are often the most disabled with this injury. For those athletes who require surgery, sports activity can usually be resumed in approximately four months. Therefore, surgery for this injury typically results in an inability to return the same season.
 
Once an athlete sustains an ankle sprain, he or she, unfortunately, is more prone to future injuries. It is for this reason that most NFL teams require their players to have their ankles taped or braced during competition in an attempt to reduce the risk for recurrence.