When is an ankle sprain not an ankle sprain? When it is a high ankle sprain. A high ankle sprain is actually an injury above the ankle joint occurring when excessive rotational stressors result in injury to the high ankle ligaments.
The high ankle ligaments are collectively called the syndesmosis complex and consist of 3 structures responsible for holding the 2 bones in the lower leg, the tibia and fibula, in the proper position so these bones can fit properly into the foot. When this complex is injured it results in laxity in the structures holding the tibia and fibula together and therefore greater instability in the ankle joint.
The syndesmosis complex is composed of 2 ligaments and a membrane between the 2 bones. The anterior inferior tibiofibular ligament, or AITFL, which runs in front of the two bones just above the ankle, the posterior inferior tibiofibular ligament, or PITFL, which runs in the back of the 2 bones and the interosseous membrane which runs between the two bones from just below the knee all the way to the ankle. This type of injury is much harder to describe and also takes a considerable amount of time to recover.
High ankle sprains are diagnosed using a series of tests including physical examination of the lower leg immediately after the injury. This is what you see the trainers and medical staff who come on to the field do. The 2 tests they perform include the Fibular Squeeze Test which is positive when pressure over the fibula applied midway between the knee and ankle results in significant pain right above the ankle.
The second test is called the External Rotation Test or Kleiger’s maneuver which is positive when significant laxity in the ankle is palpated . X-rays are used to access the lower fibula and tibia for fracture as well as the determine the amount of space between the tibia and fibula. MRI and CT scans are also used to access the extent of soft tissue damage.
High ankle sprains are graded Level 1 – 3. A Level 1 high ankle sprain is considered a stable injury and requires 5-6 weeks of conservative therapy before returning to participation. A level 2 and level 3 sprain are determined based on the amount of laxity in the ankle joint.
This is usually related to the amount of damage to the interosseous membrane. A partial tear causes mild instability. A Level 2 Sprain is a complete disruption of this membrane. A fracture of one or both lower leg bones is a Level 3 Sprain.
A Level 2 high ankle sprain generally takes 8-12 weeks to completely heel and allow a return to participation. Persistent pain or swelling after the initial rehabilitative period may require more aggressive treatment.
A Level 3 high ankle sprain usually requires surgery to stabilize the bones of the lower extremity and allow the interosseous membrane to heal. A level 3 injury can take 6-12 months to completely heal and is usually season ending when it occurs.
Treatment of High Ankle Sprains starts out with no weight bearing and the use of a non-walking boot to prevent further injury. NSAIDS (non-steroidal anti-inflammatory drugs like ibuprofen), ice and elevation are used for inflammation.
Passive ROM exercises which consist of assisted movement of the ankle by a therapist are done to prevent decreased range of motion. Once the inflammation has resolved and stability has been restored, the athlete can begin weight bearing and working with physical therapists toward passing the hop test.
This is used to assess healing and stability of the ankle. Being able to hop on the affected leg 15 times without pain or swelling is the standard established before an athlete can return to the practice field. Once the athlete returns to practice, 2-4 additional weeks are needed to continue to rehabilitate the injury. The player must also regain movements specific to their position before the athlete can resume playing.
Re-injury and/or further injury occur when a person suffering from a high ankle sprain tries to resume previous activity before the initial injury is completely healed. Additional injuries such as ankle dislocation, achilles tendon tears and knee disruptive injuries including ACL/ PCL and meniscus tears have all been reported in athletes who were returned to active participation before complete resolution of the initial injury was complete.
In Part 1 of this series I compared the common ankle sprain to a flat tire on a car. Using the car analogy again, a high ankle sprain is like a broken shock (level 1) or broken axle (level 2) or both occurring on the same wheel (level 3). Just as most drivers know axle and shock problems take longer to repair and are more expensive to fix than a simple flat tire, the high ankle sprain requires prolonged rehabilitation and extensive time to heal.
Hopefully, this explanation of ankle sprains will help everyone become more understanding about what is meant when an athlete is reported to have sustained an ankle injury and be more tolerant of the recovery time associated with the type of injury diagnosed.
All fans want to see their favorite players on the field, but trying to rush them back to the field following an injury could result in them never returning to the field. Patience is a virtue and is also a necessity when dealing with any sports injuries, especially high ankle sprains.
Editor’s babble: Thanks to Dr. Beth Sullivan for sharing her expertise and helping us understand the true nature of high ankle sprains and why they take so long to heal. You can follow Dr. Sullivan on Twitter @GAPeachPolymer.