What is the diagnosis and treatment for a high ankle sprain?

High Ankle Sprain Diagnosis and Treatment

For high ankle sprains, diagnosis requires a high index of suspicion with delayed physical examination (4-5 days post-injury) for optimal accuracy, while treatment should focus on functional support with a brace for 4-6 weeks combined with supervised exercise therapy rather than immobilization or isolated RICE protocol. 1, 2

Diagnosis

Clinical Assessment

• Mechanism of injury: Typically involves external rotation of the foot or ankle with the foot in dorsiflexion 1
• Physical findings:
  • Pain on palpation around the distal tibiofibular syndesmosis
  • Positive "squeeze test" (pain with compression of tibia and fibula at mid-calf)
  • Positive "external rotation test" (pain with external rotation of the foot)
  • Swelling above the ankle joint rather than around lateral malleolus 3, 4

Diagnostic Accuracy

• Anterior drawer test: Optimal sensitivity (84%) and specificity (96%) when performed 4-5 days post-injury 1
• Ottawa Ankle Rules: Should be applied to rule out fractures before diagnosing ligamentous injury 1, 2
• Imaging:
  • X-rays: Indicated based on Ottawa Ankle Rules to rule out fractures
  • MRI: Excellent sensitivity (93-96%) and specificity (100%) for high-grade ligament injuries, osteochondral defects, and syndesmotic injuries 1
  • Ultrasonography: High sensitivity (92%) but lower specificity (64%) compared to delayed examination 1

Classification

High ankle sprains are classified into three grades:

• Grade I: Mild sprain without joint instability
• Grade II: Partial rupture with mild instability
• Grade III: Complete rupture with significant instability 2

Treatment

Acute Phase (0-72 hours)

• Functional support: Semi-rigid ankle brace is preferred over elastic bandages or tape 1, 2
• Weight-bearing: Protected weight-bearing with crutches as tolerated
• Pain management: Oral or topical NSAIDs are effective for short-term pain relief 1
  • Diclofenac shows superior results in the first few days compared to other NSAIDs 1
  • Paracetamol (acetaminophen) is equally effective as NSAIDs with fewer side effects 1

Important Treatment Considerations

• RICE protocol alone is NOT recommended: There is no evidence that RICE alone positively influences pain, swelling, or function 1, 2
• Avoid complete immobilization: A minimum of 4 weeks in a lower leg cast results in worse outcomes compared to functional support 1
• Short immobilization may help: A short period (<10 days) of immobilization with rigid support can help decrease pain and edema 1

Rehabilitation Phase

• Early exercise initiation: Begin supervised exercises within 48-72 hours post-injury 2
• Exercise components:
  • Range of motion exercises
  • Proprioception training
  • Strength training (particularly peroneal muscles)
  • Neuromuscular control exercises 1, 3
• Duration of support: Use functional support (brace) for 4-6 weeks 1
• Supervised vs. unsupervised: Supervised exercise therapy provides better outcomes than unsupervised training 1

Return to Activity

• High ankle sprains typically require longer recovery time than lateral ankle sprains
• Patients with functional treatment return to sports 4.6 days earlier and to work 7.1 days earlier than those with immobilization 2
• Criteria for return:
  • Pain-free walking
  • Full range of motion
  • Restored strength
  • Ability to perform sport-specific movements 3, 5

Prevention of Recurrence

• Continued use of support: Especially in individuals with history of recurrent sprains 2
• Proprioceptive exercises: Incorporation of balance and proprioception training into routine 2
• Complete rehabilitation: Ensure full rehabilitation before returning to full activity 2

Common Pitfalls to Avoid

1. Misdiagnosis as a lateral ankle sprain (high ankle sprains require different management)
2. Excessive imaging without clinical indication
3. Unnecessary non-weight-bearing or prolonged immobilization
4. Relying solely on RICE protocol
5. Inadequate rehabilitation before return to activity 5

High ankle sprains generally require longer recovery time (6-8 weeks) compared to lateral ankle sprains (2-3 weeks), and premature return to activity can lead to chronic instability and recurrent injury 3, 4.