What are the diagnosis and management options for a high ankle sprain?

Diagnosis and Management of High Ankle Sprain

High ankle sprains require longer rehabilitation periods than lateral ankle sprains and should be managed with early functional treatment including proprioceptive exercises and appropriate supportive devices to optimize outcomes and prevent recurrence. 1

Diagnosis

Clinical Assessment

• Mechanism of injury: Typically involves dorsiflexion and external rotation of the ankle with internal rotation of the tibia 1, 2
• Physical examination tests:
  • Squeeze test: Pain at the syndesmosis when compressing the fibula to the tibia at mid-calf level
  • External rotation test: Pain when the foot is externally rotated while the ankle is held in dorsiflexion
  • Palpation for tenderness over the anterior and posterior tibiofibular ligaments 2

Imaging

• Apply Ottawa Ankle Rules to determine need for radiographs 1
• Standard radiographs (anteroposterior and lateral views) to rule out fractures 1
• Consider stress radiographs or MRI for suspected high-grade syndesmotic injuries 2

Classification

High ankle sprains can be classified into three grades:

1. Grade I: Stretching of syndesmotic ligaments without instability
2. Grade II: Partial tear with mild instability
3. Grade III: Complete rupture with significant instability 1

Management

Acute Phase (0-72 hours)

• PRICE protocol (Protection, Rest, Ice, Compression, Elevation) 3, 1

  • Limit weight-bearing for up to 72 hours
  • Apply ice for 15-20 minutes every 2-3 hours
  • Use compressive wrap or boot
  • Keep ankle elevated above heart level

• Pain management:

  • NSAIDs help reduce swelling and pain, potentially decreasing recovery time 3, 1
  • Acetaminophen is an alternative with fewer side effects 1

• Supportive devices:

  • Semi-rigid ankle brace is more effective than tape or elastic bandages 3, 1
  • Walking boot may be necessary for more severe sprains 2

Subacute Phase (3-14 days)

• Protected weight-bearing:

  • High ankle sprains require longer protected weight-bearing than lateral sprains 2
  • Grade I: 1-2 weeks
  • Grade II: 2-4 weeks
  • Grade III: 4-6 weeks or longer

• Early mobilization:

  • Begin gentle range of motion exercises when pain allows 3, 1
  • Functional rehabilitation is preferred over immobilization 3

Rehabilitation Phase (2-8 weeks)

• Exercise therapy should include:

  • Range of motion exercises
  • Progressive strengthening
  • Proprioception training (ankle disk exercises)
  • Neuromuscular control exercises 1, 4

• Continue supportive bracing during rehabilitation and initial return to activities 3

Advanced Training Phase (6-12 weeks)

• Sport-specific training:

  • Perturbation training on unstable surfaces
  • Agility drills
  • Plyometric exercises 4

• Return to activity criteria:

  • Pain-free walking
  • Full range of motion
  • Restored strength
  • Ability to perform sport-specific movements 1

Special Considerations

Surgical Management

• Surgery is only indicated for:
  • Grade III sprains with significant instability
  • Professional athletes requiring quicker recovery
  • Failed conservative management 3, 1

Prevention of Recurrence

• Ongoing proprioceptive training:

  • Ankle disk or balance board exercises reduce risk of recurrent injury (RR 0.37; 95% CI 0.18 to 0.74) 1
  • Continue exercises as part of regular training routine 3

• Supportive devices:

  • Semi-rigid or lace-up ankle supports decrease risk of recurrent injury 3, 1
  • Particularly important for those with history of previous sprains 3

Important Pitfalls to Avoid

• Misdiagnosis: High ankle sprains are often mistaken for lateral ankle sprains, leading to inadequate treatment 5, 2
• Premature return to activity: High ankle sprains require significantly longer recovery time (6-12 weeks) compared to lateral ankle sprains (2-6 weeks) 2
• Inadequate rehabilitation: Failing to complete a comprehensive rehabilitation program increases risk of chronic instability and recurrence 4
• Overlooking syndesmotic instability: Grade III sprains with significant instability may require surgical intervention 3, 2

Remember that high ankle sprains typically have a more prolonged recovery period compared to lateral ankle sprains, and patients should be counseled accordingly to set realistic expectations 2.