What is the treatment for a high ankle sprain?

Treatment for High Ankle Sprain

The treatment for high ankle sprains should follow a comprehensive three-phase rehabilitation program that includes protection, restricted weight-bearing, and progressive functional rehabilitation, with most patients requiring longer recovery periods compared to lateral ankle sprains. 1

Initial Management (Acute Phase: 0-72 hours)

• Apply the PRICE protocol immediately after injury 1:

  • Protection: Use of semi-rigid ankle support or lace-up brace (superior to elastic bandages)
  • Rest: Limit activities that cause pain
  • Ice: Apply cold therapy for 20-30 minutes, 3-4 times daily
  • Compression: Apply compression wrap for comfort (while ensuring circulation isn't compromised)
  • Elevation: Keep the ankle elevated to reduce swelling

• Weight-bearing restrictions:

  • Begin with partial weight-bearing using crutches 1
  • Continue crutch use for 5-10 days depending on symptom improvement 1
  • Crutches can be discontinued when walking without significant pain or limping (usually within 7-14 days for moderate sprains) 1

• Pain management:

  • NSAIDs (e.g., naproxen, celecoxib) to reduce pain, inflammation, and allow earlier return to activity 1
  • Diclofenac shows superior results compared to ibuprofen for pain during motion 1
  • Alternative: acetaminophen 1000mg every 6 hours (not exceeding 4000mg daily) 1

Subacute Phase (Days 3-14)

• Begin early functional treatment within 48-72 hours of injury 1, 2

• Implement gentle mobilization exercises:

  • Ankle circles
  • Alphabet drawing with toes
  • Towel stretches for dorsiflexion 1

• Progressive strengthening exercises:

  • Resistance band exercises in all directions
  • Heel raises (progressing from bilateral to unilateral) 1, 2
  • Gentle isometric exercises 2

• Continue bracing/support:

  • Use semi-rigid or lace-up supports rather than elastic bandages 1
  • Consider continuing compression for comfort 1, 3

Advanced Rehabilitation Phase (2-6+ weeks)

• Neuromuscular and proprioceptive training 1, 2:

  • Balance exercises
  • Perturbation training on unstable surfaces
  • Single-leg stance activities

• Progressive functional exercises:

  • Sport-specific drills
  • Agility training
  • Plyometric exercises 2

• Return to sport considerations:

  • Continue semi-rigid ankle support for sports activities for at least 6 weeks 1
  • Return when patient demonstrates adequate balance, proprioception, and strength 1, 4
  • High ankle sprains typically require longer recovery periods than lateral ankle sprains 2, 5

Important Considerations and Pitfalls

• High ankle sprains require longer rehabilitation than standard lateral ankle sprains, with recovery often taking 6 weeks or more 2, 5

• Common mistakes to avoid 4:

  • Excessive imaging (use Ottawa Ankle Rules to determine if radiographs are necessary)
  • Unwarranted non-weight-bearing (functional treatment is superior to immobilization)
  • Unjustified immobilization (patients return to work 7.1 days sooner with functional treatment)
  • Delay in functional movements
  • Inadequate rehabilitation

• When to consider advanced imaging:

  • If symptoms persist despite appropriate treatment
  • Consider MRI to evaluate ligament integrity and detect osteochondral lesions 1

• Surgical considerations:

  • Reserved for cases that fail to respond to conservative measures
  • Consider after 4-6 months of failed conservative management 1
  • May be considered earlier for professional athletes requiring rapid recovery 1

Remember that high ankle sprains involve the syndesmotic ligaments and typically require more prolonged rehabilitation than lateral ankle sprains, with careful attention to progressive functional rehabilitation to prevent chronic instability 2, 5.