High Ankle Sprain: Diagnosis and Treatment
Diagnosis
High ankle sprains (syndesmotic injuries) are distinct from common lateral ankle sprains and require specific clinical tests for diagnosis. 1
Key Diagnostic Features
- Mechanism of injury: Dorsiflexion with external rotation of the leg, or eversion with internal rotation of the tibia 1, 2
- Pain location: Syndesmosis area between tibia and fibula, above the typical lateral ligament injury site 1
- Crossed-leg test (squeeze test): Apply pressure to the medial side of the knee while the patient sits with legs crossed; positive test produces pain in the syndesmosis area 1, 3
- External rotation test: External rotation of the foot with the ankle in dorsiflexion reproduces syndesmotic pain 2
Clinical Pitfall
High ankle sprains account for only 10% of all ankle sprains and are frequently misdiagnosed, leading to prolonged disability if managed as typical lateral ankle sprains 4, 2. A high index of suspicion is essential - if the mechanism involves dorsiflexion/external rotation and pain is above the ankle joint proper, consider syndesmotic injury 2.
Timing of Assessment
Re-examine the patient 3-5 days post-injury when swelling has decreased, as this optimizes clinical assessment of ligament damage 3, 5.
Treatment Protocol
Functional treatment with early mobilization is superior to immobilization and should be initiated immediately using the PRICE protocol combined with semirigid bracing. 3, 5
Phase 1: Acute Management (First 24-72 Hours)
Implement PRICE protocol immediately:
- Protection: Apply semirigid ankle brace immediately - this is the most cost-effective option and superior to elastic bandages or tape 3, 5
- Rest: Limit weight-bearing for 3-5 days 5
- Ice: Apply cold for 20-30 minutes per application using ice and water surrounded by damp cloth (never direct skin contact to avoid cold injury) 3
- Compression: Use compression wrap ensuring circulation is not compromised 3
- Elevation: Elevate the ankle above heart level 1
Pain management:
- NSAIDs (piroxicam, celecoxib, or naproxen) improve pain control, decrease swelling, and accelerate return to activity 1, 5
- These medications showed significant benefits in controlled trials for faster return to duty and improved exercise endurance 1
Critical note: Heat application is contraindicated in acute ankle injuries 1, 3
Phase 2: Subacute Phase (48-72 Hours to Several Weeks)
Begin supervised exercise therapy within 48-72 hours - this has the strongest evidence (Level 1) for effectiveness. 3, 5
Exercise components must include:
- Range of motion exercises to restore mobility 3
- Progressive strengthening exercises addressing muscle deficits 5
- Proprioception training - this is critical and has the strongest evidence base 3, 5
- Coordination exercises 5
Key advantage: Functional treatment returns patients to work 7.1 days sooner than immobilization (95% CI: 5.6-8.7 days) 1, 5
Manual mobilization should only be used in combination with other treatment modalities, not as standalone therapy 3, 5
Phase 3: Advanced Training Phase
Progress to sport-specific training when Phase 2 is well underway:
- Perturbation training on unstable surfaces 6
- Agility drills 6
- Plyometric exercises 6
- Sport-specific drills 1, 6
- Endurance training 1
Special Considerations for High Ankle Sprains
High ankle sprains require more intensive rehabilitation and significantly longer recovery time than lateral ankle sprains. 3, 2
- Grade 3 syndesmotic injuries (complete ligament tears) may require surgical anatomic reduction 2
- Set realistic expectations: recovery is prolonged and return to sports is slower than typical ankle sprains 2
- Continue semirigid bracing throughout rehabilitation and upon return to sport, as bracing has Level 1 evidence for preventing recurrent sprains 5
Critical Pitfalls to Avoid
- Never immobilize for extended periods - immobilization shows zero benefits compared to functional treatment and delays return to work/sports by over a week 1, 3
- Do not rely on RICE alone - current evidence indicates RICE without exercise therapy has no positive influence on patient function 5
- Avoid unsupervised rehabilitation - supervised exercises provide significantly better outcomes than home programs alone 5
- Do not use elastic bandages - lace-up or semirigid supports are definitively more effective 1
Long-term Consequences of Inadequate Treatment
Inadequate treatment leads to chronic problems including decreased range of motion, persistent pain, and joint instability 1, 3, 5. Misdiagnosed or incorrectly managed syndesmotic injuries result in unfavorable late sequelae 2.
Expected Recovery Timeline
- Return to sports: 4.6 days sooner with functional treatment versus immobilization 3, 5
- Return to work: 7.1 days sooner with functional treatment versus immobilization 1, 5
- Ligamentous strength: Does not fully return until months after injury, even with optimal treatment 7
- High ankle sprains specifically: Expect prolonged recovery compared to lateral ankle sprains 6, 2