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High Ankle Sprain

A high ankle sprain is a serious injury to the syndesmotic ligaments of the ankle. These ligaments, the anterior inferior tibiofibular, posterior inferior tibiofibular, and the interosseous ligament, and the lower part of the interosseous membrane, form fibrous joints between the lower ends of the tibia and the fibula, providing critical stability to the ankle joint while at the same time allowing a slight degree of movement between the bones.

This type of sprain is less common than a lateral ankle sprain, accounting for up to 10 percent of all ankle injuries. A correct diagnosis is difficult but important as the patient needs to be aware that a high ankle sprain has a longer recovery time.

Injury to one or more of the syndesmotic ligaments occurs when ligament fibers are stretched or torn, causing the connection between the tibia and fibula to be weakened or, in severe cases, ruptured. A high ankle sprain often occurs in conjunction with other ankle injuries, such as a bone fracture, or sprains to other ankle ligaments.

A high ankle injury often occurs during sports, when the ankle is forcibly pushed beyond its normal range of motion. External rotation, that is, the foot being forced outwards, causes many such sprains, although excessive motion in any direction can damage the ligaments. The degree and severity of the injury can vary and depend on the particular ligaments involved.

Football, soccer, basketball, other contact sports players, and skiers are at risk of sustaining a high ankle sprain. Participating in these types of sport involves repeated quick changes of direction, which increases vulnerability to high ankle damage.

  • Pain, made worse with rotating and bending the foot upwards.
  • Reduced ability to walk due to pain when putting weight on the foot
  • Swelling, bruising, and tenderness on the front and outer side of the ankle
Because the more common injury is a lateral ankle sprain, a high ankle sprain often goes undiagnosed. As high ankle sprains are often associated with other injuries X-rays, in conjunction with a medical history and physical examination, will be taken of the lower leg and ankle. Two specific tests can aid with diagnosis. The squeeze test consists of squeezing the tibia and fibula together at a point several inches above the ankle, which, in the presence of a high ankle sprain, will elicit pain below that point and into the ankle. During the second test your ankle would be rotated externally. Again, a painful response indicates a high ankle sprain.

In addition, an MRI (magnetic resonance imaging) scan may be performed as these types of scan show the soft tissues more clearly than X-rays and will therefore reveal any tears in the ligaments or interosseous membrane.

High ankle sprains are treated in the same manner as lateral ankle sprains, but they take longer to heal due to the instability of the ankle joint caused by the damage.

Initial treatment consists of the following measures:
Protection and Rest:
You will need to immobilize the ankle to allow healing to begin. You will probably be placed in a walking boot or cast for a minimum of two weeks, and longer if the injury is more severe. You will have to refrain from any activity that puts pressure on the syndesmotic ligaments and rest the ankle as much as possible. Temporarily using crutches will help.
Ice, crushed in a bag and the bag wrapped in a towel, can be applied to the ankle for as long as is comfortable, several times a day. This will help reduce inflammation.
Taping the ankle with an Ace bandage will provide compression and support and will relieve pressure on the ligaments, thereby helping you to feel more comfortable. Be careful to tape the ankle firmly but not so tightly that you cause swelling.
Raise the ankle above the level of your heart, whenever possible, to reduce inflammation and swelling.

If the ligament has been completely ruptured, leading to a widening of the space between the tibia and fibula, you will probably need surgery to repair the damage. The space between the bones would be reduced and fixed in place using orthopedic screws inserted above the ankle joint. Following surgery your ankle would be placed in a cast for several weeks before you could begin partial weight bearing on the leg.

Range of motion exercises followed by strengthening exercises and balance training could begin after the period of immobilization had finished. The time necessary for a full recovery from a high ankle sprain depends on the initial level of damage, but could take up to six months.

  • Perform strengthening exercises for your ankles.
  • Wear appropriate footwear.
  • Wear a brace or tape your ankle during sports, at least initially after recovering from your sprain and returning to activity.
What to look for in an ankle brace:
In order to be effective support for your ankle, the brace should have both medial and lateral support. It should be made of strong plastic or a similar type of material as a brace constructed from neoprene or other soft substance will not provide sufficient support.

The brace should fit in your shoe comfortably, so take your athletic footwear with you when trying on ankle braces. Try several and choose one that feels comfortable but supportive.

Follow medical advice and only begin exercising with your doctor’s approval. The following exercises will help improve your range of motion and ankle strength.
Achilles tendon stretch:
Lying down or sitting, loop a towel around your toes. Pull your toes upwards by pulling on the ends of the towel. Hold the stretch in the back of the ankle for 30 seconds. Repeat 3 times.
Toe alphabet:
Lying down or sitting, write the letters of the alphabet in the air with your toes.
Toe Raise:
Stand with your toes on the edge of a step and your heels over the edge. Slowly raise your heels as high as you can, then lower your heels to their lowest point. Repeat 20 times.
Heel and Toe walk:
Keeping control and going slowly, walk across a room on your heels only. Turn around and re-cross the room, but this time on your toes only.
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