A high ankle sprain is what is sometimes referred to, when there has been an injury to the ankle “syndesmosis”. A syndesmosis injury affects the structures that hold the end of the tibia and fibula together, just above the ankle joint, and can be a very disabling and painful condition, and can take longer to recover than a standard lateral ankle sprain injury.
The ankle joint is a complex articulation, allowing multiple movement directions, providing the ability for us to walk, run and change direction with power and agility. The ankle joint itself refers to the articulation between the heel bone, the midfoot and the tibia and fibula.
The syndesmosis is supported at the front by the anterior inferior tibio-fibular ligament, at the back by the posterior inferior tibio-fibular ligament, and in the middle is the interosseous membrane.
Injury to this region can range from mild (grade 1) to severe (grade 3)
grade 1 : partial injury to the AITFL only
grade 2: severe or complete rupture to the AITFL and some injury to the IO membrane
grade 3: complete rupture to the AITFL, IO membrane and partial or complete injury to the PITFL
Injury to the syndesmosis is a significant injury, as these ligaments are vital for stability of the ankle joint to allow jumping and landing, running and change of direction.
RISK OF HIGH ANKLE SPRAINS
Syndesmosis injuries commonly occur when the foot is forcibly rotated outwards whilst the knee and lower leg is turning inwards. This rotation force causes the tibia and fibula to be spread apart and is often associated with injury to the medial (deltoid) ankle ligament, or even a fracture to the fibula. This may happen in a collision injury such as when the foot gets caught during a tackle playing football.
HOW CAN YOU TELL IF YOU HAVE A HIGH ANKLE SPRAIN?
If your ankle was injured in a tackle or a very heavy awkward landing where you felt your foot was forcibly rotated outwards (pronation and eversion of the foot), and you have pain across the front or inside of your ankle joint, or around the bottom ⅓ of your fibula, you should promptly be assessed by your physiotherapist to determine whether you have an injury to the syndesmosis. This is because correct early detection and management of this injury leads to much better functional outcomes and return to play timelines.
If you had an ankle injury that just doesn't seem to be getting better in 3-4 weeks like a normal lateral ankle sprain does, and if you have difficulty running in an arc, pushing off and accelerating or jumping and landing with any power, you may have injured your syndesmosis.
WHAT IS THE BEST MANAGEMENT OF A SYNDESMOSIS INJURY?
This depends on the severity of your injury. Your physio will likely refer you to have scans or see a sports physician to further investigate the degree of injury.
The gold standard in scans is to have an MRI, and if this shows injury to the syndesmosis, a weight bearing CT scan as a follow up scan determines the stability of the joint, which guides management.
If it is a low level sprain, you will likely be managed in a moonboot for a few weeks to allow solid scarring and repair of these important ligaments, before undergoing a structured, graduated physiotherapy guided rehabilitation program to regain your calf strength, foot intrinsic muscle endurance and function, your ankle mobility, and of course your ability to run, jump and play sport. This process may take around 3 months to complete, but is variable depending on your degree of injury and stability, how long you need to immobilize in a boot, and how long it takes for you to regain your full strength and function.
For a grade 2 or above injury, you may be referred to a surgeon for an opinion on whether surgery will be required to ensure optimal return to function. This will depend on degree of injury and stability, and whether you are aiming to return to high level agility sports. There are a couple of surgical options available and your surgeon will discuss your best option. At present the most popular surgical option is a “tightrope” procedure, used to stabilise the distal tibia and fibula whilst allowing the degree of mobility required to mimic normal ankle function. The other common option is a screw across the joint, which does make the syndesmosis stable, but may not be ideal for those aiming to achieve high level athletic ankle function.
CAN PHYSIOTHERAPY TREATMENT HELP A HIGH ANKLE INJURY?
Your physiotherapist is a key member of your management team for a high ankle injury. They can promptly diagnose your injury, and help you to get the right management in place and fast!
Your physiotherapist will then guide you each step of the way as to when to start moving, strengthening and progressing your high ankle rehabilitation. They will safely prescribe you the right exercises and help get your ankle and foot mobility back after being in a boot or having an operation. They will also advise you when you have sufficient strength and stability to start cross training, walking, running, changing directions, and when it is safe to return to your sport’s training drills and playing your sport, all whilst minimising the risk of further injury or delayed recovery.
How can we help you?
At Melbourne Sports Physiotherapy our goal is to get you moving pain free as soon as possible.
But, we also want you to actually move better and live a healthier, more active and fulfilling life!
If your sports, fitness training or work has been wearing your body down, book in with one of our expert massage therapists so we can help you reduce your pain or stiffness.
If you are showing some signs of this condition or simply want help prevent this from happening in the future then book in with one of our highly experienced Remedial Massage Therapists today!