How to fix a high ankle sprain – ankle syndesmosis injury

With the winter sports season reaching finals time, I thought I would take the opportunity to reflect on those that have been unfortunate enough to limp through our doors, their ankle injury stopping them partaking in their favoured winter pastime.

Ankles are the most commonly injured body part in a wide variety of popular Australian sports.

If you hurt your ankle, an important injury not to miss is the ‘high ankle sprain’, or syndesmosis injury.

Syndesmosis injuries, account for approximately 11% of all ankle injuries, with a higher occurrence in sporting activities that involve twisting or cutting maneuvers (i.e. the mainstays of Australian winter sport). This is where the diagnosis is important – high ankle sprains can lead to long term instability and weakness of the ankle complex if not treated right – including pain from extra movement and longer term complications such as arthritis.

High ankle sprains refer to damage to the ligaments that connect the bottom portion of the tibia (shin bone) to the fibula (outside leg bone).

The most common way to injure these ligaments is through an external rotation mechanism (where the foot is turned away from the body), or with excessive dorsiflexion (the movement at the ankle where the shin moves forward over the fixed foot in weight-bearing).

The ankle will be painful and difficult to walk on, and there will usually be pain on touch above the ankle joint itself. Pain may be present through to the calf, and it is usually painful or difficult to pull the foot and toes up. A high ankle sprain, if on its own, will usually have less swelling than with a classic lateral ankle sprain.

As with any soft tissue injury, it is important to get the right management underway straight away – this involves the R.I.C.E.D strategy:

R – rest the injured ankle, and stay away from aggravating activities until directed. Use crutches to off-load the injured ankle if it is painful to walk.
I – ice the injured ankle. Cooling the injured area (every 2hours in the first 48 hours after initial injury) will decrease inflammation and swelling, and speed up the recovery process.
C – compress the swollen area with elastic bandaging to aid with swelling control.
E – elevate the ankle to decrease the swelling symptoms
D – diagnosis. Book in an appointment at Sport and Spinal Physiotherapy, to get a clear diagnosis and management plan for your high ankle sprain injury – to get you back to your sport FAST! The diagnosis is particularly important here, as continued weight-bearing on a high ankle sprain can delay healing whereas walking with a lateral ankle sprain can actually promote healing.

There are specific tests that your physiotherapist will carry out to confirm or deny a high ankle sprain – and if suspicious a stress x-ray is required to see if the ankle is stable or not when a force is applied. If instability is noted on the x-ray, an MRI may be required to determine the extent of damage to the ligaments – a MRI will also show up any bone bruising, which can affect how your rehab progresses.

Through the use of history taking, clinical tests, and relevant imaging, it will be determined if surgery is required or not. Unstable high ankle sprains may require a ‘syndesmotic screw’ – a screw between the two long bones of the lower leg, which generally requires 6 weeks of no weight on the foot after surgery, and a general return to sport time of 3-4 months. The screw can be later removed.

If no surgery is required, a comprehensive conservative rehab programme will be put in place by your physiotherapist. This will generally involve a period of non-weightbearing on crutches – as with high ankle sprain,s weight through the ankle can continually stress the damaged ligaments as they are initially healing.

Personally I find this very true, as during the last rugby season I treated two different people with high ankle sprains – each coming in within a week of the other, with both showing very similar clinical signs. One gentleman followed the rehab protocol (especially involving the time non-weight bearing) exactly, while the other gentleman did not and continued to walk on the injured ankle against our instructions. The first player returned to the rugby field after three weeks, while our second more ‘relaxed ‘character took 8 weeks before return to match play. Needless to say, his coach was not impressed.

An aircast ‘boot’ will help stabilize the joint but still allow you to maintain range of motion.

As your rehab progresses, stretches and activities will be put in place to return the mobility, strength, and balance reactions of your injured ankle. As a general rule, high ankle sprains of a lower grade can take up to 6-8 weeks to recover, or twice as long as a classical ankle sprain. However, there are no set rules for return to running, training, and sport – as each injury is different and our physios will manage your progress closely.

In summary, it is important to get your ankle injury assessed, as a missed high ankle sprain can have long-term consequences. A thorough rehab programme in place from our physios can get you back on the playing field as soon as possible.

If you have an ankle sprain (whether it be a syndesmosis or lateral ligament injury) please call Sport & Spinal Physiotherapy on 6262 4464 TODAY to get your injury sorted out FAST!

References:
Fong DT, Hong Y, Chan LK, Yung PS, Chan KM. A systematic review on ankle injury and ankle sprain in sports. Sports Med. 2007;37(1):73-94
Norkus, S. A., & Floyd, R. T. (2001). The anatomy and mechanism of syndesmotic sprains. Journal of Athletic Training., 36, 68-73