High Ankle Sprains Cause Lasting Pain And Instability If Untreated.
Have you ever rolled your ankle, only to find that the pain doesn’t seem to go away no matter how much you rest? It’s frustrating, right? You might think it’s just a regular sprain, but what if it’s something more? Have you ever heard of a high ankle sprain? Most people haven’t, and it can easily be mistaken for a typical ankle injury.
While a low ankle sprain is more common and usually heals with some rest, a high ankle sprain involves damage to a different part of your ankle—specifically, the ligaments that connect the two bones in your lower leg. These injuries are often more serious, taking longer to recover from, and can be a real pain if not treated properly.
Anatomy of the Ankle
Neck pain is more common than you might think. In fact, it’s one of the leading reasons people visit a physio. But what exactly causes it? Poor posture, stress, and muscle tension can all contribute, but one of the most overlooked factors is how you sleep—especially when your pillow isn’t doing its job.
When you sleep, your head, neck, and spine should be aligned in a neutral position, meaning your neck isn’t pushed forward, tilted back, or scrunched up to the side. If your pillow is too thick, too thin, or just doesn’t support your neck properly, it can lead to muscle strain, nerve compression, and joint discomfort.
Over time, this misalignment can lead to chronic neck pain, headaches, or even more serious conditions like cervical disc herniations.
How to find the Right Pillow
Most people are familiar with a typical low ankle sprain, which usually occurs when the ankle rolls inward, damaging the ligaments around the ankle joint. However, a high ankle sprain is a different injury. It happens above the ankle joint and involves the ligaments that hold the tibia and fibula together. This injury can result in longer recovery times and more severe pain.
The primary ligaments involved in a high ankle sprain are part of the syndesmosis, a system of ligaments that connect the tibia and fibula. When these ligaments are damaged, it affects the stability of the entire ankle joint. The main ligaments involved include:
Anterior Inferior Tibiofibular Ligament (AITFL)
The AITFL is located at the front of the lower leg and is the primary ligament that connects the tibia and fibula. This ligament is crucial for preventing the bones from moving apart. When injured, it can cause pain, swelling, and difficulty rotating or moving the foot.
Posterior Inferior Tibiofibular Ligament (PITFL)
The PITFL is located at the back of the lower leg and connects the tibia and fibula. While it’s less commonly injured than the AITFL, damage to the PITFL can still contribute to the instability of the ankle and prolong recovery.
Interosseous Membrane
Running between the tibia and fibula, the interosseous membrane is a thick, fibrous sheet of tissue that plays a key role in stabilising these two bones. It also provides a surface for muscle attachment and helps distribute forces between the tibia and fibula. Injury to the interosseous membrane is common in high ankle sprains, as it assists in keeping the tibia and fibula aligned. A tear or stretch in the interosseous membrane can lead to significant pain and swelling, making it difficult to bear weight on the leg.
Causes of High Ankle Sprains
High ankle sprains are often caused by specific movements or forces that place stress on the ligaments and structures connecting the tibia and fibula. Unlike common low ankle sprains, which occur from the foot rolling inward (inversion), high ankle sprains usually result from more complex mechanisms that involve twisting or rotating forces. Understanding these mechanisms can help identify how and why a high ankle sprain occurs, as well as the specific onset of pain.
Inversion Injuries: A Less Common Mechanism
Inversion injuries, or those that cause the foot to roll inward, are typically associated with low ankle sprains. However, when an inversion injury occurs with additional forces acting on the ankle, it can lead to a high ankle sprain.
While inversion is less common for high ankle sprains compared to low ones, it can still lead to injury, particularly when there is a sudden and forceful twist of the ankle.
External Rotation Mechanism: The Primary Cause
The more typical cause of a high ankle sprain is the external rotation mechanism. This occurs when the foot is planted, and the lower leg is rotated outward (externally). This outward rotation of the tibia and fibula stretches the syndesmosis ligaments, and in severe cases, can tear the anterior inferior tibiofibular ligament (AITFL) or damage the interosseous membrane.
External rotation often occurs during activities like football, soccer, or skiing, where a player might plant their foot firmly while their body continues to rotate. This type of injury can happen when a sudden change of direction is made or when the foot is caught in an awkward position, such as when a defender tackles a player from behind or the foot gets stuck in uneven ground. The twisting motion forces the tibia and fibula apart, leading to ligament damage.
Symptoms of a High Ankle Sprain
A high ankle sprain can often be confused with a regular ankle sprain, but its symptoms have distinct characteristics that set it apart. While both injuries involve pain, swelling, and difficulty with movement, high ankle sprains typically cause more specific and sometimes delayed symptoms that can help with diagnosis.
Pain Above the Ankle Joint
The most noticeable symptom of a high ankle sprain is pain above the ankle joint, particularly in the front and outside of the lower leg. Unlike low ankle sprains, where pain is centered around the ankle itself, a high ankle sprain causes pain in the area where the tibia and fibula connect.
Swelling and Tenderness
Swelling is a common symptom of any sprain, and with a high ankle sprain, the swelling typically occurs higher up the leg, around the area of the syndesmosis—the connection between the tibia and fibula. The swelling may spread across the lower leg and can be accompanied by tenderness when pressure is applied. This tenderness can be quite pronounced when trying to touch the area near the injury
Difficulty Walking or Bearing Weight
One of the key symptoms of a high ankle sprain is the difficulty walking or bearing weight on the injured leg. The instability caused by damage to the ligaments, particularly the syndesmosis, makes it painful to put weight on the affected foot. Unlike low ankle sprains, where some weight-bearing may still be possible, high ankle sprains often make it hard to walk without assistance.
Pain with Rotation or Twisting Movements
People with a high ankle sprain often experience pain with rotation or twisting movements of the foot or leg. External rotation—where the foot stays in place while the lower leg turns outward—tends to cause intense pain. This pain can be aggravated by activities such as cutting, pivoting, or any movement that involves turning the ankle. The pain tends to be sharp and located above the ankle joint, making it different from the typical lateral ankle sprain.
Difficulty with Knee-Over-Toe Movements
Another key symptom of a high ankle sprain is difficulty performing knee-over-toe movements, such as squatting or lunging. This is because these movements force the tibia and fibula to separate slightly, which places additional stress on the damaged syndesmosis ligament. As a result, patients often experience sharp pain when trying to bend the knee forward over the toes, as the separation between the two bones exacerbates the injury. This is a distinctive symptom that helps distinguish a high ankle sprain from a low ankle sprain, as the latter typically doesn’t cause this specific issue with knee-over-toe motions.
Diagnosing a High Ankle Sprain
Diagnosing a high ankle sprain requires a combination of physical examination and imaging to accurately assess the injury and rule out other conditions. Since the injury involves the ligaments that connect the tibia and fibula, a thorough evaluation is essential to determine the severity.
During a physical examination, the physiotherapist will assess your symptoms, pain response, and movement limitations. They will focus on areas of tenderness, particularly around the syndesmosis, where the tibia and fibula meet.
The physiotherapist will also evaluate your range of motion and the stability of your ankle joint. They will perform specific tests designed to stress the syndesmosis and assess how the injured ligaments respond to pressure, rotation, and movement. This helps them determine the severity and stability of the sprain and whether the injury is isolated to the ligaments or involves other structures.
The physiotherapist will also look for characteristic symptoms such as localised pain above the ankle joint and difficulty with weight-bearing activities. These findings will give them valuable insight into the extent of the injury and help guide the decision for imaging.
Imaging Tests: MRI and Standing X-rays
While a physical examination can provide important clues, imaging tests are often necessary to confirm a high ankle sprain and assess the full extent of the injury. These tests help identify the degree of ligament damage and rule out other potential issues, such as fractures.
MRI: An MRI is commonly used to diagnose a high ankle sprain, as it provides detailed images of the soft tissues, including the ligaments. It can reveal tears or strains in the syndesmosis ligaments and the interosseous membrane, helping determine the severity of the sprain and whether surgery is needed.
Standing X-rays: X-rays are used to rule out fractures and assess the alignment of the tibia and fibula. In the case of a high ankle sprain, standing X-rays can show if there is any abnormal separation between the tibia and fibula, which may suggest a more severe injury requiring additional intervention.
Treatment of a High Ankle Sprain
The treatment for a high ankle sprain depends on the severity of the injury, but the majority of cases can be effectively managed with physiotherapy and conservative care.
For most individuals with a high ankle sprain, the first step in treatment involves a period of immobilisation to allow the injured ligaments and tissues to heal. This is typically done with an air boot or brace, which helps stabilise the ankle and prevent excessive movement that could aggravate the injury. Immobilisation allows the ligaments to heal in a stable position, and it’s usually recommended for a few weeks, depending on the severity of the sprain.
Once the initial period of immobilization is over, physiotherapy becomes the cornerstone of recovery. A physiotherapist will work to improve strength, mobility, and function, focusing on exercises that promote ankle stability, flexibility, and balance. Rehabilitation can take up to 3 months depending on the severity of the injury.
Surgical Treatment
In cases where the injury is more severe—often referred to as high-grade injuries—surgery may be necessary. High-grade injuries typically involve significant diastasis, or separation, between the tibia and fibula. This can lead to instability in the ankle joint, which can cause ongoing pain and functional issues if not properly treated.
For these types of injuries, the most common surgical procedure is the tightrope technique. This procedure involves the placement of a special suture or cable system across the syndesmosis to bring the tibia and fibula back together and stabilise the joint. The tightrope system mimics the function of the syndesmosis ligament and is designed to keep the bones properly aligned while they heal.
The tightrope procedure is minimally invasive and usually requires only a small incision. It can be performed arthroscopically in some cases, allowing for a quicker recovery and reduced risk of complications. After surgery, patients typically undergo rehabilitation to restore strength and range of motion, with a gradual return to normal activities.
If you’ve experienced an ankle injury that just won’t seem to go away, it’s important to get it properly evaluated and treated. High ankle sprains can be tricky to diagnose and can cause persistent pain if left untreated. Don’t hesitate to reach out to us for a thorough assessment and to discuss your treatment options.
The Sharp Physio Team
Request A Free Discovery Call & Ask All The Questions You Need
