High Ankle Sprain in Depth AKA: Syndesmosis Sprain

Common Signs & Symptoms

High Ankle Sprain Explained

High ankle sprain Anatomy of ankle sprain injuryA sprained ankle is one of the most common injuries caused by participation in sports. It refers to soft tissue damage (mainly ligamentsligaments ) around the ankle joint. A High Ankle Sprain refers to ligament damage at the joint between the shin bone (Tibia) and splint bone (Fibula). This joint is referred to as the Ankle Syndesmosis.

A Syndesmosis is a joint where the two bones are bound tightly together by ligament tissue. The Ankle Syndesmosis refers to the fibrous band of ligament tissue which connects the shin bone and Fibula. Specifically, this refers to the ‘Interosseous Membrane’ between the two bones, as well as the anterior (front) and posterior (back) Tibio-Fibular ligaments.

In the case of a High Ankle Sprain, the mechanism of injury is excessive ankle dorsi-flexion (where the toes come up towards the knee) as well as external rotation of the shin, which causes damage at the ankle ‘Syndesmosis’.

As well as damage to the ligaments, the capsule that surrounds the ankle joint can also be damaged. The damage causes bleeding within the tissues but, unlike a medial or lateral ankle sprain, the ankle joint doesn’t usually swell too much.

Syndesmotic ankle sprains can be classified as follows :

  • First degree, where only a few ligament fibres are damaged within the interosseous membrane
  • Second degree sprain refers to more extensive damage to the interosseous membrane with some widening of the Tibio-Fibula joint
  • Third degree sprain refers to a complete rupture of the interosseous ligament with gross widening of the Tibio-Fibula joint and possible joint dislocation

In the more severe injuries there may be associated bone injury and it is wise to get an x-ray to determine whether there is a fracture.

High Ankle Sprain Signs & Symptoms

With a first degree sprain there is usually pain on ankle movement and when the damaged area is touched. Typically, with a second degree sprain the pain is more severe, there may be swelling all around the area and it is painful to walk. With a third degree sprain the pain is excruciating and walking is impossible. A swollen ankle is typical and there may be a visible deformity if the ankle is dislocated. A Physiotherapist will differentiate a high ankle sprain from an inversion sprain or other injury.

High Ankle Sprain Treatment

What you can do

Consult a sports injury expert
Apply ice packs/cold therapy to reduce swelling
Wear a removable plastic cast for protection
Wear an ankle support for protection

In the case of a Grade Three Ankle Syndesmosis injury then surgery may be required to fix the Tibia and Fibula back in place. Grade One and Two injuries take between one and two months to recover from completely.

In the first 48-72 hours following the injury it is important the follow the PRICE protocol – protection, rest, ice, compression and elevation (never apply ice directly to the skin). Ice Packs for a period of twenty minutes every couple of hours may help with the pain but pain-relieving medication may also be necessary. The Aircast Ankle Cryo/Cuff is the most effective method of providing ice therapy, whilst protecting the injured tissues from further damage, and is the professional’s choice. It can provide continuous ice cold water and compression for 6 hours – and significantly reduce pain and swelling.

It is important not to put too much weight on the damaged ankle. Excessive walking should be avoided if it is painful. Ankle injuries can be protected using a Plastic Cast Walker and these are regularly used by Premier League football players.

Where a fracture is suspected an x-ray should be carried out at an accident and emergency department as soon as possible. If a fracture is found or a Grade Three sprain is diagnosed, the advice of the attending doctor should be followed. It should be borne in mind that some hairline fractures do not show up on x-ray until about 10-14 days after the injury, so if the pain persists medical attention should be sought.

In the case of a Grade Two sprain, crutches should be used to protect the injured ankle. However, it is important not to be on the crutches for longer than necessary and as soon as the pain allows the patient should begin to gently put weight through the ankle by walking. Plastic Cast Walkers can be very helpful as they allow the patient to walk, protect the injured area and help to resolve ankle swelling.


Once the patient is able walk on the ankle, more active rehabilitation can be started. Manual therapy is then very effective at restoring ankle movement and resolving stiffness. Physiotherapists can help by manipulating and massaging the joint to help restore a full range of movement.

High Ankle Sprain Prevention

What you can do

Wear an ankle support for protection
Use a wobble board for ankle strengthening

Ankle instability is characterised by ankle weakness and giving way, even though the ankle ligaments are intact and the joint is mechanically stable. It is due to an impairment of proprioception, which leads to a lack of balance and ankle joint position sense. Proprioception is the mechanism by which nerve receptors in skin, muscle, ligament and joint tissue relay information to the brain about body position sense, where this information is quickly processed and movement strategies are formulated and executed using nerve signals to muscles. This mechanism can help you ‘catch yourself’ when you are about to turn your ankle.

In the unstable ankle these receptors may have been damaged directly during an ankle sprain. This impaired proprioceptive ability may, therefore, lead to a delay in protective muscle activity and the resultant loss of postural awareness and stability around a joint. This may explain why recurrent ankle sprains are so common. Proprioception should be a primary focus of rehabilitation to reduce the risk of re-injury and help ensure a successful return to sport and activity.

The Wobble Board together with Ankle Braces are commonly used in the rehabilitation of ankle instability. Wobble Boards are designed to assist the re-education of the proprioceptive system by improving sensory receptor function. Previous research has also shown that wobble board training improves single leg stance ability and balance; while other studies have suggested that patients with ankle instability who underwent wobble board training experienced significantly fewer recurrent sprains during a follow-up period than those who did not follow the training programme.

Exercise bands (Resistance Bands) may also be used to start to encourage range of movement and gentle strengthening exercises. Different levels of resistance can be used so “light” bands are used at first then as pain, swelling and function all improve the level of resistance can be increased.

Taping and Bracing the ankle can also help to reduce recurrent ankle injury. Previous research has shown the injury incidence in students with taped ankles was 4.9 ankle sprains per 1000 participant games, compared with 2.6 ankle sprains per 1000 participant games in students wearing ankle braces. This compared with 32.8 ankle sprains per 1000 participant games in subjects that had no taping or bracing.

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