What is a “High” Ankle Sprain?
The
ankle joint is composed of a complex hinge with both bone and ligamentous
structures playing a role in stability. The ligaments of the ankle allow a wide
range of motion while providing stability throughout the range of motion. These ligaments are divided into two groups –
the lateral ligaments located on the outside of the ankle, and the medial
ligaments located on the inside of the ankle.
The
most common ankle sprain (a “low” ankle sprain) occurs when the foot is turned
inward which stretches and tears the ligaments on the outside part of the ankle
complex. Low ankle sprains represent 90%
of all ligament injuries to the ankle. The
term “high” ankle sprain refers to an injury involving the ligaments on the
inside of the ankle joint that occurs when the foot is forcibly turned outward
from either a contact or non-contact injury.
If the force is great enough, there is also damage to the ligaments
spanning the lower leg bones – the tibia and fibula. These injuries represent only 10% of all
ankle sprains, yet they are increasingly seen in football and soccer players of
all levels. High ankle sprains result in
significantly more lost time from sports due to the nature of the damage that
occurs.
How is a High Ankle Sprain Diagnosed?
High
ankle sprains are reliably diagnosed by sports medicine specialists through careful
attention to the history, examination, and imaging studies. A thorough physical
examination specifically isolating the ligaments suspected of being injured is
imperative. Unfortunately, the physical
examination is often non-specific, especially immediately following the
injury. Plain x-rays are usually normal in
terms of showing the normal relationship between the tibia and fibula (Figure 1).
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Figure
1: X-ray of a normal right ankle. Note the close relationship between the two ankle
bones (tibia and fibula).
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However, if the injuring force is great
enough, there may be separation of these bones which allows an abnormal shift
of the ankle joint (Figure 2). This can lead to chronic stiffness, pain, and
ultimately arthritis of the ankle joint. Magnetic resonance imaging (MRI) may
also be used to show more subtle signs of injury as well as to rule out other
damaged soft-tissue structures such as ligaments, tendons, and cartilage.
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Figure
2: X-ray of a right ankle that has
sustained a serious high ankle sprain.
Note the separation between the tibia and fibula as well as the shift of
the talus bone. This more severe injury
will require surgery and potentially lead to osteoarthritis and chronic pain if
not treated appropriately.
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What is the Usual Treatment for a High
Ankle Sprain?
The
vast majority of high ankle sprains are treated conservatively (non-operatively)
with splinting of the ankle to reduce motion of the painful joint. Elevation and icing to the ankle is helpful to
reduce swelling. Icing should not be
applied for any longer than 20 minutes as this may result in an increase in the
amount of ankle swelling. Non-steroidal anti-inflammatory
medications are usually prescribed to aid in pain control and swelling, though
there is limited scientific evidence of the effectiveness of these drugs. Crutches may be necessary to assist with
ambulation. Gentle range of motion exercises are begun as tolerated. This is followed by strengthening exercises
to the muscles of the lower leg.
Graduated, sport-specific exercises are then initiated with the goal to
return the athlete to sports when he or she is able to run, jump, cut, and
pivot without pain. An ankle brace or
taping of the ankle may help reduce the risk for recurrent injury once the
athlete returns to sports. Surgery is rarely necessary for high ankle sprains
and is indicated only if there is significant injury to the ligaments around
the ankle resulting in significant separation of the lower leg bones.
When Can Athletes Return to Sports
Following a High Ankle Sprain?
Despite
the fact that most athletes who experience a low ankle sprain can return to
sports within one to three weeks following the injury, those players who
sustain a high ankle sprain are often out of sports for four to six weeks
depending upon the injury severity.
Sports that involve cutting and pivoting, such as football, are
especially difficult to play in the setting of a high ankle sprain. The player’s position may also dictate the
length of recuperation as running backs or linebackers who have to quickly
change direction are often the most disabled with this injury. Once an athlete sustains
an ankle sprain, he or she, unfortunately, is more prone to future sprains.
