High ankle sprains


High ankle sprains

Your ankle is a complex hinge joint forming between the bones of the lower leg  (tibia and fibula) and a bone of the foot (the talus) and allows your foot to bend upwards (dorsiflexion) and downwards (plantarflexion). Because of the number of ligaments, muscles and tendons in the ankle region and the volume and variation in the tasks we complete on our feet, the ankle is one of the most common musculoskeletal injuries treated by physiotherapists.[1]

There are three major ligaments that make their way along the outside of the ankle: the anterior talofibular ligament (ATFL), the posterior talofibular ligament (PTFL), and the calcaneofibular ligament (CFL). The common ankle sprain, also known as an inversion sprain usually involves injury to the ATFL and CFL and occurs when you roll your ankle.

What is a high ankle sprain?

The high ankle sprain is a little bit different and much less common than a lateral sprain and involves the syndesmosis between the lower tibia and fibula just above the ankle joint. The word ‘syndesmosis’ could be familiar to you if you’re a fan of AFL, NRL, Basketball or NFL as syndesmosis injuries have been on the rise in these contact sports in recent years.

The syndesmosis is a fibrous joint located where the two leg bones connect together by ligaments or connective tissue and usually have very little mobility. High ankle or syndesmosis injuries may not be as common as their lateral cousins, but they are more painful and debilitating.

What causes high ankle strains?

Chances are, if you play any sport requiring jumping, turning and twisting movements like AFL, football, basketball, volleyball or explosive changes of direction such as soccer, tennis and hockey then you’ve likely already suffered an ankle injury of some kind.

High ankle sprains can also be caused by slightly different mechanisms such as when the weight of a tackling opponent is put onto the ankle causing inversion or dorsiflexion trauma to the syndesmosis.

How are ankle strains diagnosed and classified by physiotherapists?

Your physio will ask you to describe the movement you were performing when your injury took place and under what circumstances, assess your symptoms, and conduct an in depth physical assessment including testing the syndesmosis. In addition, if indicated, further investigation such as X-rays or/and MRI may also be required if the results of your tests are inconclusive.

Physiotherapists and medical professionals generally grade ankle sprains on a scale of 1 to 3 – mild, moderate, and severe depending on the severity of any tearing to the ankle ligaments. In most cases, x-rays are performed to rule out a fracture or dislocation accompanying the tear too using the Ottawa ankle rules.

Grade 1 strain – (mild)

  • Minor tear
  • Minimal pain
  • Little of no joint instability
  • Mild pain with weight bearing activities
  • Slight loss of balance


Grade 2 strain – (moderate)

  • Some tearing of the ligament fibres
  • Moderate to severe pain
  • Moderate instability of the joint
  • Swelling and stiffness
  • Possible pain with weight bearing
  • Poor balance


Grade 3 strain – (severe)

  • Complete tear of the ligament
  • Severe pain followed by minimal pain
  • Gross instability of the joint
  • Severe swelling
  • Pain with weight bearing activities
  • Poor balance


What are the Symptoms of a High Ankle Sprain?

High ankle sprains are typified by a feeling of pain that radiates up your leg from the ankle. Each step you take will probably be very painful, especially so if you move your foot in the same way as when the injury occurred. High ankle sprains do not “look that bad” compared to lateral sprains in that they do not generally cause as much bruising or swelling, causing many people to be unaware of how severely they have injured themselves causing them to not rest and rehabilitate as necessary for complete healing.

How are high ankle strains treated?

Ideally, your high ankle strain would be treated by a competent physiotherapist, titled musculoskeletal physio or a Specialist Sports and Exercise Physiotherapist as it is a tricky injury to manage. You don’t need to be an athlete to see a Specialist Sports Physio either and specialist sports and exercise physios have attained the highest level of diagnostic and clinical skills within the physiotherapy profession resulting in Fellowship of the Australian College of Physiotherapists (FACP).

In short, they are experts in the management of complex sports and musculoskeletal injuries along with the prevention and evaluation of injuries resulting from sports and exercise participation at all ages and levels of ability.

In the immediate aftermath of your injury it is important to use the same “RICE” protocol used for the common ankle sprain:

Rest – Keep your weight off the affected leg. The amount of rest required for healing is usually much nearly twice as long as lateral ankle sprains

Ice – Apply ice to the area for about 15-30 minutes every few hours in the first couple of days after the injury, to reduce inflammation and swelling.

Compression – Wrap the lower leg with an elastic bandage to reduce swelling, but not tight enough to cut off circulation.

Elevation – Sit or lie down with your foot elevated to a position above the level of your heart to reduce swelling and pain.

Despite the fact that most athletes who experience a low ankle sprain can return to sports within one to three weeks following injury, those unlucky enough to sustain a high ankle sprain are often out of sports for four to six weeks depending upon the injury severity.

If you have suffered an ankle injury or have pain in the ankle/lower leg region it is important to seek guidance and treatment before causing further harm to the area. Don’t end up spending more time on the sidelines through not getting timely treatment.


[1] Lin CW, Hiller CE, de Bie RA. Evidence-based treatment for ankle injuries: a clinical perspective. J Man Manip Ther. 2010;18(1):22–28. doi:10.1179/106698110X12595770849524