High Ankle Sprain

Anatomy of a high ankle sprain

The ankle joint consists of three bones; the tibia (shin bone) the fibula which is a smaller bone in the back outside portion of the lower leg, and the talus which is a bone in the foot that connects to the lower leg to make the ankle joint. These bones are held together by several ligaments as well as many muscles that attach from the shin to the foot. The main ligaments involved in a high ankle sprain are the Anterior Inferior Tibiofibular Ligament (AITFL), the Posterior Inferior Tibiofibular Ligament (PITFL), the Interosseous Membrane (which connects the tibia and fibula together), and the Deltoid ligament. A high ankle sprain is when one or several of these ligaments get injured.^1-3

Like most soft tissue injuries there is a grading scale for high ankle sprains.⁴ Grade I sprain involves a partial tear of the AITFL, grade II sprains involve a tear of the AITFL and a partial tear of the Interosseous Membrane, and grade III sprains are a complete sprain of all the ligaments.^4,5

Normally, the way the lower portion of the tibia and fibula bones connect with the talus bone of the foot creates a functional “mortise” where the talus bone is housed snugly between the tibia and fibula, and this is dependent on these ligaments being intact. This allows the ankle to be stable when pushing off such as sprinting, cutting, jumping, and many other explosive athletic activities. With a grade II-III high ankle sprain the injured ligaments no longer are able to properly hold the bones in place, therefore we see a gaping of the space between the tibia, fibula, and talus bones. This is both is painful and also impacts an athlete’s ability to generate force off of that ankle.^4,6

Cause of a high ankle sprain

Ankle injuries make up roughly 29% of football-related injuries, with about a quarter of all ankle injuries being high ankle sprains.⁶ The cause of a high ankle sprain is quite clear and consistent. This injury occurs when an athlete’s foot is planted in the ground and the shin rotates inward or outward with the foot maintaining in a planted position either due to being stuck in the turf or another player has landed on their foot.^1-4,6 Injury can also occur when the foot is planted and the player gets rolled up on from behind, causing their shin to propel forward over the ankle.⁴ Anatomically, the mechanism that occurs is a rotational force through the ankle and shin that strains the ligaments mentioned above more than they are capable of handling.

Surgical procedure for a high ankle sprain

The surgical procedure for high ankle sprains grade II or III was made famous in 2018 when Tua Tagovailoa suffered this injury while playing for Alabama. He underwent the “Tight Rope” procedure and returned to the field in only 4 weeks to lead Alabama to a national championship victory over Oklahoma.

The surgical procedure is relatively quick, often being completed in under an hour. With the patient under anesthesia, the surgeon will use a clamp on each side of the lower portion of this shin to bring the tibia and fibula bones closer together where they are supposed to be. Next, the surgeon will drill two holes into the outside lower portion of the shin. Wires are inserted through these holes to the inside portion of the lower shin, and when pulled will tighten the tibia and fibula bones together in their normal position.⁴

High ankle sprain rehab process

Rehabbing from a high ankle sprain is often a slower process than other types of ankle sprains. This is because of the amount of stability in the lower leg and ankle that is lost by this injury. Additionally, if an athlete rushes back to the field too soon they run the risk of further injuring the ligaments, creating more instability in the ankle joint and lower leg.⁷ This differs quite a bit from a lateral ankle sprain where it is much easier to use external appliances such as tape and braces, as well as muscular control to stabilize the joint.

Rehab is dependent on the grade of sprain with grade I injuries averaging 6-8 weeks to return to sport, grade II averaging 45 days, and grade III injuries averaging 10-14 weeks, however, some athletes have been able to return much faster.⁴ Age also appears to be a factor in return to sport. Some research has shown that every year under age 25 players return to games 1.1 days faster, whereas every year past age 25 players return to games 1.1 days slower on average.⁶

Grade I injuries can be easily rehabbed, whereas grade II injuries may or may not respond well to rehab alone and sometimes will need casting or surgery, and grade III injuries almost always need casting or surgery.^3,5,8 Often even with a grade I injury there is a 2 week period of wearing a boot and using crutches to protect the injury. This progresses to gentle range of motion and weight-bearing, eventually progressing to strengthening and balance exercises before finally returning to sport-specific exercises.¹ Grades II and III injuries follow a similar pattern of progression in rehab however have a longer period of protection phase, and as mentioned may include surgery or casting.

Interestingly, with new surgical advances such as the tight rope procedure mentioned above, some athletes (ex. Tua) are beginning to return to the field much sooner. Some surgeons following the tight rope procedure allow the entire rehab process to be sped up, which may include partial weight-bearing and some range of motion exercises right after surgery rather than waiting 2 weeks.⁵ It will be interesting to see over the next few years if this becomes the norm. Below outlines the current most frequent timeline for rehabbing from a high-ankle sprain with the understanding that surgically managed injuries will follow a similar timeline but a few weeks slower.

Rehab Phases1	Treatments
Phase I: Protection	Cast or boot with crutches progressing to brace or tape when able to tolerate weight-bearing. Ice, compression, elevation. Gentle cycling if pain-free. Strength of core, glutes, quads, hamstrings with exercises on a table.
Phase II: Restore Mobility	Progressively weight-bearing as tolerated. Continue with ice, compression, and elevation. Continue with cycling, strength of leg and core muscles. Begin ankle range of motion exercises progressing to light resistance bands, and eventually progressing to standing heel raises. Standing balance exercises starting on a firm surface, progressing to unstable surfaces. When able, initiate light jogging and hopping (ideally in gravity eliminating treadmill),
Phase III: Sport Specific Training	Aggressive strength training (squats, lunges, deadlifts, etc.) Jumping, agility ladder, plyometrics, hopping, cutting. Football specific moves (route running, QB dropbacks and throwing, RB taking handoff and running)

Prior to returning to sport, there is a battery of tests that have shown to be correlated with readiness to play and reduction in re-injury risk. This includes strength testing of major lower body muscle groups, several different single-leg hop tests for speed, distance, and balance, and single-leg balance tests. Generally, the research shows that if an athlete’s injured leg scores within 95% of the uninjured side with these tests and they have no pain, they are safe to return to sport.

Recurrence and future injury risk

Like most lower body injuries, when a high ankle sprain has occurred, the athlete is at an increased risk for future injury. In the NFL, high ankle sprains have an 8-11% recurrence rate for a subsequent high ankle sprain. No better example exists than Jonathan Taylor in 2022 when he experienced three high ankle sprains on the same ankle.

Prior high ankle sprains often influence other lower body injuries as well. Two characteristic consequences of high ankle sprains are chronic stiffness in dorsiflexion and chronic instability. While these sound like they would contradict each other, they don’t. No firm data is available on how frequent prior high ankle sprains cause other lower body injuries, but these lasting mechanical consequences can put excessive stress on the knees, hips, back, etc.

References

1. Williams GN, Jones MH, Amendola A. Syndesmotic ankle sprains in athletes. Am J Sports Med. 2007;35(7):1197-1207
2. Lin CF, Gross ML, Weinhold P. Ankle Syndesmosis injuries: anatomy, biomechanics, mechanism of injury, and clinical guidelines for diagnosis and intervention. J Orthop Sports Phys Ther. 2006;36(6):372-384.
3. Press CM, Gupta A, Hutchenson MR. Management of ankle syndesmosis injuries in the athlete. Curr Sports Med Rep. 2009;8(5):228-233.
4. D’Hooghe P, Grassi A, Alkhelaifi K, et al., Return to play after surgery for isolated unstable syndesmotic ankle injuries (West Point grade IIb and III) in 110 male professional football players: a retrospective cohort study. Br. J Sports Med. 2020;54:1168-1173.
5. D’Hooghe P, Alkhelaifi K, Abdelatif N, Kaux JF. From “Low” to “High” Athletic Ankle Sprains: A Comprehensive Review. Operative Techniques in Orthopaedics. 2018;54-60.
6. Knapik D, Trem A, Sheehan J, Salata M, Voos J. Conservative Management for Stable High Ankle Injuries in Professional Football Players. Sports Health. 2017;10(1):80-84.
7. Houck J, Neville C, Chimentl R. The Foot and Ankle: Physical Therapy Patient Management Using Current Evidence. Current Concepts of Orthopaedic Physical Therapy. 2016(4).
8. Taylor DC, Tenuta JJ, Uhorchak JM, Arciero RA. Aggressive surgical treatment and early return to sports in athletes with grade III syndesmosis sprains. Am J Sports Med. 2007;35(11):1833-1838.