High Ankle Sprain Rehab
The ankle is the most commonly injured joint in soccer as well as most other sports. Ankle injuries make up 11-23% of all injuries recorded during FIFA competitions. The vast majority (~85%) of ankle sprains involve the lateral ligament complex. High ankle sprains or syndesmotic sprains are much less common and account for approximately 10% of all ankle sprains. These sprains typically occur as a contact injury when another player tackles or steps on the outside or front of your ankle while your foot is planted. This may force the foot up and/or out, which can disrupt or sprain the ligaments between the tibia and fibula. This injury may also occur when pivoting wrong, landing awkwardly when shooting or jumping, or if your foot gets stuck while playing on a lumpy or sticky/turf field.
High ankle sprains typically take longer to recover from compared to medial and lateral ankle sprains, potentially even twice as long as lateral. As a result, we must be more patient with the rehab process and may need to progress more slowly. Also be aware that these sprains rarely occur in isolation and often happen simultaneously with bone bruises, lateral or medial ligament sprains, fractures of the fibula or tibia, or bone/cartilage lesions.
You will likely have pain with walking and more trouble pushing off of your toes while walking if you have a high ankle sprain. If any of these tests below are painful, you may have a high ankle sprain and possibly need imaging.
Dorsiflexion-external rotation test
Squeeze test
Crossed leg test
Kneeling (or standing) dorsiflexion test
Ankle Sprain Grades
Grade 1: Stretching or slight tearing of the ligament with mild tenderness, swelling and stiffness. The ankle feels stable and it is usually possible to walk with minimal pain.
Grade 2: A more severe sprain, but incomplete tear with moderate pain, swelling and bruising. Although it feels somewhat stable, the damaged areas are tender to the touch and walking is painful.
Grade 3: This is a complete tear of the affected ligament(s) with severe swelling and bruising. The ankle is unstable and walking is likely not possible because the ankle gives out and there is intense pain.
When should you get an x-ray?
The Ottawa Ankle Rules determine the need for x-rays with acute ankle injuries. This screening tool is very effective in ruling out patients who do not have a fracture and is useful for avoiding unnecessary imaging. A patient who presents with none of these symptoms is less than 1% likely to have a fracture.
Ottawa Ankle Rules
X-rays if you have pain in ankle region and
Bone tenderness at the posterior edge of the medial/lateral malleolus (see picture), or
Inability to put weight on your foot right after the injury for 4 steps
X-rays if you have pain in the midfoot and
Bone tenderness at the base of the 5th or navicular bone (see picture), or
Inability to put weight on your foot right after the injury for 4 steps
If you have excessive swelling after the injury it may be wise to get it checked out.
If you are unsure at all, use crutches and go see a healthcare professional.
Risk Factors
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This is the number one risk factor.
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Athletes who complete full or at least partial warm-ups substantially reduce their risk of ankle injuries.
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There is evidence for increased risk with poor field conditions, artificial grass, or improper footwear.
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There is evidence that reduced hip strength increases the risk of lateral ankle sprains. This may also increase the risk of medial and high ankle sprains, but the research if less clear.
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There may be a greater risk of high ankle sprains in athletes with flat feet or increased pronation.
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There is very likely a fatigue risk factor as there are more injuries near the end of each half.
Rehab and return to play
Many players return to play far too soon after a sprain. There is strong evidence that athletes have a twofold risk for re-injury after ankle sprain, especially during the first year post-injury. We will cover the different phases of recovery below. Rehab in general for a high ankle sprain is going to be very similar to lateral or medial, however, it will typically take longer to return to sport with this injury.
Phase 1 - Acute Phase (0-4 weeks)
(Exercises should be performed at least 2x/week, ideally more often in the early phases. These are general guidelines, rehab protocols are never one size fits all. Some athletes will progress much faster and others more slowly. If you have a low grade sprain or these exercises become too easy, move onto the next phase.)
Goals for this stage:
Reduce swelling/pain
Protect the ankle from further injury
Normal walking/weight bearing
Restore motion
Begin strengthening
Reduce swelling
Movement, Ice, Compression, Elevation.
Protect the ankle
While you do want to begin moving again as soon as possible, you should still try to avoid higher level activities in the acute phase if they are aggravating.
A walking boot and crutches may be needed for the first 3 weeks.
If you can go up and down stairs and walk outside without much discomfort, you are likely ready for full weight bearing and can stop using crutches.
At that point I recommend transitioning to an ankle brace that limits external rotation.
Normal weight bearing and walking
Early motion and weight bearing for acute ankle sprains has been shown to significantly increase ankle range of motion and decrease pain and swelling sooner than immobilization.
Try to avoid activities that excessively aggravate symptoms at this time, which could include running, jumping, cutting, uneven ground, etc.
Restore motion
Restrict end range dorsiflexion initially.
This motion widens the syndesmosis (between the fibula and tibia).
Wait at least 2-3 days, up to 3 weeks for higher grade sprains.
If a standing calf stretch is painful, try this stretch with a strap and add traction if necessary.
Strengthening
(Multiple sets with higher reps at this stage. Whatever set/rep range you choose, make sure you are challenging the muscles enough and going near failure.)
Restrict dorsiflexion at first, at least at end range.
Should you brace or tape your ankle?
Taping and bracing the ankle following injury has been shown to reduce the risk of repeated sprains in many studies.
I recommend using a fairly rigid brace with this injury.
Limiting external rotation can help reduce risk of re-injury.
(See the lateral ankle sprain article for an overview of various ankle braces)
Taping can also be very helpful, but this differs from typical ankle sprain taping.
For a high ankle sprain, I prefer to use a more rigid tape called leukotape to compress the lower fibula and tibia.
Clinically, I have found this taping technique to be very helpful once you start weight bearing as well as return to sport.
The tape holds up better than traditional athletic tape and will not affect the fit in your cleats.
Progress to the next phase when you are able to walk at a normal speed without limping, go up and down stairs, and perform all exercises with minimal discomfort.
Phase 2 - Intermediate (4-10 weeks)
Continue to progress strengthening and aerobic training.
You may begin jogging when you are able to balance on one foot, walk, and use stairs with no discomfort.
Trial inside of the foot passing when you are able to run pain free.
Sprinting, cutting, and agility training may begin later in this phase.
Including single-leg balance with perturbations or on unstable surfaces has been shown to reduce re-injury risk following ankle sprains.
If you are able to perform all of the exercises below without pain, begin basic field drills and move on to the next phase.
Phase 3 - Advanced (10-18 weeks)
Continue progressing strengthening, aerobic training, plyometrics, and agility.
Return to play
You can begin training sessions with your team once you have fully rehabbed the ankle and have full strength and motion, minimal swelling, and little to no pain with activity. Injuries are more likely to occur during a match than in training and the majority of these injuries are contact rather than noncontact. I recommend going through several full training sessions without discomfort prior to playing in a competitive match. Keep in mind that even if you feel 100%, full ligamentous strength and healing may not be regained for several months or longer after the injury.
Key Takeaways:
High ankle sprains or syndesmotic sprains account for 10% of all ankle sprains.
High ankle sprains typically take longer to recover from compared to medial and lateral ankle sprains.
You may have pain or restriction with walking, pushing off of your toes, and squatting.
A walking boot and crutches may be necessary for the first 3 weeks.
Once you can go up/down stairs and walk outside without much discomfort, you are likely ready for full weight bearing and can stop using crutches.
You may need to restrict end range dorsiflexion for the first few weeks.
Taping or bracing may reduce the risk of re-injury when you return to sport.
References
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