High Ankle Sprain (Ankle Syndesmosis Injury)
1. Introduction
An ankle syndesmosis injury (also known as a high ankle sprain) is a rare cause of ankle pain following an injury, usually those involving sports such as football, basketball or athletics (1). The ankle syndesmosis consists of a group of ligaments that help connect the lower tibia and fibula (lower leg bones) together. These ligaments can be damaged by any mechanism that involves the foot turning outwards with force; this may be after landing following a jump or twisting sharply on the ankle to change direction in sports such as rugby or football (2). If you have this injury, you may experience pain in front of the ankle, swelling and difficulty walking or placing full weight on the ankle joint (3).
Frequently Asked Questions
- An ankle syndesmosis injury (also known as a high ankle sprain) is a rare cause of ankle pain following an injury, usually those involving sports such as football, basketball or athletics (1).
- Uncommon
- An ankle syndesmosis injury (referred to as a ‘high ankle sprain’), is a rare cause of ankle pain, usually following trauma such as a slip, twist or fall.
- It is an injury to one of the ligaments that connect the bottom half of the two shin bones (1).
- This type of injury only makes up 10% of all ankle joint sprains (1)
- The condition occurs after a high force incident such as a fall or a sports injury (2).
- No
- The right assessment, treatment and rehabilitation will generally provide a full recovery (3).
- There is no reason that an individual who has sustained a syndesmotic injury cannot return to their previous level of sport or activity.
- This condition is most likely to affect those who are involved in sports or physical activity, particularly those involving changes of direction or landing (4).
- These include football, basketball, netball, running, athletics.
- Pain after a twisting or landing that is located around the front and outside of the ankle (4,5).
- Swelling and/or bruising around the ankle may occur.
- Pain whilst walking.
- Difficulty putting weight on the injured leg (4).
- Initial treatment focuses on controlling the degree of swelling, pain and limiting stress to allow for healing to take place (6).
- You may be provided with a walking boot to wear for the first 2-4 weeks (7).
- In the early stage of management good practice now involves use of the Peace & Love protocol.
- Physiotherapy exercises can begin after a period of relative rest and include range of movement and strengthening exercises to promote faster recovery (8).
- Outcomes following a syndesmotic injury are generally good, but recovery may take longer than in a typical ankle sprain (1).
- Complete recovery and return to sport may take up to six months depending on the severity of injury (9).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
The signs and symptoms of a high ankle sprain may vary from person to person but are likely to include the following:
- Pain at the front and the outside of the ankle joint.
- Swelling and bruising of the ankle.
- Tenderness to touch around the bottom third of the shin.
- Difficulty in walking or placing weight on the affected leg.
- Feelings of “instability” or that the ankle may “give way” during walking or weight-bearing (5).
3. Causes
This condition is most seen in those who participate in sports or physical activity. This may include sports such as basketball or netball (that involve landing) or those that involve directional changes and pivoting (such as football or rugby). The injury normally occurs with a combination of landing heavily on the foot, whilst the upper body twists outwards and the foot remains fixed (3, 4).
4. Risk Factors
The risk factors for sustaining a high ankle sprain injury are usually linked to the type and level of participation in sports.
The injury is usually associated with those who participate in sports where there may be a combination of twisting and landing. It is also seen in sports which required the lower limb to be relatively fixed, such as skiing or snowboarding.
It is more commonly seen in competitive sport due to the increased speeds and forces involved. Poor or ill-fitting footwear may contribute to the risk of sustaining an injury if it provides poor stability to the ankle (5,6).
5. Prevalence
High ankle sprains compared to other ankle ligament injuries are relatively uncommon, with this type of injury responsible for only 20% of all ankle soft tissue injuries and only 10% of all ankle sprains (1).
6. Assessment & Diagnosis
Your physiotherapist will take a detailed history of your ankle pain, the injury that may have led to it and your symptoms before carrying out a detailed physical assessment. The physiotherapist may examine your ankle for any swelling, bruising and determine the range of available movement within the joint. The physiotherapist may perform a series of special tests to gently stress various soft tissue structures around the ankle, to determine whether they are the cause of your pain. If an ankle fracture is suspected, an x-ray of the ankle will be arranged to rule this out.
7. Self-Management
As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help the recovery from your high ankle sprain. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as advised to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference.
In the early stage of management, good practice now involves use of the Peace & Love protocol see below for more explanation.
PEACE & LOVE:
Protect: the injury the first few days, avoid activities that increase pain.
Elevate: the leg higher than the heart as often as possible.
Avoid anti-inflammatories: they may reduce tissue healing in the early stage.
Compression: can help reduce swelling.
Education: your body knows best, avoid unnecessary treatments
&
Load: let pain guide your return to normal activities.
Optimism: remain confident and positive.
Vascularisation: choose a pain free exercise that elevates your heart rate.
Exercise: restore strength by adopting an active approach to recovery.
8. Rehabilitation
Treatment for this injury can be split into three stages with different goals from therapy.
Once a diagnosis of a high ankle sprain has been confirmed, you may be advised to avoid fully-weight-bearing on the affected joint or be provided with a walking boot for 2-4 weeks to assist in managing pain, reducing swelling and promoting quicker tissue healing.
9. High Ankle Sprain (Ankle Syndesmosis Injury)
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
Once a diagnosis of a high ankle sprain has been confirmed, you may be advised to avoid full weight-bearing on the affected joint or provided with a walking boot for 2-4 weeks to assist in managing pain, reducing swelling and promoting quicker tissue healing. Simple, isometric (static) strengthening exercises can begin in non-weight-bearing positions to start to strengthen the muscles around the joint and healing tissue. Low-level manual therapy – as guided by your physiotherapist – can help improve pain, range of movement and swelling (8).
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- 910
Once the initial early phase goals of rehabilitation have been reached, further exercises and treatment to restore full range of movement, strength and endurance in the ankle can begin. These exercises may be progressed from non or partial weight-bearing to full weight-bearing and will aim to strengthen the ankle as well as other key muscle groups in the leg.
Manual therapy, mobilisation and soft tissue therapy may be continued to help promote pain relief, restore end of range ankle joint movement (8) and treat residual soft tissue tightness. A phased return to sport or activity can begin, with guidance and monitoring from your physiotherapist. This should not exceed more than 4/10 on your perceived pain scale.
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Exercises at this stage may more closely mimic the demands of sport or physical activity and may involve more dynamic movements (plyometrics) or focus on muscle endurance. These exercises can be combined with a progressive and monitored return to play or sport, guided by your physiotherapist.
A high ankle sprain is a more complex injury than a lateral ankle injury (ligament injury to the outside of the ankle) and thus, complete recovery may take anywhere from 6 weeks to 6 months, depending on the person and the severity of the injury (9). This should not exceed more than 4/10 on your perceived pain scale.
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- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport we would encourage reviews with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage.
Whilst recovering you might benefit from further assessment to ensure you are making progress and establish appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future re-occurrence. Before returning to sport, a rehabilitation programme should incorporate dynamic exercises and a progression of strength exercises to ensure a safe and effective return to sport (5,7).
11. Other Treatment Options
In some very rare cases surgery may be needed if the two bones show signs of significant separation or if rehabilitation has been unsuccessful. If surgery is necessary, then the success rate is high, but it should be noted that this is only necessary in a very small percentage of this type of injury.
References
- Williams, et al. Syndesmotic Ankle Sprains in Athletes. American Journal of Sports Medicine. 2007; Vol 35, No. 7.
- Baltes TPA, Al Sayrafi O, Arnáiz J, Al-Naimi MR, Geertsema C, Geertsema L, et al. Acute clinical evaluation for syndesmosis injury has high diagnostic value. Knee Surg Sports Traumatol Arthrosc 2022 -05-04;30(11):3871.
- Liu J, Valentine D, Ebraheim NA. Management of Syndesmosis Injury: A Narrative Review. ORR 2022 -12-10;Volume14:471.
- Lin CF, Gross ML, Weinhold P. Ankle syndesmosis injuries: anatomy, biomechanics, mechanism of injury, and clinical guidelines for diagnosis and intervention. JOSPT. 2006; 36(6):372-384.
- Salameh M, Hantouly AT, Rayyan A, Dabbas J, Toubasi AA, Hartnett DA, et al. Return to Play After Isolated Syndesmotic Ligamentous Injury in Athletes: A Systematic Review and Meta-analysis. Foot; Ankle Orthopaedics 2022 -04;7(2).
- Bleakley CM, McDonough SM, MacAuley DC. Some conservative strategies are effective when added to controlled mobilization with external support after acute ankle sprain: a systematic review. Aust J Physiother. 2008;54(1):7-20
- Prima Dewi KS, Kadek N, Fridayani Y, Prima KS. Physiotherapy Interventions in Ankle Sprain. Kinesiology and Physiotherapy Comprehensive 2022 –01;1(1).
- Landrum EL, Kelln BM,, Parente WR, Ingersoll CD, Hertel J. Immediate effects of anterior-to-posterior talocrural joint mobilization after prolonged ankle immobilization: a preliminary study. J Man Manip Ther 2008;16(2):100-105
- Penning DM, Vermeulen RCM, Van Den Heuvel SBM, Halm JA, Schepers T. How has acute syndesmotic injury management evolved over the last decade? Results from a national survey. The Journal of Foot and Ankle Surgery 2024 -09-25.
Other Conditions in
Ankles
Tibialis Posterior Tendinopathy
A condition involving injury to the tendon found around the bone at the inner side of the ankle leading to pain and weakness.
Lateral Ankle Sprain
Pain and loss of function following an injury to the ligaments on the outside of the ankle.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Ankle Fractures
When a bone, or bones, that make up the ankle joint are stressed beyond their capability resulting in a fracture.
Achilles Tendon Rupture
A rupture of the Achilles tendon is a complete tear of the tendon which is the tendon that joins your calf muscles to your foot.
Achilles Tendinopathy
Pain, swelling and stiffness of the achilles tendon that joins the heel bone to the calf muscles.