Diagnosis: High Ankle Sprain

 In Exercise and Health

How High Ankle Sprain Presents

Ankle sprains are a very common sports injury. The most common type of ankle sprain are low, or lateral ankle sprains.

High ankle sprains, also known as syndesmotic sprains are rare, accounting for 1 to 11% of all ankle sprains. They are often difficult to distinguish from common low ankle sprains. Patients with high ankle sprains often present to clinic with the following symptoms:

  • Pain at the front of the leg above the ankle
  • Bruising above the ankle
  • Significantly less swelling than a common lateral (‘low’) ankle sprains
  • Unable to fully bear weight through the injured leg, leading to difficulties walking
High ankle sprains are rare, accounting for 1 to 11% of all ankle sprains. #performbetter @pogophysio Click To Tweet

How High Ankle Sprain is Diagnosed

High ankle sprain presents similarly to other common ankle injuries, like low sprains and fractures, making it challenging for the clinician to diagnose.

Your skilled physiotherapist can make a diagnosis based on:

  • A full history of the injury, and how it occurred
  • Your physio will perform the External Rotation (Kleiger’s), Squeeze, Fibula Translation and Cotton Tests. Positive outcomes from these tests is indicative of a high-ankle sprain.
  • Other medical investigations such as:
    • X-Rays are used to rule out fractures of the tibia, fibula and talus. X-Rays may show a widening of the distal tibia and fibula, but this is not common unless the injury is severe.
    • Ultrasound may be able to reveal injury of the syndesmosis while it is being stressed.
    • MRI is the gold standard for soft tissue injuries, but it is expensive and not widely available.
    • Arthroscopy is the most accurate diagnostic method for identifying High Ankle Sprains, but it is invasive and also expensive. Along with MRI, it should be considered as a last resort if a diagnosis cannot be reached.

Causes of High Ankle Sprain

The 3 bones that form the Ankle joint are the tibia (shin bone), fibula (calf bone) and talus. The tibia and fibula are the bones of the lower leg and run parallel to each other. At the distal end, these 2 bones form the ‘mortise’ or the ‘socket’ of the ankle joint, where they are tightly bound together by 2 ligaments: the anterior inferior tibiofibular ligament and the posterior inferior tibiofibular ligament. These ligaments stabilise the joint, allowing a very minimal amount of movement between the 2 bones, as large ground forces are transferred through them in walking, running and jumping.

In a high ankle sprain, the anterior inferior tibiofibular ligament is stretched or ruptured. This injury occurs in extreme positions of the foot where it is moved into hyper dorsiflexion, pronation and external rotation – think of movements where the foot is squashed towards the shin and twisted outwards.

High Ankle Sprain

High ankle sprain (source: www.physioroom.com)

It is a traumatic injury that can be experienced by athletes, footballers, hockey players and military personnel. The level of pain and instability of the ankle is indicative of the severity of the injury.

Treatment of High Ankle Sprain

Most patients with High Ankle Sprain respond well to physiotherapy and conservative treatment. Only patients who suffer a complete rupture (grade 3 tear) of the anterior inferior tibiofibular ligament require surgical intervention.

Physiotherapy aims to restore ankle function following a High Ankle Sprain following the following approach:

  1. Reduce inflammation and pain, and protect the ankle from further injury (1 – 2 weeks)
  2. Graduated return to full range of motion of the ankle, strength of the muscles and ligaments surrounding the injury, balance and full weight bearing. (Week 3 onwards)
  3. Progressive return to walking, running, jumping and participation in sports (Week 5 onwards)

Most importantly, physiotherapy aims to prevent recurrence of the injury through education and training to avoid movements that stress the distal tibiofibular joint.

Wayne Wu
Student Physiotherapist


Bleakley, C. M., McDonough, S. M., & MacAuley, D. C. (2008). Some conservative strategies are effective when added to controlled mobilisation with external support after acute ankle sprain: a systematic review. Aust J Physiother, 54(1), 7-20.

Passmore, J., Zachary, H., Wetherald, R., Duncan, H., & Bales, P. (n.d.). Syndesmotic Ankle Sprains  Retrieved December 06, 2016, from http://www.physio-pedia.com/Syndesmotic_Ankle_Sprains

Wikipedia contributors. (2016, June 17, 2016). High ankle sprain  Retrieved December 06, 2016, from https://en.wikipedia.org/w/index.php?title=High_ankle_sprain&oldid=725789069

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