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The Lowdown on High Ankle Sprains

Posted by Douglas W. Stoddard MD, M Sp Med, Dip Sport Med, ES on 13 August 2018
The Lowdown on High Ankle Sprains

High ankle sprains, also referred to as syndesmotic ankle sprains, are often under-diagnosed in the athletic and general population, but if left untreated, it can result in significant pain and disability, chronic ankle dysfunction and arthritis.

What exactly is a high ankle sprain, and how does it happen?

High ankle sprains affect the ligaments that provide stability to the distal tibiofibular joint, which is the area just above the ankle.

There are four ligaments responsible for stabilizing this joint the Anterior Inferior Tibiofibular Ligament (AITFL), Posterior Inferior Tibiofibular Ligament (PITFL), interosseous ligament and transverse tibiofibular ligament. Their job is to hold the tibia and fibula together, limiting excessive movement between the two bones. These ligaments are very strong and require a great deal of force to tear these fibers.

During normal movement, particularly in a weight-bearing position (e.g. standing and walking), the ligaments allow for some separation (or splaying) between the tibia and fibula. However, when they are forced beyond their limit, damage to these ligaments can occur. The most common ways of sustaining a high ankle sprain are:

1) Forced external rotation of the foot.

  • Example: planting foot into the ground and pivoting/twisting on the spot

2) Forced eversion of the talus.

  • Example: contact from the outside of the foot from an external force such as a slide tackle in soccer

3) Excessive ankle dorsiflexion.

  • Example: another person falling and landing on foot/ankle that is already in a dorsiflexed position

The athletic population, more specifically athletes that participate in contact sports or activities that involve quick directional changes and jumping, are more at risk of sustaining this type of injury due to the amount of force and specific ankle position or movement required to tear these ligaments.

What does a high ankle sprain feel or look like?

  • Pain around the front of the ankle
  • Swelling and bruising around the entire ankle
  • Difficulty putting weight onto affected leg
  • Point tenderness over the ligaments

What should I do if I suspect I have a high ankle sprain?

Follow the principles of P.R.I.C.E.:

Protect -  limit weight-bearing position as much as possible if it is painful to walk or stand. Use crutches if needed.

Rest - avoid activities that are painful during the acute phase of the injury. Allow the pain, inflammation and swelling to decrease first and by doing so, this can maximize the ability for the ligament(s) to start healing.

Ice -  use ice to decrease pain and prevent swelling.

Compress - wrap a tensor bandage around your ankle to prevent swelling.

Elevate - raise your ankle up above your heart level to prevent and decrease swelling.

Please consult your health care professional as soon as possible to determine if you have a high ankle sprain or other condition(s) that can be similar in presentation or accompany this type of injury. It is important to rule out/in the presence of an ankle fracture, other ligamentous or tendon injuries as the management can change depending on which structures are involved.

Your health care professional may refer you to get diagnostic imaging or consult with another health care professional such as a specialist to help determine the appropriate course of treatment (e.g. medical/surgical vs. conservative management).

What is the rehabilitation process for a high ankle sprain?

Your health care professional such as a physiotherapist will perform an assessment to determine what your impairments and goals are for therapy (e.g. walking pain-free, return to playing sports etc.).

Your rehabilitation process will likely include:

  • Pain management strategies
  • Education about your injury and activity modification or limitations
  • Return to weight-bearing protocol
  • Regain full ankle range of motion and strength
  • Balance retraining
  • Return to sport-specific activities (e.g. plyometrics, agility drills etc.)

Why is it important to seek care from a health care professional for a high ankle sprain?

It is important to get a high ankle sprain diagnosed in a timely manner since research has shown that high ankle sprains have a longer recovery period compared to other types of ankle sprains such as a high grade lateral ankle sprain. It requires up to 3 times more treatment and takes twice as long to return to full activity.

Therefore, an accurate diagnosis and the appropriate treatment approach are key in helping you get back to regular activities faster and preventing the development of chronic ankle instability, long-term pain and disability and arthritis.

If you're suffering from a high ankle sprain, an ankle sprain, or any other type of foot or leg pain, SEMI's healthcare practitioners use evidence-based treatments custom to your diagnosis, getting you back to the sports and activities you love.

Book an appointment online today!



Cheng-Feng L, Gross MT, 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.

Hermans JJ, Beumer A, de Jong TAW, Kleinrensink GJ. Anatomy of the distal tibiofibular syndesmosis in adults: a pictorial essay with a multimodality approach. J. Anat.2010;217:633-645

Mauntel TC, Wikstrom EA, Roos KG, et al. The epidemiology of high ankle sprains in national collegiate athletic association sports. The American Journal of Sports Medicine. 2017;45(9):2156-2163.

Reisseg J, Bitterman A, Lee S. Common foot and ankle injuries: what not to miss and how best to manage. J Am Osteopath Assoc. 2017;117(2): 98-104.

Williams G, Allen E. Rehabilitation of syndesmotic (high) ankle sprains. Sports Health: A Multidisciplinary Approach. 2010; 2(6):460-470.

Williams GN, Jones MH, Amendola A. Syndesmotic ankle sprains in athletes. The American Journal of Sports Medicine. 2007;35(7):1197-1207.
Author: Douglas W. Stoddard MD, M Sp Med, Dip Sport Med, ES
About: Dr. Douglas Stoddard is a sports medicine physician and is the Medical Director of the Sports & Exercise Medicine Institute (SEMI). After receiving his medical degree from the University of Toronto, he trained in Australia at the Australian Institute of Sport in Canberra, obtaining his Master Degree in Sports Medicine. He is also a diplomat of the Canadian Academy of Sport and Exercise Medicine and has his focussed practice designation in Sport Medicine from the Ontario Medical Association. Dr. Stoddard is a consultant to the Canadian Military and has consulted with well over 30,000 unique patients in his career. Dr. Stoddard is constantly searching for new and promising therapies to help SEMI patients, and is responsible for developing the RegenerVate Medical Injection Therapy Program. He is married and the proud father of two boys, is an avid triathlete and occasional guitar player.
Tags: Lower body Treatment options


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