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How to identify and treat a high ankle sprain or syndesmosis injury

If you’re a fan of AFL, NRL, Netball, Basketball or NFL, chances are the word ‘syndesmosis’ is one you’ve heard a lot of in the last few years. Syndesmosis injuries have been on the rise in contact sports in recent years as games are played faster by bigger and more agile players.

Your ankle is a complex hinge joint between the bones of the lower leg  and a bone of the foot and allows your foot to bend upwards (dorsiflexion) and downwards (plantarflexion). Because of the number of ligaments, muscles and tendons in the ankle region and the volume and variation in the tasks we complete on our feet, the ankle is one of the most commonly injured musculoskeletal zones treated by physiotherapists.[1]

What is a high ankle sprain?

The anterior talofibular ligament (ATFL), the posterior talofibular ligament (PTFL), and the calcaneofibular ligament (CFL) make their way along the outside of the ankle. The common ankle sprain, also known as an inversion sprain usually involves injury to the ATFL and CFL and occurs when you roll your ankle.

A high ankle sprain is a little bit different and much less common than a lateral sprain and involves the syndesmosis between the lower tibia and fibula just above the ankle joint.

The syndesmosis is a fibrous joint located where the two leg bones connect together by ligaments or connective tissue and usually have very little mobility. Syndesmosis injuries may not be as common as their lateral cousins, but they are more painful and debilitating.

A sports physio will generally grade ankle sprains on a scale of 1 to 3 – mild, moderate, and severe depending on the severity of any tearing to the ankle ligaments. In most cases, x-rays are performed to rule out a fracture or dislocation accompanying the tear.

Grade 1 strain – (mild)

  • Minor tear
  • Minimal pain
  • Little of no joint instability
  • Mild pain with weight bearing activities
  • Slight loss of balance

Grade 2 strain – (moderate)

  • Some tearing of the ligament fibres
  • Moderate to severe pain
  • Moderate instability of the joint
  • Swelling and stiffness
  • Possible pain with weight bearing
  • Poor balance

Grade 3 strain – (severe)

  • Complete tear of the ligament
  • Severe pain followed by minimal pain
  • Gross instability of the joint
  • Severe swelling
  • Pain with weight bearing activities
  • Poor balance

What causes high ankle strains?

Chances are, if you play any sport requiring jumping, turning and twisting movements like AFL, football, basketball, volleyball or explosive changes of direction such as soccer, tennis and hockey then you’ve likely already suffered an ankle injury of some kind. High ankle sprains can also be caused by slightly different mechanisms such as when the weight of a tackling opponent is put onto the ankle causing inversion or dorsiflexion trauma to the syndesmosis.

What does a high ankle sprain feel like?

Compared to lateral sprains, high ankle sprains do not “look that bad” in that they do not generally cause as much bruising or swelling. This lack of in your face swelling can cause many people to be unaware of how severely they have injured themselves, until the pain sets in. High ankle sprains are usually accompanied by a pain that radiates up your leg from the ankle. Each step you take will probably be very painful, especially so if you move your foot in the same way as when the injury occurred.

How are high ankle strains treated by a physio?

Your physio will ask you to describe the movement you were performing when your injury took place and under what circumstances, assess your symptoms, and conduct an in depth physical assessment including testing the syndesmosis. High ankle strains can be tricky to manage and are best treated by a sports physio or titled musculoskeletal physio.

In the immediate aftermath of your injury it is important to use the same “RICE” protocol used for the common ankle sprain:

Rest – Keep your weight off the affected leg. The amount of rest required for healing is usually much nearly twice as long as lateral ankle sprains

Ice – Apply ice to the area for about 15-30 minutes every few hours in the first couple of days after the injury, to reduce inflammation and swelling.

Compression – Wrap the lower leg with an elastic bandage to reduce swelling, but not tight enough to cut off circulation.

Elevation – Sit or lie down with your foot elevated to a position above the level of your heart to reduce swelling and pain.

If you have suffered an ankle injury or have pain in the ankle/lower leg region it is important to seek guidance and treatment before causing further harm to the area. Don’t end up spending more time on the sidelines through not getting timely treatment.

[1] Lin CW, Hiller CE, de Bie RA. Evidence-based treatment for ankle injuries: a clinical perspective. J Man Manip Ther. 2010;18(1):22–28. doi:10.1179/106698110X12595770849524

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