The high ankle sprain, your guide to recovery

ankle sprains | Arana Hills Physiotherapy


High ankle sprains or ankle syndesmosis injuries are a relatively common lower limb injury that is often observed in field sports such as AFL or football codes. However it also not uncommon to see them in less competitive arenas and can often be part of a “simple” ankle sprain. It has been observed that they are involved in around 11% of ankle injuries , but this figure is higher in sports related ankle injuries.

What is a high ankle sprain / ankle syndesmosis injury ?

Ligament anatomy of the foot

High ankle sprains involve injury to to the ligaments that join and create  a degree of stability between the fibula and tibia of the lower leg. These ligaments are the;

  • Anterior inferior tibiofibular ligament, (AITL)
  • Posterior inferior tibiofibular ligament, (PITL)
  • Interosseous ligament, (IOM)

Damage to these ligaments leads to a loss of stability at the bottom of the shin and particularly the ankle, often resulting in reduced ankle joint function and potentially affecting the strength and stability of the joint.

How does a high ankle sprain / syndesmosis injury  occur ?

Unlike a lateral ligament sprain where the tissues are stretched as the foot rolls inwards and underneath the syndesmosis is generally injured when the foot is fixed on the ground and the lower leg is force ably twisted or rotate internally. This causes the fibula and tibia to gap or separate tearing the ligaments in that area.

Usually you feel pain just above the ankle joint rather than at the outer aspect of the ankle and there may be swelling and tenderness in that region.

How long does it take to recover from a high ankle sprain ?

There has been a proposed grading for syndesmosis injuries which helps to guide how long recovery will take:

  • Grade 1: Sprain/Partial rupture AITFL  Joint tends to be stable, typical recovery within 6-8 weeks of injury
  • Grade 2: Tear AITFL, IOM tear (PITFL intact or sprain)- These injuries can be stable but also present with instability. As a guide can take anywhere from 6 – 12 weeks to recover.
  • Grade 3: Rupture of all 3 ligaments,( AITFL , PITFL, IOM) : Joint inherently unstable , surgical opinion required. Recovery months rather than weeks

How to treat a high ankle sprain / syndesmosis injury

Acute management of high ankle sprain

In  the initial stages treatment the injury often involves offloading and protecting the injured tissues and this may involve strapping or even a moon boot and using crutches in the early phases to let the injured tissues heal .

Ice can help to reduce the swelling  as well as help with pain.

Physiotherapy for high ankle sprain

Physiotherapy is good to commence as soon as possible so you get the best advice and a set yourself up for success. Its important not only to consider the ankle but also look at the whole lower limb / hip and core integration. Your rehab should be tailored to get you back to your desired activity and level of performance.

Ideally your rehab should following these 5 stages:

  1. Recovery from acute phase , reduce pain restore movement and weight bearing ability.
  2. Strength and neuro-muscular control
  3. Running agility and ability to land safely
  4. Return to sport
  5. prevent re-injury

Depending on the grade of injury and how you recover will determine how quickly you progress through these stages.

In these videos we look at examples for stages of rehab, these aren’t exhaustive but should give you a clear idea what you will need to do:early stage high ankle sprain rehabilitation

Mid stage high ankle sprain rehabilitation : week 2-4

Late stage high ankle sprain rehabilitation


What does surgery for high ankle sprain / syndesmosis injury involve ?

Surgery is usually left for grade 3 injuries whereas the more common grade 1 and 2 type injuries tend to be left in the domain of a conservative rehabilitation approach.

If you are unlucky enough to have sustained a grade 3 type injury and require surgery the aim is to restore stability back to the distal tib fib joint either by using screws , ( pic on the right) or a tightrope system on buttons fixed to the bones, ( left picture).

surgical techniques for syndesmosis injuries


Thanks for reading  and If you need any help with a high ankle sprain or other ankle related injury feel free to contact us or book in here:


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