When is an ankle sprain not an ankle sprain? When it is a high ankle sprain. A high ankle sprain is actually an injury above the ankle joint occuring when excessive rotational stressors result in injury to the high ankle ligaments. The high ankle ligaments are collectively called the syndesmosis complex and consist of 3 structures responsible for holding the 2 bones in the lower leg, the tibia and fibula, in the proper position so these bones can fit properly into the foot. When this complex is injured it results in laxity in the structures holding the tibia and fibula together and therefore greater instability in the ankle joint.
The syndesmosis complex is composed of 2 ligaments and a membrane between the 2 bones. The anterior inferior tibiofibular ligament, or AITFL, which runs in front of the two bones just above the ankle, the posterior inferior tibiofibular ligament, or PITFL, which runs in the back of the 2 bones and the interosseous membrane which runs between the two bones from just below the knee all the way to the ankle. This type of injury is much harder to describe and also takes a considerable amount of time to recover.
High ankle sprains are diagnosed using a series of tests including physical examination of the lower leg immediately after the injury. This is what you see the trainers and medical staff who come on to the field do. The 2 tests they perform include the Fibular Squeeze Test which is positive when pressure over the fibula applied midway between the knee and ankle results in significant pain right above the ankle and the External Rotation Test or Kleiger’s maneuver which is positive when significant laxity in the ankle is palpated. X-rays are used to access the lower fibula and tibia for fracture as well as the determine the amount of space between the tibia and fibula. MRI and CT scans are also used to access the extent of soft tissue damage.
High ankle sprains are graded Level 1 – 3. A Level 1 high ankle sprain is considered a stable injury and requires 5-6 weeks of conservative therapy before returning to participation. A level 2 and level 3 sprain are determined based on the amount of laxity in the ankle joint. This is usually related to the amount of damage to the interosseous membrane. A partial tear causes mild instability and a Level 2 Sprain and a complete disruption of this membrane or a fracture of one or both lower leg bones is a Level 3. A Level 2 high ankle sprain generally takes 8-12 weeks to completely heal and allow a return to participation. Persistent pain or swelling after the initial rehabilitative period may require more aggressive treatment. A level 3 High Ankle Sprain usually requires surgery to stabilize the bones of the lower extremity and allow the interosseous membrane to heal. A level 3 injury can take 6-12 months to completely heal and is usually season ending when it occurs.
Treatment of High Ankle Sprains starts out with no weight bearing and the use of a non-walking boot to prevent further injury. NSAIDS, ice and elevation are used for inflammation. Passive ROM exercises which consist of assisted movement of the ankle by a therapist to prevent decreased range of motion. Once the inflammation has resolved and stability has been restored, the athlete can begin weight bearing and working with physical therapists toward passing the hop test. This is used to access the healing and stability of the ankle and being able to hop on the affected 15 times without pain or swelling is the standard established before an athlete can return to the practice field. Once the athlete returns to practice, 2-4 additional weeks to continue to rehab the injury and also regain movements specific to their position will be needed before the athlete can resume playing.
Reinjury and/or further injury occur when a person suffering from a high ankle sprain tries to resume previous activity before the initial injury is completely healed. Additional injuries such as ankle dislocation, achilles tendon tears and Knee disruptive injuries including ACL/ PCL and Meniscus tears have all been reported in athletes who were returned to active participation before complete resolution of the initial injury.
In part 1 of this series I compared the common ankle sprain to a flat tire on a car. Using the car analogy again, a High Ankle Sprain is like a broken shock (level 1) or broken axle (level 2) or both occurring on the same wheel (Level 3). Just as most drivers know axle and shock problems take longer to repair and are more expensive to fix than a simple flat tire, the high ankle sprain requires prolonged rehabilitation and extensive time to heal.
Hopefully, this explanation of ankle sprains will help everyone be more understanding of what is meant when an athlete is reported to have sustained an ankle injury and be more tolerant of the recovery time associated with the type of injury diagnosed. All fans want to see their favorite players on the field but trying to rush them back to the field following an injury could result in them never returning to the field. Patience is a virtue and is also a necessity sometimes when dealing with sports injuries.
***editor note: Paxton Lynch suffered this injury in November and played a month later; however, he was seen in February sporting tape along his shin. Conclusion is he was rushed back before minimum guidelines. I’d guess a common occurrence in the NFL.