High Ankle Sprain

The high ankle ligaments are located above the ankle, as opposed to the more commonly injured ligaments on the outside of the ankle.  High-ankle sprains are entirely different from their low-ankle counterpart and closer look at the anatomy of the ankle makes it clear why.


What Is an Ankle Sprain?

A sprained ankle is an injury to one or more ligaments in the ankle, usually on the outside of the ankle. Ligaments are bands of tissue that connect one bone to another and bind the joints together. In the ankle joint, ligaments provide stability by limiting side-to-side movement.  Unfortunately, similar to a rubber band, ligaments can overstretch or tear—called a sprain.

The severity of a sprained ankle depends on whether the ligament is stretched, partially torn, or completely torn, as well as on the number of ligaments involved. Physicians generally classify a sprained ankle based on their severity as a grade one, two, or three.

Because your ankle supports the weight of your entire body, all positions on the football field from the kicker to the wide receiver, are vulnerable to ankle injuries. Positions that require more dynamic mobility and cutting activities, such as a wide receiver, are going to sustain higher rates of injury, versus a kicker, who performs in a limited role.


ankle sprain grade of injuryGrade 1 sprain: 

Some stretching or perhaps minor tearing of the lateral ankle ligaments.
Little or no joint instability.
Mild pain.
There may be mild swelling around the bone on the outside of the ankle.
Some joint stiffness or difficulty walking or running.


Grade 2 sprain: 

Moderate tearing of the ligament fibers.
Some instability of the joint.
Moderate to severe pain and difficulty walking.
Swelling and stiffness in the ankle joint.
Minor bruising may be evident.


Grade 3 sprain: 

Total rupture of a ligament Gross instability of the joint.
Severe pain initially followed later by no pain.
Severe swelling.
Usually extensive bruising.

Other signs of a more extensive injury include tenderness along the bone, either on the inside or outside, as well as swelling and bruising along the inside of the ankle.


What’s the Difference Between a Low-Ankle Sprain and a High-Ankle Sprain?

A high ankle sprain, also known as a syndesmotic ankle sprain, is a sprain of the syndesmotic ligaments that connect the tibia and fibula on the lower leg. Syndesmotic ankle sprains are known as high because their location on the lower leg is above the ankle. Unlike common ankle sprains when ligaments around the ankle are torn or receive injury through an inward twisting, high ankle sprains are caused when the lower leg and foot twist out. The biggest difference between the two injuries is that whereas athletes can predictably return to sport in 4-6 weeks after a standard sprained ankle, it can take much longer to return after high ankle sprains-as long as 6 months.. Additionally, in cases of unstable high ankle sprains, surgery is usually needed. In order to rule out a high ankle sprain and/or an associated fracture your physician may order a series of tests including an xray, CT scan, or MRI. 


How Does an Athlete Suffer Each Type of Ankle Sprain?

As mentioned, sprains occur when a hit or fall forcefully overstretches or tears a ligament.  In the case of the low-ankle sprain, one classic injury cause is the rolled ankle.  When an athlete rolls his or her ankle, the lower leg moves over the outside of the foot, stretching the ligaments that connect the outside portion of the lower leg to the heel.

Conversely, high-ankle sprains occur when the tibia and fibula move about one another, extending the ligaments that connect them. This occurs when the lower leg sharply rotates outward.

In football, high-ankle sprains can occur when, for example, a wide receiver lands on his toes on one side and collapses toward the opposite, forcing his toes to turn outward.


High-Ankle Sprains, A Longer Recovery Time

Unlike low-ankle sprains, high-ankle sprains can compromise the very integrity of the lower leg.  Since they stabilize the tibia and fibula, healthy syndesmotic ligaments are crucial to safely bear weight. Without them, the tibia and fibula could rotate about each other, collapse and fracture.

In the worst-case scenario, a complete rupture of one or moresyndesmotic ligaments could result in an unstable lower leg, necessitating surgery to restore function and fix the bones in place.

Fortunately, most low-grade high-ankle sprains will heal on their own. But for that to happen, an athlete must allow them to rest.  That said, resting syndesmotic ligaments is much more difficult than it sounds.  While a walking boot can help with a low-ankle sprain by preventing the application of inversion stress on the healing ligament, there are fewer options for a high-ankle sprain.

Unless an athlete assumes an entirely non-weight-bearing status—crutches or a wheelchair, for example—healing syndesmotic ligaments will continue to receive their share of mechanical burden whenever the athlete bears weight.


Treatment and Recovery

Low Ankle Sprain: Generally a low ankle sprain for an NFL athlete will take anywhere from a few days to 4 weeks to return to play. The lower the grade of the sprain, the quicker the recovery. Physical therapy or working with a trainer in the training room is the main course of treatment. The focus is to eliminate the swelling and pain, and restore stability and functional strength. With a mild ankle sprain, you can be back to play within a week, usually taped up and spatted (tape around the outside of the cleat for stability). Higher grade sprains may take up to four weeks, due to pain and instability. A player’s position will also affect time frame for return to play. A lineman, who performs within a relatively small area, will have an easier time returning than a wide receiver, who has to sprint, cut, and change directions. Moving in forward or backward motions, puts much less stress on these ligament than do lateral or rotational movements.

High Ankle Sprain: A high ankle sprain is more sever, and can take anywhere from 3- 6 weeks to recover, for a professional football player. The average time for an NFL athlete to return is 4 weeks, but again, the player’s position will play a part in his time frame for return to play. As soon as a player can tolerate rotational stresses about his lower leg, he will attempt a return to play.


Grade 1 – Mild

In mild cases, you can expect full ligament healing at approximately 6 weeks, but it may take longer to prepare you for functional sport again.  If not adequately treated these often cause your ankle and foot joints to compensate movement at adjacent joints, which can lead to several other injuries months or years down the track.


Grade 2 – Moderate

Grade 2 injuries occur when you have a significant ligament injury that allows the ligament to excessively stretch. In most cases these injuries result in a recovery period of 6 to 12 weeks. With increasing injury severity, the rehabilitation process becomes more complex and extensive.


Grade 3 – Severe

Grade 3 ligament injuries are when the ligament is completely ruptured. More severe high ankle sprain injuries can also include fractures of the bones or high ankle sprains, which will require additional rehabilitation time to a simple ankle sprain.

If the injury is unstable, then a “syndesmotic screw” can be placed between the tibia and fibula to hold the bones in proper position while the syndesmotic ligament heals.

Patients will have the screw in place for about 3 months while the syndesmotic ligament heals.

The rehabilitation of a Grade 3 ankle sprain normally takes 3 to 6 months, but is quite variable depending on your specific injury. Your physiotherapist or surgeon will be able to provide you with more specific guidelines and advice.











Graph from Questionable To Start


For more detailed information on High Ankle Sprains visit SportsMD.com



McKeon PO, Mattacola CG. Interventions for the prevention of first time and recurrent ankle sprains. Clin Sports Med 2008. 27(3): 371-382.

Jelinek JA, Porter DA. Management of unstable ankle fractures and syndesmosis injuries in athletes 2009. 14(2) 277-298.

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