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Twisted your ankle in football? Four stages of rehabilitation for the high ankle sprain

Updated: Jul 8, 2023


What is it?


A syndesmotic or ‘high’ ankle sprain involves injury to the ligaments surrounding the contact point of the tibia (shin bone) and fibula (smaller bone on the outside of the lower leg). This contact point is called the Distal Tibiofibular joint, the collective ligament structures that are damaged are called the Distal Tibiofibular Syndesmosis. The damaged ligaments may include some or all of:

  • anterior inferior tibiofibular ligament

  • posterior inferior tibiofibular ligament

  • interosseous membrane

  • transverse tibiofibular ligament

  • interosseous ligament

  • inferior transverse ligament

It’s called a ‘high’ ankle sprain because the pain is usually felt above the ankle. High ankle sprains typically occur when your foot is planted on the ground and the foot turns excessively outwards. High ankle ligaments can also be sprained when your ankle is loaded severely and pushed into excessive dorsiflexion (toes and foot lifting towards head). This often occurs in football tackles. These ankle sprains can also commonly present with fractures of the bottom tips of the tibia or fibula bones, fibula fracture being more common.


High ankle sprains account for up to 11% of all sports injuries, whereby they account for 7% of all ankle sprains. Out of all the high ankle injuries, 70-80% are contact-related. In football/soccer, there is an evident annual increase in the occurrence of high ankle sprains.



High ankle sprains most commonly occur following traumatic injuries. The most common symptoms are as follows:

  • pain felt above the ankle

    • increases when foot is turned outwards

  • pain upon palpation of the higher ankle ligaments

  • pain with walking

  • significant bruising and swelling across the higher ankle

  • difficulty or inability to walk on toes


Your severity of symptoms will depend on the grade of ankle sprain: mild, moderate or severe. Athletes with a high ankle sprain without fracture may be able to weight-bear, but will have pain over the junction between the tibia and fibula – just above the level of the ankle, which is located higher than the typical ankle sprain.


To be diagnosed, your physiotherapist and/or doctor will clinically assess the ligament’s integrity. Imaging such as X-rays, MRI, etc. may be used to diagnose a syndesmosis injury with certainty.


Let’s guide you through how we treat high ankle sprains using our Roadmap to Recovery:

  • Step 1. Pain Reduction

  • Step 2. Activation

  • Step 3. Movement

  • Step 4: Strengthening / Sports Performance


Pain Reduction


For this stage, let’s follow the PEACE and LOVE principle.


Retrieved from: https://www.apemedical.com.au/initial-treatment-response/


If you are unable to weight-bear, it is highly recommended that you hire or purchase a pair of crutches from a physiotherapist or chemist. It is likely that your physiotherapist will put you in a moon boot for about 2-3 weeks to prevent excessive movements of the ankle and thus further injury, before starting to rehab. However, it is still important to take off the boot and gently move your ankle as often as you can to stimulate further blood flow and therefore more healing!


Furthermore, do no HARM!


Retrieved from: https://www.apemedical.com.au/initial-treatment-response/



There is strong evidence around the risk factors that may pre-determine a high ankle sprain such as:

  • previous ankle injuries

  • reduced ankle muscle strength

  • high BMI

  • higher level of competition

Therefore, it is crucial to address some of these risk factors in your rehabilitation to facilitate injury prevention. Once your ankle has recovered most of its strength and range of motion, it is important that you optimally train and condition your ankle


Activation


Your ankle has now hopefully healed and reduced in pain, let’s start to work on regaining your range of motion and strength. We will work on progressive loading to make your ankle stronger and stronger to the point where you can start to do more sport-specific training! The key to succeeding is to be patient and diligent with your rehab process.


After coming out of the moon boot, it is highly likely that the ankle muscles on your affected side have shrunk and become weak. You will notice that your shins and calves are quite thin. The activation phase will be to introduce the ankle muscles to load again. This phase is essential to provide you with a foundation for getting back to sport. Some common activation exercises for the ankle are as below:

  • Banded Plantarflexion: As calf raises may be too difficult initially, these are a great start to gradually load the ankle for this movement and build your calf muscles again. This movement is essential for walking to be able to propel yourself forward.


  • Banded Dorsiflexion: This exercise will recover your shin muscles and help you regain strength and range of motion. This movement is essential for walking to be able to strike your heel when stepping forward.


  • Banded Inversion: This muscle group is crucial for side-to-side ankle stability. Having strong ankle inverters are very useful for balancing and adapting to various surfaces when walking.


  • Banded Eversion: As above for inverters.


These four movements are essential when it comes to ankle sprain rehab as they are so simple yet effective in activating all major muscles around the ankle.


Videos of these exercises:



Movement


This stage is about incorporating what we’ve been working on so far into larger movements. Your ankle is the foundational support for everything above it – your knees, hips, and lower back. Therefore, building a strong ankle and then incorporating it with other joints is crucial. Compound movements are the best way of building strong, stable ankles to support your body weight and adapt to various types of surfaces, movements, etc. Some awesome yet difficult movement exercises to try are:

  • Single Leg Squat Catch (Unstable surface): This movement is excellent in building not only strong ankles but amazing neuromuscular control in the hip, knee and ankles. This exercise is great to use to transition to return to sport training. If this is too difficult, try it on flat ground.


  • Lateral Banded Bounding: This exercise is perfect for loading the ankle in the side-to-side plane. The band creates resistance to the movement, requiring you to work even harder on core stabilization and single-leg balance!


  • Banded Single Leg Anti-Rotation: This exercise is fantastic at challenging your ankle and foot from rotating outwards and rolling out, which is the most common mechanism of injury. Also, the resistance band challenges the core. This enhances proximal stability which promotes distal mobility!


Videos of these exercises:




Strengthening/ Sports Performance


The final stage is very important to improve your ability to participate in a higher-level competition. For syndesmosis injuries in football, it is important to include training that involves cutting, change of direction, dribbling, etc. Strength and conditioning should be ongoing when playing sports to limit the potential risk of further injuries.


It is recommended that you see a physiotherapist to provide you with a sports-specific training and strengthening program as well as a return to sport criteria, to provide you the best chance to get back on the field as soon as possible!



References

Lin, C.-F., Gross, M. L., & Weinhold, P. (2006). Ankle syndesmosis injuries: anatomy, biomechanics, mechanism of injury, and clinical guidelines for diagnosis and intervention. The Journal of orthopaedic and sports physical therapy, 36(6), 372-384. https://doi.org/10.2519/jospt.2006.2195

Lubberts, B., D'Hooghe, P., Bengtsson, H., DiGiovanni, C. W., Calder, J., & Ekstrand, J. (2019). Epidemiology and return to play following isolated syndesmotic injuries of the ankle: a prospective cohort study of 3677 male professional footballers in the UEFA Elite Club Injury Study. British journal of sports medicine, 53(15), 959–964. https://doi.org/10.1136/bjsports-2017-097710

Waterman, B. R., Belmont Jr, P. J., Cameron, K. L., Svoboda, S. J., & Owens, B. D. (2011). Risk factors for syndesmotic and medial ankle sprain: role of sex, sport, and level of competition. The American journal of sports medicine, 39(5), 992-998. https://doi.org/10.1177/0363546510391462














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