A high ankle sprain affects the group of ligaments connecting the two lower leg bones, the tibia and the fibula. This injury is distinct from the more common lateral ankle sprain and is often more severe, requiring a longer recovery period. Treatment decisions depend heavily on the severity of the ligament damage and the mechanical stability of the ankle joint. Not all high ankle sprains require surgery; the need for intervention is determined by a careful assessment of the injury’s extent.
Defining the High Ankle Sprain and Severity Assessment
A high ankle sprain targets the syndesmosis, a fibrous joint held together by strong ligaments. This structure maintains the stable relationship between the tibia and fibula, forming a socket for the talus (ankle bone). Unlike a common ankle sprain, a syndesmotic injury typically occurs with a forceful external rotation and upward bending (dorsiflexion) of the foot, often seen in contact sports. This mechanism forces the tibia and fibula apart, stressing or tearing the ligaments.
Medical professionals classify the severity of a high ankle sprain using a grading system, with Grade 1 being the least severe and Grade 3 the most. Grade 1 and 2 injuries involve a stretch or partial tear of the ligaments. A Grade 3 injury involves a complete disruption of the ligaments. The most important factor guiding treatment is the mechanical stability of the joint, which is tested clinically and with specialized imaging.
Stable injuries mean the tibia and fibula do not separate significantly when stress is applied, allowing for non-surgical treatment. Conversely, an unstable injury, often a Grade 3 sprain, indicates a complete ligament tear and a noticeable widening of the space between the bones. This instability compromises the ankle’s ability to bear weight and maintain proper alignment, making it the primary indicator for surgical intervention.
Non-Surgical Treatment Protocols
The majority of high ankle sprains are successfully managed without surgery, focusing on protection, rest, and a structured rehabilitation plan. Initial management follows the RICE protocol—Rest, Ice, Compression, and Elevation—to control pain and swelling. Non-steroidal anti-inflammatory drugs (NSAIDs) may also be used to improve pain control and decrease swelling.
A significant difference from common ankle sprains is the extended period of non-weight-bearing or limited weight-bearing required for the ligaments to heal. Patients are typically placed in a protective boot or cast and may need to use crutches for four to six weeks. Prematurely putting weight on the ankle risks re-injury and chronic instability, so a gradual return to weight-bearing is carefully managed.
Following the immobilization phase, physical therapy begins, focusing on restoring range of motion, increasing strength, and improving proprioception. Range of motion exercises help regain flexibility, particularly in dorsiflexion. Strengthening exercises target muscles around the ankle and leg. Proprioception training involves balance and coordination exercises important for preventing future injuries.
The overall recovery time for a stable high ankle sprain can range from six to eight weeks. This is considerably longer than recovery from a typical ankle sprain.
When Surgical Intervention Becomes Necessary
Surgery is reserved for high ankle sprains where mechanical instability exists. This instability is usually confirmed through imaging like X-rays or CT scans, often performed while the ankle is stressed. An unstable syndesmosis will not heal properly on its own, leading to chronic ankle instability, pain, and potentially early-onset arthritis if left untreated.
The goal of surgical intervention is to reduce the space between the tibia and fibula and hold them securely in position to allow the torn ligaments to heal. Two common techniques are used for stabilization: syndesmotic screw fixation or the use of a suture button device. Screw fixation involves placing a metal screw across the two bones, which provides rigid stabilization but often requires a second surgery later to remove the hardware.
The suture button technique involves connecting the two bones with a strong, flexible suture between two small buttons. This method has gained popularity because it offers dynamic stabilization and may allow for an earlier start to rehabilitation.
Following surgery, the patient is typically placed in a non-weight-bearing cast or boot for six to eight weeks. The total recovery time for a surgically treated high ankle sprain is substantially longer, often taking three to six months or even up to a year for a full return to high-level activity.