A high ankle sprain, known medically as a syndesmotic sprain, involves damage to the robust group of ligaments situated above the ankle joint. These ligaments, collectively called the syndesmosis, connect the two lower leg bones, the tibia and the fibula. Because the syndesmosis is responsible for maintaining the stability of the entire ankle mortise, its injury can destabilize the lower leg and typically necessitates a much longer recovery period. A structured and cautious rehabilitation program is therefore paramount for ensuring the ligaments heal properly and the ankle regains its full functionality.
Immediate Care and Injury Stabilization
The initial management following a high ankle sprain focuses on reducing inflammation and protecting the compromised syndesmotic ligaments from undue stress. Immediately applying the RICE protocol—Rest, Ice, Compression, and Elevation—is the standard first step in the acute phase of recovery. Rest usually means adhering to a strict non-weight bearing (NWB) status, often requiring crutches for mobility.
Applying ice for 15 to 20 minutes several times a day helps manage initial swelling, while compression with an elastic bandage or specialized boot controls edema. The ankle should be elevated above the level of the heart as frequently as possible to allow gravity to assist in reducing fluid accumulation. Immobilization with a protective boot or brace is often used to prevent the tibia and fibula from spreading apart, a movement that puts high stress on the healing ligaments.
Restoring Range of Motion and Early Strength
Once the initial pain and swelling have subsided, typically within the first few days, the rehabilitation process transitions to gentle movement to prevent long-term stiffness. The goal of this early phase is to encourage fluid exchange and maintain range of motion without placing harmful load or torque on the high ankle ligaments. Exercises are performed in a non-weight bearing position, often with the leg elevated to assist with swelling reduction.
Simple ankle pumps, involving pointing the foot up (dorsiflexion) and down (plantarflexion), are foundational for improving circulation and restoring movement. Performing the “ankle alphabet”—tracing the letters with the toes—gently moves the joint through all possible planes of motion. As tolerance improves, light resistance can be introduced using an elastic band for movements like plantarflexion and inversion. These movements must be performed slowly, avoiding excessive external rotation or forceful dorsiflexion, as these directly stress the syndesmotic ligaments.
Progressive Weight Bearing and Functional Training
The middle phase of rehabilitation begins with a gradual reintroduction of weight bearing, initiated only once medically cleared and guided by pain tolerance. This progression starts with partial weight bearing, using crutches or a boot to control the amount of force placed on the ankle. Exercises like standing weight shifts, where the body’s weight is slowly transferred onto the injured foot while holding onto a stable support, help the body re-acclimate to accepting load.
As full weight bearing is achieved without pain, the focus shifts to building functional strength, endurance, and proprioception, which is the body’s sense of joint position. Resistance training progresses to include double-leg calf raises, strengthening the calf muscles important for walking and running. Balance training is introduced through exercises like a single-leg stance, initially performed on a stable surface and later advanced by closing the eyes or standing on an unstable surface, such as a foam pad. Functional training includes controlled movements like “clock reaches,” where the individual stands on the injured leg and taps the ground at various points to improve dynamic stability.
Determining Readiness for Full Activity
The final phase of rehabilitation centers on ensuring the ankle is fully prepared to withstand the demands of sport or strenuous activity. Return to activity must be based on objective criteria rather than simply the absence of pain. A full, pain-free range of motion must be recovered, particularly in dorsiflexion, which is necessary for proper landing mechanics and movement.
Strength testing is a significant component, often requiring the injured ankle to demonstrate at least 90% strength symmetry compared to the uninjured side across all key movements. Functional assessment progresses to include advanced drills, such as single-leg hop tests and agility maneuvers like figure-eights or lateral shuffles. A gradual return to activity is recommended, starting with light, sport-specific movements and slowly increasing intensity and duration. For long-term prevention, the use of a supportive ankle brace or taping may be advised during high-risk activities.