A high ankle sprain is an injury to the ligaments that connect your two lower leg bones (the tibia and fibula) just above the ankle joint. Unlike a common ankle sprain, which happens when you roll your foot inward, a high ankle sprain involves a different set of ligaments and typically takes much longer to heal. These injuries account for about 12% of all ankle sprains in young athletes and are especially common in sports like basketball and football.
How It Differs From a Regular Ankle Sprain
A regular (lateral) ankle sprain damages the ligaments on the outside of your ankle, usually after the foot rolls inward. A high ankle sprain damages the ligaments higher up, between your shinbone and the smaller bone that runs alongside it. The two injuries feel different, look different, and heal on very different timelines.
One of the most deceptive things about a high ankle sprain is that it often doesn’t look that bad. A regular sprain typically produces visible swelling and bruising that can spread down into the foot. A high ankle sprain, by contrast, causes relatively little swelling or bruising. This frustrates athletes and coaches because the injury appears minor even though it’s often more serious and debilitating than a standard sprain.
The pain pattern is also distinct. With a high ankle sprain, pain radiates upward from the ankle into the lower leg rather than concentrating around the ankle bone. It’s typically worse when you put weight on the foot or try to pivot, push off, or rotate. Walking may feel unstable or deeply painful in a way that doesn’t match what you see on the surface.
The Ligaments Involved
Three ligaments make up the syndesmosis complex that holds your tibia and fibula together at the ankle. The first runs across the front of the ankle, connecting the two bones at the front. The second mirrors it at the back. The third sits between them, filling the space and providing stability through the middle. Together, these ligaments allow a small amount of natural rotation between the two bones while keeping them tightly aligned.
When one or more of these ligaments tears, the two bones can spread apart slightly. Even a small amount of widening changes how weight transfers through the ankle joint, which is why the injury causes so much pain with every step.
How These Injuries Happen
The classic mechanism is having your foot planted and twisted outward while your lower leg stays fixed. This external rotation forces the wider front part of the ankle bone (the talus) into the joint socket, pushing the tibia and fibula apart. The injury can also happen when something strikes the outside of the knee while your foot is planted and flexed upward, creating the same spreading force through the ankle.
This is why high ankle sprains are so common in contact sports. A tackle that catches the lower leg while the foot is stuck in turf, or a hard pivot where the body rotates over a planted foot, creates exactly the kind of rotational force these ligaments can’t withstand.
How It’s Diagnosed
Two simple physical tests help identify a high ankle sprain. In the first, a clinician holds your leg still and gently rotates your foot outward. Pain above the ankle during this movement points toward syndesmotic damage. In the second, called the squeeze test, the clinician compresses your tibia and fibula together at mid-calf level. If this produces pain down near the ankle, it suggests the ligaments connecting those bones are injured.
X-rays can confirm whether the two bones have separated. Doctors look at the gap between the tibia and fibula on imaging. A clear space greater than about 6 millimeters, or overlap between the bones measuring less than about 3 millimeters, suggests the syndesmosis has been disrupted. MRI is sometimes used for a more detailed look at the ligaments themselves, particularly when the X-ray appears normal but the physical exam is suspicious.
Recovery Takes Longer Than You’d Expect
This is the part that catches most people off guard. A mild lateral ankle sprain can heal in one to three weeks. A moderate one takes three to six weeks. A high ankle sprain, even one that doesn’t require surgery, often takes several months before you’re fully back to activity. The ligaments between the tibia and fibula experience constant stress with every step, which slows healing significantly compared to the ligaments on the outer ankle.
Early treatment focuses on protecting the joint, reducing swelling, and avoiding movements that stress the syndesmosis (particularly rotation and pushing off). You’ll likely spend time in a walking boot or on crutches. Physical therapy becomes important once the initial pain settles, rebuilding strength and stability before returning to sport or intense activity. Rushing back is one of the most common mistakes, since the injury can feel deceptively manageable while the ligaments are still compromised.
When Surgery Is Needed
If the tibia and fibula have separated enough that the joint is unstable, surgery may be necessary to hold the bones in proper alignment while the ligaments heal. Left untreated, this instability changes how weight moves through the ankle and can lead to early joint degeneration.
The traditional approach uses a screw placed across the two bones to hold them rigidly together. This works well, with success rates around 88%, but the screw sometimes needs to be removed in a second procedure and can limit motion during the healing period. A newer technique uses a flexible suture-button system that holds the bones together while still allowing some natural movement. This approach lets patients bear weight sooner and start rehabilitation earlier, though it carries its own risks, including the button becoming prominent under the skin or the fixation loosening.
Your surgeon’s recommendation depends on the severity of the separation, whether other structures (like the ankle fracture or deltoid ligament) are also damaged, and your activity goals. Both methods aim to restore the normal alignment between the tibia and fibula so the ankle joint can function without accelerated wear.