Ankle sprains are by far the most common injury in high school sports.

In fall high school sports, ankle sprains are the most common volleyball injury and the third most common football injury. However, researchers agree that there is no such thing as a “simple” ankle sprain. Serious injuries can occur when you sprain your ankle including: cartilage damage to the inside bone of the ankle (talus bone); peroneal tendon injury, peroneal nerve injury, and fractures.

Sprains of the lateral ligaments (on the outside of the ankle) are the most common injury in high school sports. Sprains to the ankle ligaments that hold the lower leg bones together (tibia and fibula bones) comprise about 10-15 percent of all high school ankle sprains, but are more disabling, requiring a longer period of recovery to return to sports. These sprains are called “high ankle sprains” because of their location above where the common ligament sprains occur.

The high ankle sprain can be frequently misdiagnosed, thus it may seem to be an enigma to coaches, parents, and athletes.

Anatomy: The tissues that hold the lower leg together are called the Anterior-Inferior (front of the ankle) and Posterior-Inferior (back of the ankle) Tibio-Fibular ligaments, and the interosseous membrane in between the bones. Injury to these ligaments is the definition of a high ankle sprain.

Mechanism of Injury: Lateral ankle sprains usually involve a rolling over of the ankle while the ankle is plantarflexed (pointing downward). In a high ankle sprain, the athlete usually has the ankle slightly dorsiflexed (pulled upward) while in a bent knee position, and the foot turns outward while the leg turns inward. This type of mechanism of injury is most likely to occur in high school football and soccer than other high school sports.

Diagnosis: Athletes can exhibit minimal swelling from a high ankle sprain, and when present it is more on the front of the ankle (versus the lateral ankle sprain, in which swelling is on the outside of the ankle). Tenderness to touch will be located on the front (and back) of the ankle more than the lateral side. If more severe damage is present, then there may be diffuse tenderness due to other ligament involvement or fractures present. Radiographs (x-rays) are advised if a fracture is suspected.

Severity of Injury: High ankle sprains can be classified as follows:

First degree - Only a few ligament fibres are damaged within the interosseous membrane. There is minimal swelling present and no difficulty walking. Time to recovery: Approx. 3 weeks.

Second degree - Refers to more extensive damage to the interosseous membrane with some widening of the Tibio-Fibula joint (ankle). Moderate swelling usually present and the athlete will have difficulty walking. Time to recovery: Approx. 4-8 weeks.

Third degree - Refers to a complete rupture of the interosseous ligament with gross widening of the Tibio-Fibula joint and possible joint dislocation. The deltoid ligament (on the medial side of the ankle) may be injured, too. Severe swelling is present along with severe disability (athlete unable to walk without crutches). Time to recovery: Approx. 8-12 weeks or more, if surgery is required.

Treatment: Early treatment requires some form of immobilization to allow healing of the ankle ligaments to occur. This may be an ankle brace or boot, depending on severity of the injury. Crutches are advisable to unload the joint and allow healing to occur. Reducing swelling and gradual restoration of the range of motion of the ankle is imperative to allow progression to functional exercise. Restoring functional balance, proprioception, and kinesthetic sense is paramount to moving to the next stage. Sport specific exercise is the final stage of treatment, preparing the athlete to be able to return to practice and then return to play safely.

Taping and Bracing: Current research reveals more scientific information about ankle sprains and the use of taping or bracing with athletes in high school sports. For every 1,000 games of participation in high school sports, the rate of ankle sprain of athletes not using tape or braces is approximately 33 percent; for athletes using tape only, the rate of ankle sprain is 5 percent; and the rate for athletes using bracing only is 2.5 percent.

Surgery: Aggressive treatment for the third degree high ankle sprain is surgical fixation using 1-2 screws to bring the lower leg bones back together. This usually takes six weeks of protected weight-bearing and up to six weeks of weight-bearing. Commonly, the screws are then removed later to prevent breakage with the high physical demands of sports.

The high ankle sprain is not easily recognized by medical professionals who are not familiar with sports medicine and athletic injuries, and is often misdiagnosed. Research reveals that 25 percent of high school athletes who sprain their ankles will suffer a re-injury within a year if not properly treated. Up to 50 percent of these athletes will go on to have chronic ankle instability, which will predispose the athlete to degenerative arthritis in their ankle later in life.

Your athletic trainer at high school will refer you to a sports medicine physician who can diagnose your high ankle sprain. Treatment by your trainer and a sports medicine physical therapist will put you on the right path to recovery. Proper healing and functional restoration of balance will promote early return to play and act as an insurance policy against developing chronic instability. Research clearly supports ankle bracing as a good prevention tool.

To find out more about general care of ankle sprains, please refer to my article in MSR on May 1st, 2011: Grading the sprains, soccer’s common injury. To find out more about high ankle sprains, visit these websites:

http://www.wheelessonline.com/ortho/syndesmotic_sprain
http://www.orthogate.org/patient-education/ankle/ankle-syndesmosis-injuries.html
http://www.thesportsphysiotherapist.com/ankle-syndesmosis-injuries-evidence-based-diagnosis-and-management/

(About the Author: John Tomberlin has worked with high school athletes in the Cedar Rapids Metro area since 1995. He was a four-sport athlete in high school and a high school coach for two years in Illinois. John has more than 25 years of experience working with athletes as a physical therapist and a certified strength and conditioning specialist. He has worked with professional athletes in the NFL, MLB, and on the PGA and LPGA tours. John also has worked with elite amateur athletes in alpine skiing, figure skating, and track and field.)