What is a high ankle sprain?
Most ankle sprains happen when you roll your ankle and injure the ligaments on the outside of the joint. A high ankle sprain is different. It’s an injury to the inferior tibiofibular syndesmosis: a group of ligaments, just above the ankle, that holds your two shin bones (the tibia and fibula) together.
The key structures include:
- the anterior inferior tibiofibular ligament (AITFL), at the front
- the interosseous membrane, between the two bones
- the posterior inferior tibiofibular ligament (PITFL), at the back
Why it matters
High ankle sprains account for roughly 18% of all ankle injuries in athletes, and up to 25% in contact sports.
They also typically take much longer to recover from than a lateral (outer) ankle sprain. The average recovery time is 39 days, compared with 15 days, which means athletes miss 2 to 3 times more playing time.
How does it happen?
A high ankle sprain typically happens when the foot is planted on the ground and forced into a combination of three movements:
- external rotation: the foot twisting outwards
- dorsiflexion: the foot bending up towards the shin
- pronation: the foot rolling inwards
This forceful movement causes the syndesmosis joint to widen, placing extreme loads on the ligaments that stabilise it. In higher-grade injuries, the damage can extend to a tear of the deltoid ligament (on the inside of the ankle) or associated fractures of the fibula.
Approximately 73% of these injuries happen during contact or tackling, such as in football or AFL.
Signs to look for
Because the injury sits higher than a typical sprain, the signs are a little different:
- swelling above the ankle
- pain above the ankle joint, rather than on the outside
- pain when the foot bends up and twists outwards (dorsiflexion and external rotation)
If you’ve hurt your ankle in a tackle or with your foot planted and this sounds familiar, get it assessed early.
How it's assessed and graded
Early assessment and grading are essential for the right management and long-term ankle health.
Clinical tests. Your clinician will use specific physical tests, such as the Dorsiflexion-External Rotation Stress Test, Fibular Translation and the Squeeze Test.
Imaging. Weight-bearing X-rays check for widening between the bones (diastasis). MRI is the gold standard for assessing whether the ligaments are intact.
Grading. Injuries are graded using the West Point System:
|
Grade
|
What's injured
|
Joint Stability
|
|---|---|---|
|
I
|
Mild sprain or partial tear of the AITFL
|
Stable
|
|
II
|
AITFL and interosseous ligament
|
Borderline (IIa, managed as stable) or unstable (IIb)
|
|
III
|
Complete disruption of all major syndesmotic ligaments
|
Unstable ankle mortise (the socket the shin bones form around the ankle), requiring careful evaluation
|
Treatment: stability decides the path
Management depends heavily on whether the joint is stable.
Stable injuries (Grades I–IIa)
These are usually managed conservatively. That typically means a brief period of immobilisation or protection in a walking boot, often with partial weight-bearing. This is followed by progressive range-of-motion, strength and balance training.
Unstable injuries (Grades IIb–III)
Unstable syndesmoses or complete disruptions often require surgical stabilisation, such as dynamic suture-button (tightrope) fixation or screw fixation. Surgery restores the anatomical alignment of the joint and helps prevent long-term joint degeneration. It’s generally followed by targeted rehabilitation.
Getting back to sport
Rehab progression is strict and criterion-based, rather than just timeline-based. Before moving to the next stage, you’ll need to show:
- pain-free loading
- single-leg hop competency
- functional stability
After surgery, elite athletes frequently return to play within 8 to 12 weeks, depending on the fixation method and injury grade.
The bottom line
- High ankle sprains need careful assessment and management, because they can mean a prolonged recovery and long-term ankle instability.
- Identifying the severity of the injury early, and most importantly whether the syndesmosis is stable, guides the right treatment, including whether surgery is required.
- A progressive, criterion-based rehab program restores strength, mobility and function. Return to sport is decided by objective performance measures, not time alone.
Hurt your ankle?
If you’ve injured your ankle and the pain sits above the joint, book in with our team at Restore Function Physiotherapy in Greenslopes. As the official physio partner of Football Queensland, we can assess and grade your injury and guide your rehab all the way back to sport.
Book online at restorefunction.com.au or call (07) 3148 4417.