What is a HIGH Ankle Sprain?

We are glued to the TV watching the big game and there goes a key player. Out with a High Ankle Sprain!!! So….what is a high ankle sprain? Can you have a low ankle sprain? The Vikings have been struggling, and now that Adrian Peterson, their star running back, has a high ankle sprain, do they even have a chance? The answer is no, but Peterson will be just fine and back in the game soon.

A high ankle sprain is a tear in the syndesmotic ligament. This ligament lies between the tibia and fibula and connects the bones throughout the lower leg. A typical ankle sprain involves the ligaments that surround the ankle joint. As the name suggest, the Syndesmosis is above the ankle joint and thus a tear in this ligament is called a “high ankle sprain.” Syndesmotic tears occur more commonly with an ankle fracture but isolated syndesmotic tears are also reported. The typical mechanism of injury is external rotation of the foot on the tibia and fibula, as seen on the photo below, on the right.



Syndesmosis injuries are more common than classic ankle sprains. They frequently occur in collision sports or those sports that have rigid ankle immobilizing gear such as skiing. Nearly 74% of ankle injuries reported in hockey are syndesmotic sprains. In the general population syndesmotic sprains make up only 10-20% of all ankle sprains. Typically, the athlete will present with a sore sometimes sharp pain over their leg between the tibia and fibula. The pain is worse when bearing weight and often the athlete cannot bear any weight on the extremity. The diagnosis of a syndesmotic tear is not difficult on physical exam but further studies are performed to identify any associated injuries or the extent of the injury. It is standard to take x-rays and to examine for any fractures, typically seen in the fibula or tibia. Often, an MRI is also ordered to identify the extent of the tear. Very rarely, surgery to repair the torn ligament is necessary.

The degree of severity can vary greatly. Due to the high incidence of associated injuries, it is difficult to outline the recovery time. Multiple studies have been done to determine the average recovery time. This can range from as low as 1 week to as high as 6 months. Studies have consistently showed that stage I and II ankle sprains on average have a faster recovery time than a syndesmotic sprain.

If an isolated syndesmotic sprain is identified with no other associated injuries than recovery time is very short. I feel comfortable saying that Peterson will be back on the field with the rest of the Vikings to finish the season. Unfortunately, with or without and injured Peterson, I don’t see them making it to the play offs.

Q&A: The top 7 Questions about Ankle Fractures

Breaking your ankle can be a very devastating injury which can involve significant time off your feet depending on the extent of your injury. The below question and answer format will give you much of the information you need to know about treatment if you or someone you know sustains a broken ankle.

FAQ (Frequently asked questions):

1. What should I do if I think I broke my ankle?
You should be treated immediately. If a local podiatric surgeon is not immediately available in his/her private office, a hospital emergency room is the best place to go. Pain medication will be administered and X-rays will be taken. If a fracture is confirmed and the fracture segments have moved apart significantly, pain medication will be given and a manual (closed) reduction to put the segments closer together will be attempted. If surgery isn’t needed, then an above or below the knee fiberglass cast will be applied and crutches, a walker and/or wheelchair will be given as no weight can be applied to the foot.

2. How do I know if I have a broken bone vs. a bad sprain?
There is no way of knowing whether you sprained your ankle instead of fracturing it without getting an X-ray. Blisters, swelling, pain, bruising and redness with either a fracture or a sprain may be present. Pain directly on the bones of the ankle with direct touch is a clinical test but often times even in a sprain there is pain everywhere even on the bone. X-rays are the only way of knowing for sure if you broke a bone. If you sustained a very intricate fracture, your doctor may also order a CAT scan.

3. Will I need surgery?
If the bones cannot be manually reduced or put back together, than surgery will be performed. This surgery for an ankle fracture is called an open reduction with internal fixation (ORIF).

4. How long does it take to recover?
Bony healing typically takes 6-8 weeks to occur. However depending on your overall health, other factors such as smoking, diabetes, poor nutrition and poor circulation can delay this process.

5. How long will I be in a cast?
Regardless of if you have surgery or not, a cast will be in place for at least 6-8 weeks in order to give the bone enough time to heal
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6. When will I be able to walk normal again?
This depends on the severity of the fracture but typically one will be able to ambulate in a sneaker after 8-10 weeks. Even then, the ankle will still be somewhat swollen.

7. How long will I be out of work?
It depends on the type of work you do. If you have a very accommodating job and can sit most of the time, then you may be able to return as soon as 2-3 weeks after treatment. While at work you need to keep your foot elevated on another chair. You should keep ice applied for 20 minutes every hour when awake. Most people will need to take at least 4-6 weeks off from work, but if you have a job where you need to stand and walk, then you will need to take at least 3-4 months off from work. You may qualify for short-term disability or workman’s compensation (if the injury occurred at work).


SAQ (Should ask questions):
1. What bones are involved in an ankle fracture?
The ankle consists of the end of the tibia bone called the medial malleolus, the end of the fibula bone called the lateral malleolus and the bottom of the ankle called the talus bone.

2. Are certain people prone to breaking their ankle?
Oftentimes, an ankle fracture involves a simple, unintentional slip, fall or accident. Other times it involves a twisted ankle injury from someone who has frequently sprained his or her ankle in the past. These people have chronic ankle instability and have high arches that are unstable on uneven surfaces. This leads them to sprain their ankle a lot and even fracture it if the force of the sprain is high enough.

3. How can I prevent an ankle fracture if I am prone to this?
If you have high arches, have sprained your ankle in the past and feel unstable on uneven surfaces, you need the proper support to prevent not just another sprain but a fractured ankle. Good, sturdy shoes as well as a pair of functional customized orthotics (inserts) to straighten out the foot and offer stability are best to prevent a fracture or sprain.

4. What determines if I need surgery for the ankle break?
If the bony segments of the fracture are shifted enough more than 2mm and closed manual reduction cannot close the gap enough, you will need surgery/ORIF. Also surgical repair of the ligaments may be performed if the ligaments are torn as seen as a wide gap of the bones on X-ray.

5. Will I have long-term pain after the ankle is healed?
Just as in other joints, the ankle joint should be comprised of healthy cartilage that covers the bone to allow for up (dorsiflexion) and down (plantarflexion) motion. A break of the ankle usually involved a break or injury to the cartilage as well. Therefore and theoretically, someone who sustains an injury to the ankle joint (intra-articular fracture) may develop chronic ankle arthritis called osteoarthritis or degenerative joint disease. Arthritis involves cartilage damage where the bones rub together causing inflammation and pain. You might not have severe arthritis, but if the cartilage is slightly damaged you may have persistent but occasional pain and stiffness in cold or rainy weather.

6. Will I need physical therapy?
Yes, most patients whom are in a cast for 6-8 weeks will develop weakness and visible calf atrophy or a smaller calf. These muscles need to be strengthened and the ankle needs to be moved to increase ankle range of motion. A formal therapy program of 2-3 times per week for at least 1 month is needed at a therapy facility for optimal healing.

7. What is the difference between a podiatric surgeon and orthopedic surgeon? Who should I see for my ankle injury?
Seek treatment from a podiatric foot and ankle surgeon as they are uniquely qualified to not just perform the surgery but also to carry out the long-term care of patients by addressing the biomechanical conditions affecting the foot and ankle. Unlike orthopedists, a podiatric foot and ankle surgeon, in addition to the general medical training, focuses on the foot and ankle from the beginning of their medical training.

By Dana Waters, DPM
Podiatric Surgeon in Hillsborough and Piscataway, NJ