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Treating a High Ankle Sprain

26th March 2021

Ankle sprains are common, but did you know that there are 2 types.

One is the common and normal ankle sprain which most people will have suffered when you roll or go over on your foot and ankle and sprain your ankle joints and ligaments.

However – there is another type of ankle sprain and it is known as a high ankle sprain or syndesmosis injury.

The common ankle sprain will damage the ankle ligaments at the outside of the ankle. A high ankle sprain will damage the ligaments that sit higher up the ankle between the tibia and fibula.

This guide is going to help you gain an understanding of this type of injury and all of the things that you can do to help improve symptoms and manage the injury.

If you have had this injury before, you might still be suffering symptoms of this or if it’s just happened there is something in this guide for everyone.


What causes a high ankle sprain and who is more likely to suffer one?


A high ankle sprain is typically caused by an inversion (ankle rolling / going over on foot) or dorsiflexion (foot pointing downwards) trauma to the syndesmosis. These injuries usually occur with a sudden twisting, turning or cutting motion while a person is running or jumping.

Athletes who play high-impact running sports like football, rugby, hockey and basketball could all be prone to this type of injury. These injuries can be unavoidable at times due to the unpredictable nature of sport and also the surfaces involved.

Of course its not always sports that can cause this injury, you could be exercising in the park, at work or even just walking on an unstable surface which could cause this injury.


Ways to reduce the chances of suffering a high ankle sprain?


In sport – as an athlete, a good strength and conditioning program will help you to reduce your injury rate. Strength and conditioning helps your body to remain strong, conditioned and also helps to iron out any imbalances which can lead to injury.

If you play sport, and you don’t do any separate strength and conditioning work alongside your sport – it is worth investing time in this as it will mean better performance and less injury.

With high ankle sprains, ensuring you have:

  • Equal range of motion throughout your lower limb joints
  • Good proprioception within the lower limb – this means being able to balance and react to direction changes whilst controlling your joints.
  • Good strength and control in your lower limb muscles

Using correct footwear for correct surfaces is also another great way to reduce risk of injury. Using spikes/studs on more unstable surfaces can help you be more stable when the surface may not be.

In specifics for high ankle sprain, balance exercises and ankle strength are great exercises to introduce regularly. Check out the section at the end on the best exercises and rehab for the high ankle sprain.




Get to know the high ankle or its technical name of the syndesmosis better with some basic anatomy. Understanding the parts which are injured always helps to improve the recovery process as you know how things fit together and why you perform each of the exercises.

A syndesmosis joint is defined as a fibrous joint where 2 bones are connected by the ligaments. The distal tibiofibular syndesmosis, between the fibula and tibia, is formed by three major ligaments:


  • anterior inferior tibiofibular ligament (AITFL)
  • posterior inferior tibiofibular ligament (PITFL)
  • interosseous tibiofibular ligament (ITFL)
  • inferior transverse tibiofibular ligament (ITTFL)


While technically the syndesmosis is the joint itself, it is commonly agreed a syndesmosis injury as affecting the ligaments of the high ankle.


Grading a high ankle sprain? How severe can they be?


Here is a general grading of ankle sprains and how they are graded in to 3 different levels.

Ligaments hold ones to bones and typically occur with impact, twists and over extension injuries to body parts.

Grade I – structural damage only on microscopic level, with slight local tenderness and without joint instability.

Grade II – partial tear (rupture) of the ligament, visible swelling and noticeable tenderness, but without joint instability (or with mild instability).

Grade III – a severe sprain: complete rupture of the ligament with significant swelling and with instability of the joint.

Injury recovery times from all of these grade of injuries vary. A grade 1 injury can be within 2-6 weeks, but most high ankle sprains will be a minimum of 6-8 weeks and worst case scenarios can be up to 6 months.

These figures are all unique to the person and injury, for accurate advice on your recovery time, seek a physiotherapy opinion.


What to do after you have suffered a high ankle sprain?


The acronym PRICE is a great way to manage acute injuries. However there has been a change in recent times with evidence emerging that ice is now not beneficial other than pain relief and could actually delay healing.


P – Protection – Remove yourself from danger or the activity which caused it and discontinue exercise or anything that may be causing further harm.

R – Relative Rest – do not stop moving or exercising completely. If you have hurt your knee, hip or ankle – maybe reduce the amount of walking you are doing but find ways to move the affected body part regularly – this will help the tissues to heal and get blood to them

I – ice – only benefit is for pain relief – consider if you cannot use medication. Otherwise- try not to ice.

C – Compression of the injury – this helps to reduce bleed and reduce the swelling which can make it more painful and also delay recovery,

E – Elevate your injury above heart height to ensure the swelling drains efficiently.


Compression sleeves and ankle supports are a great way of providing support to a newly injured ankle and can help to improve your rate of recovery as they reduce pain and provide support to a weakened ankle.




If you have suffered an ankle injury and you suspect a high ankle sprain – get it checked out. If there is any concern around fracture or you are having trouble weight bearing – please get this checked by the hospital initially.

If you have been lucky enough to not have broken any bones, then seek the help of a good physiotherapist as soon as you can. Physiotherapists who specialise on sporting injuries are typically the best people to go and see for this type of injury.

Pick an experienced physiotherapist as this injury needs attention to help it improve and you will need kept on track throughout your recovery period.

Here are some of the things that physiotherapy will cover in order to help you recover from your high ankle sprain:


  • Subjective Assessment – this is a detailed set of questions which help to give the physio an understanding of how and when the injury occurred. The physio will also ask how it is affecting you, what aggravates you and what your goals and expectations are – this all helps them to build a picture to provide a good service and ensure you have the best recovery. A medical history and medication history will be taken if this applies to you.
  • Objective Assessment – This is the physical part of your assessment and this helps to see how the ankle is moving and how compromised it is. Basic movements will be performed by you and then passive movements by the physiotherapist to how you are moving. Specific tests will be applied to the ankle to see what structures are affected and to get an understanding of the extent of the injury in order to grade it.
  • Treatment – soft tissue massage, passive joint mobilisation, shockwave therapy, taping – there are a p[plethora of different treatments the physio can use to help manage your pain, which ones to use depend on the injury, the person and what you both agree on being best for the injury.
  • Advice / Education – this is the biggest benefit of physio following injury, the physio who is an expert can advise you how to move and when to progress your recovery, this helps to provide reassurance and understanding.
  • Rehabilitation – This is the most important part of recovering from this injury. Without rehabilitation – your ankle will struggle to recover. Please see the section below for handy tips and hints to help your ankle improve.


Rehabilitation of your high ankle sprain!


Early stage exercises


Ankle Pumps and Circles – this one is simple. Lie down, feet elevated to help swelling and simply move your ankle whilst they are in the air. Move them as much as is comfortable for your injury. Perform for as long as is comfortable. The best recommendation is to do this in small amounts and often.

Gait Practice – practice barefoot walking in the house and focus on walking properly. Limping can actually put a lot of pressure on the ankle and make it sorer than it needs to be. The earlier you can restore your walking pattern to normal, the better as it helps to strengthen the foot and ankle.


Mid Stage Exercises


Light and non-impact exercising – when you are ready think about exercise that you can do. Swimming is a good place to start as there is no weight on the ankle. Even getting in the pool and walking and performing exercises with the ankle is a good thing to do. Using an exercise bike and cross trainer is a good safe way to mobilise the ankle and prevent further injury whilst strengthening the ankle.

Gentle strength Exercises – start using a towel or a resistance band to help provide resistance to the downwards strength of the ankle. This can be progressed to calf raises when you feel you are able to weight bear properly.


End Stage Exercises


Proprioception/ Balance Exercises – simply balance on the injured foot and ankle. Try to build your time and keep your ankle and knee steady. Ensure there is a small bend in the knee. As this gets better try standing for longer and also closing one eye as eyesight is a major component of balance.

Running – return to sport is highly important. When you begin running, run in straight lines for short periods. This can then be progressed to curved running and then sharp direction changes when able.

Plyometrics – this is jumping and agility based exercises which help to strengthen the joint but also help to protect it from future injury.


These are just basic guides, and again, being guided by a professional is the best way to recover. Everyone has a different type of injury and also path to recovery.

We hope that this guide has been helpful – syndesmosis injury is a complex topic and this guide is designed to be an introduction to help you gain a basic understanding.

If this has helped you and you think it could help someone else, please share it with them.

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