A "high ankle sprain," distinct from the more common "low ankle sprain," is a term often heard in sports contexts like American football broadcasts. Unlike low ankle sprains that affect the ligaments on the outer side of the ankle, high ankle sprains involve the ligaments positioned above the ankle. These ligaments, collectively known as the syndesmosis, connect the tibia to the fibula and are crucial for stability during activities like walking and running, which exert significant force at this junction.

A high ankle sprain, also referred to as a syndesmotic injury, occurs when these high ankle ligaments sustain tearing and damage. Although less frequent than traditional ankle sprains, high ankle sprains can cause substantial discomfort and impairment.

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Symptoms

Patients with associated ankle fractures often find it challenging to bear weight on the affected foot/ankle and may require surgical intervention. In cases without fractures, individuals may experience heightened pain during activities that involve dorsiflexion of the ankle, such as climbing stairs. These movements place additional strain on the injured ligaments, particularly affecting the syndesmosis.

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Causes

High ankle sprains typically result from twisting or rotational injuries, common in sports with impactful movements. External rotation mechanisms, where the foot turns outward relative to the leg, are often responsible for such tears. Additionally, high ankle sprains can occur alongside ankle fractures. In severe instances, the deltoid ligament on the inner side of the ankle may tear, transmitting force through the high ankle ligaments to the fibula and resulting in a fracture known as a Maisonneuve fracture.

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Anatomy

The syndesmosis comprises three primary components:

1. The anterior inferior tibiofibular ligament (AITFL) runs in front of the tibia and fibula.
2. The posterior inferior tibiofibular ligament (PITFL) runs behind them.
3. The interosseous (IO) membrane, situated between the two ligaments, provides significant support.

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Diagnosis

Patients with high ankle ligament tears typically experience pain above the ankle, distinguishing them from traditional ankle sprains. Physical examinations, including the squeeze test and external rotation test, can aid in diagnosis. X-rays are essential for identifying fractures and assessing the relationship between the tibia and fibula. Advanced imaging like MRI or CT scans may provide further insights.

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Treatments

The treatment aims to realign the tibia and fibula into their proper positions and facilitate healing in those alignments, ensuring optimal functioning of the ankle joint. It's crucial to understand that these injuries often require longer recovery times compared to "low" ankle sprains. 

For non-fractured sprains, immediate post-injury care involves resting the leg, applying ice for 20 minutes every two to three hours, gently compressing the leg with an ACE wrap, and elevating the leg with the toes positioned higher than the nose. Depending on tenderness, a removable walking boot may be necessary. Physical therapy focuses on strengthening the peroneal tendons and restoring ankle movement to facilitate a return to activities.

Recovery can take between 6 to 8 weeks, but occasionally longer. As a general guideline, bones typically heal in around six weeks, while soft tissues like ligaments may require up to three months. A useful indicator for readiness to resume sports is being able to hop on the foot 15 times without significant discomfort, provided X-rays show no widening between the tibia and fibula. In cases of widening or fracture, surgical intervention may be required. Surgical approaches aim to realign the fibula and tibia, often using screws or innovative devices containing sutures to maintain stability.

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Recovery

High ankle sprains typically require longer recovery periods than standard ankle sprains. Patients may need non-weight bearing periods followed by gradual rehabilitation. Surgery may be necessary for severe cases or fractures, aiming to stabilize the tibia and fibula with screws or innovative devices.

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Outcomes and Complications

Although outcomes are generally favorable with appropriate treatment, ankle stiffness and potential complications like infection or nerve damage are risks, especially with surgical interventions. Ankle arthritis can develop in cases of severe sprains with cartilage damage.