High Ankle Sprain

High ankle sprain

A high ankle sprain is also known as a Syndesmosis injury. It is a tear of the anterior tibiofibular ligament which joins the tibia and fibula together just above the ankle. This ankle injury is generally more severe and more complicated to treat than a normal ankle sprain.


  • Symptoms of a high ankle sprain include pain when pressing in on the tibiofibular ligament at the front of the ankle. This is the ligament which joins the tibia and fibula at the bottom of the leg/top of the ankle.
  • Swelling and bruising will be seen at the front and outside of the ankle.
  • You will have difficulty walking.
  • Pain is reproduced by rotating and dorsiflexing the ankle (external rotation test). This means rotating your ankle with toes and foot pushed upwards.

Assessment tests

The squeeze test

The squeeze test is used to assess a high ankle sprain or Syndesmosis injury. The therapist squeezes the lower leg to compress the tibia and fibula. The test is positive if symptoms are reproduced.

External rotation test

The therapist moves the foot into dorsiflexion (pointing upwards) and rotates the lower leg outwards. The test is positive if pain is reproduced.

Internal knee rotation test

This test is done by rotating the knee inwards with the knee bent. It causes the ankle to dorsiflex and foot to rotate outwards. If symptoms are reproduced then the test is positive.

What is a High ankle sprain?

Ankle anatomy high ankle sprain

A high ankle sprain is a tear of the tibiofibular ligament at the top of the ankle. It is sometimes associated with a fracture of one of the lower leg bones and is often more severe than the normal lateral ankle sprain. It can also be more problematic to treat.

The most commonly injured ligament in a high ankle sprain is the anterior tibiofibular ligament. Severe injuries can also cause damage to the syndesmosis which is a membrane connecting the Tibia and Fibula.

High ankle sprain treatment

High ankle sprain treatment at home

  • As soon as possible after exercise, the PRICE principles (protection, rest, ice, compression, elevation) should be applied to reduce pain and limit swelling.
  • Ice should not be applied directly to the skin but through a wet tea towel or using a commercially available hot and cold pack. Ice can be applied for 10 minutes every hour initially with the frequency reduced to two or three times per day as symptoms require.
  • Elevating the foot will help swelling and tissue fluids drain away from the site of injury.

Professional treatment

  • A doctor, physiotherapist or other sports medical professional may prescribe anti-inflammatory and painkilling medication such as ibuprofen. This will help reduce pain and swelling after a High ankle sprain.
  • Ibuprofen should not be taken if you have asthma. Always check with a doctor before taking medication.
  • Sports massage can be applied after a period of 72 hours to help reduce swelling, loosen muscles and prevent the build-up of scar tissue.
  • Electrotherapy such as ultrasound can help with swelling and aid the healing process as well as reducing pain.
  • Once the ankle is pain-free, the physical therapist would advise on mobility and strengthening exercises to restore the ankle to full function.
  • Wobble board exercises should be done to restore the co-ordination or proprioception of the injured ankle.

References & further reading

  1. van Dijk CN, Longo UG, Loppini M et al. Classification and diagnosis of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1200–16.
  2. Gerber JP, Williams GN, Scoville CR et al. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int 1998;19(10):653–60

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