When Can I Play Again: High Ankle Sprain

October 6, 2020 | Ankle

Dev Mishra, M.D.

President, Sideline Sports Doc

Medical Director, Apeiron Life

Fellow, American Academy of Orthopaedic Surgeons

Institute For Joint Restoration, Menlo Park, CA

October 6, 2020

Key Points:

  • High ankle sprains happen with body rotation, such as being tackled with the foot planted at the same time as changing direction
  • Most mild and moderate high ankle sprains are treated without surgery
  • Expect return to play to take longer than common ankle sprains- typically 6 to 12 weeks for young athletes, depending on the sport

I’ve recently written about common ankle sprains, but there is a different type of ankle sprain, often called a “high ankle sprain” that happens when body rotation is combined with forceful contact. What is the difference between a common ankle sprain and a high ankle sprain? And why do athletes with a high ankle sprain seem to be out for a longer period of time? The explanations center on the anatomy of the ankle and the different ligaments injured in a common vs. high ankle sprain.

The common ankle sprain involves injury to a ligament on the outside of the ankle called the “ATFL”, which stands for the anterior talofibular ligament. This ligament runs between the end of the fibula to the talus on the outside of the ankle. It is one of the primary stabilizers of the ankle and is frequently injured when an athlete “rolls” the ankle. Athletes frequently will have pain, swelling, and even bruising in more severe sprains. These symptoms can be experienced on the outside of the foot, just below the ankle joint.

In the high ankle sprain, however, a different ligament is injured, called the “syndesmosis”. The syndesmosis is a tough sheet of tissue that lies between the tibia and fibula and holds these two bones together. In normal walking and running the syndesmosis is preventing the tibia and fibula from being pulled apart. The high ankle sprain typically occurs with rotation of the body around the planted foot, such as with a player being tackled at the same time he is making a cut or direction change. This is very different from the rolling that results in a common ankle sprain.

The high ankle sprain can be mild, moderate, or severe, similar in grading to the common ankle sprain. Severe high ankle sprains will cause a widening of the space between the tibia and fibula. The severe high ankle sprain will need surgery to repair the proper space between the bones.  Most mild high ankle sprains can be treated without surgery. We will typically place the leg in a boot with weight support with crutches. As healing progresses the boot and crutches are stopped, and physical therapy started. An ankle brace can be very helpful in the rehab and return to play phases.

Return to play after high ankle sprains almost always takes longer than return after a common ankle sprain. The reasons for this are not known. With adolescent athletes and adults I find that return to full sport participation will take 6 to 12 weeks, depending on the sport and the position. Physical therapy is very helpful to help the athlete regain strength, agility, power, and confidence. I send all my patients to physical therapy after high ankle sprains. The good news about these injuries is that they tend to be “one and done” events and tend not to happen over and over. If they are treated correctly, keep your spirits up, you’ll almost always get back to normal activity but just expect it to take a bit of time.






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