COMMON AND UNCOMMON ANKLE SPRAINS

Many of us have twisted an ankle at some point. Typically, you’re walking or running, and you step on an uneven surface. Suddenly the ankle rolls towards the outside, and you’re on the ground experiencing intense pain. This type of ankle sprain is an inversion sprain, and it’s the most common type that healthcare providers treat. While this sprain heals relatively quickly, the “high” ankle sprain is less common and takes more time to heal.

The ankle joint is comprised of the distal tibia, fibula and talus.  The bones are held together with leather-like ligaments which provide static stability while the muscle structure gives dynamic stability.  When a sprain occurs, the static stabilizing ligaments are damaged and the injury severity ranges from a strain to a complete rupture.

There are three types of ankle sprains: the inversion (lateral), eversion (medial), and the high ankle sprain.  All three can be mild to severe depending upon the extent of the damage that occurs to the ligaments.  Lateral and medial ankle sprains are more common than the high sprain and usually less debilitating.  When time missed from an athletic activity is used as a basis for determining the severity of these sprains, the lateral and medial are considered relatively minor.  The high ankle sprain requires a significant amount of “down” time to prevent re-occurrence and long-term damage to the joint.

The distal tibia and fibula and talus (ankle mortise) are held together with thick ligaments on the anterior and posterior aspect.  There is a membrane that extends up into the calf region that also helps to “hold” the bones together.  When the foot is dorsiflexed the talus is moved upward into the mortise and the distal end of the fibula translates slightly superiorly and posteriorly.  The natural movement of this bone “separates” slightly and makes more room for the top of the talus in the mortise.  When the movement of the talus into a dorsiflexed position is abnormal and too forceful, the ligament structure that binds the distal tibia and fibula together can be damaged. This is considered a high ankle sprain.

Nearly all high ankle sprains occur during contact sports. When an athlete makes contact with another athlete their foot can be forcefully moved into the dorsiflexed position. If this happens, the ligament structure is damaged and the injured athlete has to be treated differently than other types of ankle sprains.  Due to the normal “gapping” that occurs in the mortise secondary to the movement of the fibula during normal gait, the high ankle sprain has to be treated with a period of non-weight bearing in most cases. The severity of the injury determines the length of the non-weight bearing time period.

Most high ankle sprains take a very long time to heal and inhibit the athlete from returning to action for an average of 3 weeks or more.  One of the primary reasons for the delay is the period of non-weight bearing that is required for the acute injury to begin to heal.  Non-weight bearing is detrimental to the other structures throughout the involved lower extremity.  The muscle mass is greatly affected by atrophy and weakness occurring throughout leg.

Treatment of a high ankle sprain can begin immediately, and the Physical Therapy rehabilitation will focus on reducing the swelling and pain while the patient remains non-weight bearing.  Regaining motion and exercising the core and lower extremity muscles without putting weight on the involved foot will help to prevent gross muscle strength loss and atrophy.  When the patient is given the ok to weight bear, the rehabilitation program can be progressed to include various weight bearing or closed chain exercises.

There is an increased rate of re-occurrence of this type of ankle sprain.  Unfortunately, many people that have experienced this type of sprain develop arthritic changes in the mortise later in life.  Fully rehabilitating the involved ankle will lessen the chance of developing arthritic changes.

Healthcare providers suggest that athletes and especially those that play contact sports should incorporate balance and proprioception exercises and drills into their regular routine in hope of preventing the high ankle sprain from occurring. Some suggest that proper bracing might limit the amount of dorsiflexion that can occur in an ankle which would limit the severity of the injury should it occur.  Unfortunately, many athletes report that this type of brace limits their function and performance.

High ankle sprains occur infrequently when compared to medial and lateral ankle sprains.  This is very fortunate because a high ankle sprain can be extremely debilitating for an athlete.   The cause of this type of ankle sprain is almost solely due to contact and due to a period of non-weight bearing the rehabilitation process can be lengthy.