High Ankle Sprain Management in the NFL

New England Patriots’ TE Rob Gronkowski’s ankle sure is getting a great deal of attention as we head into this weekend’s big Super Bowl matchup.  Managing a high ankle sprain is not easy.  Rehabbing a high ankle sprain requires a significant amount of experience.  Managing this injury is a balance of properly stabilizing of the entire lower leg while assessing the athlete’s function prior to the game for optimal results.

First of all, I’m not writing this to specifically comment of Gronkowski’s present injury.  Rob is in great hands with Head Athletic Trainer Jim Whalen and his staff caring for him.  They are a very talented medical staff with a track record of doing a wonderful job of getting high-profile players back for big games.  I’ve worked with Head Coach Bill Belichick early in my career as an assistant athletic trainer/physical therapist for the New York Giants.  Bill is a tough coach who is absolutely loved and respected by his players.

What the Heck is a High Ankle Sprain?

An ankle sprain is considered to be a high or “interosseous” ankle sprain when the ligamentous damage involves the structures above or high to the ankle.  The shin bone is made up of two long bones (the tibia and fibula) which are stabilized between the two by a thick and strong interosseous membrane.

When the ankle is pinned to the ground and excessively rotated in relationship to the shin, the talus bone of the ankle forces the two shin bones to spread apart, much like a wedge would do between two pieces of wood.  The extreme rotational spreading of the lower shin bones tears the interosseous membrane and stabilizing ligaments above the ankle….hence creating a “high ankle sprain”.

Key Steps to Positively Influence an Interosseous Ankle Sprain

During the week(s) leading up to the game, there are some key factors to be considered when rehabbing a high ankle sprain.

Rest – Allowing the interosseous membrane and the stabilizing ligaments to become tighter is the #1 benefit going into the game.  Anything you do that negatively influences that stability of the ankle and distal shin will make the ankle worse.

Walking Boot – It’s simple and smart.  “The Boot” allows the ankle to rest while walk by minimizing the motion, especially the twisting.

Ice, Ice & More Ice – To decrease the swelling and the pain.  Inflammation is not your friend and cryotherapy is the key.  The more acidic blood that pools within healing tissue the longer the healing time.

Pain-free Strengthening – As long as the strengthening is pain-free and doesn’t increase the swelling, it can be performed in a limited range of motion.  I like to use the expression: “If you’re not going to make the athlete better, at least don’t make them worse“.  It’s easy to initiate an aggressive strengthening program for a high ankle sprain heading into an important game.  When it comes to a high ankle sprain, this is usually more to show the coaches that the player is working hard when in reality it may be making the player worse!  Rehabbing smarter not harder is always important with a high ankle sprain.

Factors That Will Impact Your Decision to Play With  a High Ankle Sprain

When determining if a player should play in a game with a high ankle sprain, there are a few key factors that should be considered before the game begins.  This is where an athletic trainer’s experience comes into play and he/she really earns their money.  It’s time to dust off the ol’ crystal ball and show your worth!

Efficient vs Effective – Will the player be able to play 40 plays at 80% speed (efficient) or will he be able to take 15-20 snaps at 95% speed with great power (effective)?

The Super Bowl Factor – Sure, it’s just 1 game with a 4 month Bye starting the day after the game, but will playing in this game with this injury create long-term damage that will negative impact the remainder of his career?

Ability to Play 5 Quarters – I can have a huge influence on getting a player back onto the field but when it comes to how long that player stays on the game, it has more to do with the player himself.  I always get more nervous at the start of the 2nd half of the game with a player with a high ankle sprain.  With an extra long halftime during the Super Bowl and the hype of the game worn off, how stiff and sore will that ankle become walking down the ramp to play 2 or 3 more quarters?

Taping, Orthotics, Shoe Alteration and/or Bracing – No book or seminar or 7 wise men can easily solve these questions. How do I tape a high ankle sprain?  Will orthotics help minimize the rotation of the talus bone effectively? Will higher shoes with more stability help or hurt a skilled position player who needs to change directions quickly?  Should I spat or tape over the shoes or will that put too much pressure on the injury site? So much to think about!

My rule of thumb: It takes lots of experience and 1-on-1 time with just me and the athlete on the practice field later in the week to answer all of these questions.  It takes great listening skills, a sharp eye and trust in each other to do this right.  We try many combos of various tape jobs and ankle postings as he runs his specific football-position drills while he gives me honest feedback.  It’s trial and error times 100.  I know how to influence the body mechanics and pain while the player knows what he needs to do to do his job.  Working together will ultimately create the balance between stability and mobility that allows him to do his job effectively.

Two Minute Warning for Ankle Rehab

Managing a high ankle sprains is stressful but I love it!  Rehabbing this injury successfully truly tests my ability to work with an athlete.  There is no magic pill or brace to get them back in the game.  I’ve developed many strong bonds with athletes rehabbing high ankle sprains and it’s those relationships that make my profession so rewarding.


Author: Mike Ryan

After 26 seasons as a full-time certified athletic trainer and registered physical therapist in the National Football League, Mike Ryan has outstanding first-hand experience. His unique professional and athletic background has sharpened his skills in the arts of sports injury management, elite rehabilitation, performance enhancement and injury prevention. Mike is now taking his experience to mainstream America. His mission is simple: Sports Medicine advice that is easy to use and brings fast results. Learn more about Mike Ryan

7 thoughts on “High Ankle Sprain Management in the NFL”

  1. Mike. If I was asked to write something about High Ankle Sprains and their impact on ‘ability to play’, my article would have been very similar, even though my specialy is working with elite soccer players (Premier League Soccer). Thanks for posting this. It’s a nice reminder to all about how the trust between Physical Trainer and Athlete is crucial in allowing players to play, maybe, against the odds.

  2. Mike,
    Thanks for forwarding this. I have found attempts to maintain cardiovascular fitness (without causing pain) is ideal for a little quicker return. If available, aquatic rehab can be very helpful. Deep water running to maintain physicality and progressing to weightbearing (shallower water), as the athlete can tolerate,is a great adjunct to the treatments also being performed to control inflammation.

    Since mortise widening will be the pain eliciting event (with dorsiflexion and any inversion/eversion while dorsiflexed), controlling widening will help with easing functional pain when loading. I have had some success with adding a heel lift. This lessened the mortises need to accomodate the anterior aspect of the talus (anatomically wider than the posterior aspect) and lessened the widening that will funcitonally occur during loading and decreasing symptoms. this could be in their walking boot, their training shoes, in the pool (taped on) and in their cleat.

  3. Mike, I just joined the BOC LinkedIn group and this was at the top of the list. Great article with a good overview of managing these injuries. You did not mention weight bearing as being a concern early in the rehabilitation/management process. By going directly to the boot, my experience has been that simple weight bearing can drive the talus proximally and impede healing (with or without rotation of the talus in the mortise). Thoughts?

    1. Great point! I should have addressed that and I appreciate you bringing that point up, Mark. With a high ankle sprain the weight bearing (WB) factor is important if the articular cartilage or the integrity of the talocrural is a problem. Swelling control and pain cannot be controlled if the WB progression is too aggressive. That is another reason why I love using walking boots with acute high ankle sprains for my athletes.

    2. I have found that if time is not a crucial factor, especially in my sport specialty- Gymnastics, then a week or little longer in the boot with NWB does wonders for the back end of recovery. Also the swelling was controlled so much better with little visible after week 2 and no effleurage massage needed! Thanks for posting this though Mike. It is interesting to see the difference between Football and Gymnastics when it comes to injuries.

      1. Very true, Kayla. If you can give the athlete an extra week while returning with a high ankle, it will help increase the ankle stability and decrease the chronic symptoms. Smart rehab, Kayla, and your athletes will love you for it!

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