High Ankle Sprain Management

High Ankle Sprain Management

Managing a high ankle sprain is not easy, and rehab requires a significant amount of experience.  It reflects a balance of properly stabilizing the entire lower leg while assessing the athlete’s function prior to the game for optimal results.  Read on to learn more.

What the Heck is a High Ankle Sprain?

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

When the ankle is pinned to the ground and rotated excessively in relation to the shin, the talus bone in the ankle forces the two shin bones to spread apart (similar to a wedge between two pieces of wood).  When this extreme rotational spreading tears the interosseous membrane and stabilizing ligaments above the ankle, voila…a “high ankle sprain” is born.

Key Steps to Address an Interosseous Ankle Sprain

Some key factors must be considered when rehabbing a high ankle sprain to get back to the sport or activity you love.

Rest – Allowing the interosseous membrane and stabilizing ligaments to tighten up is of utmost importance, as activities that negatively impact ankle and distal shin stability will only worsen the problem.

Walking Boot – It’s simple, yet effective.  “The Boot” allows the ankle to rest during walking by minimizing motions such as twisting.

Ice, Ice & More Ice – This is necessary to decrease swelling and 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 strengthening activities are pain-free and don’t increase swelling, they can be performed with a limited range of motion.  I like to rely on the expression:  If you’re not going to make the athlete better, at least don’t make them worse.  It’s tempting to initiate an aggressive strengthening regimen for a high ankle sprain when heading into an important game, for example:  players may want to prove their “toughness” and show they are working hard, when in fact doing so will only worsen the problem!  Rehabbing smarter, not harder, is always important when it comes to a high ankle sprain.

Factors That Impact the Decision to Play With a High Ankle Sprain

A few key factors must be considered to determine if it’s okay for an athlete to play in a game with a high ankle sprain.  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 by considering the following questions.  

Efficient vs Effective – Will the athlete be able to play for more time at 80% speed (efficiency) or less time with 95% speed and greater power (effectiveness)?

The Long View – Will playing injured in one particular game create long-term damage that will negatively impact the athlete’s remaining career?

Consider the Whole Enchilada – How long exactly can the athlete remain in the game?  The start of the second half is a telling time in sports like football, soccer, or basketball, for example, as the ankle can become sore or stiffen up while at rest during halftime.

Taping, Orthotics, Shoe Alteration and/or Bracing – No book, seminar or Seven Wise Men can easily solve questions surrounding these items. How do I tape a high ankle sprain?  Will orthotics effectively minimize rotation in the talus bone?  Will higher shoes with more stability help or hurt an athlete who needs to quickly change direction?  Will shoe taping help or put too much pressure on the injury site?  So much to think about!

My Rule of Thumb:  It takes lots of experience and one-on-one time with the athlete on the practice field to answer all of these questions, as well as great listening skills, a sharp eye and trust in each other to do this right.  Performing combinations of varied tape jobs and ankle postings during drills alongside honest athlete feedback are critical.  Intertwined with an immense amount of trial and error, I know how to influence body mechanics and pain while the athlete knows what is required to perform. Working together ultimately strikes a balance between stability and mobility that allows the athlete to play effectively.

A Final Word About Ankle Rehab

Managing high ankle sprains is stressful, but I love it!  Successfully rehabbing this injury truly tests my ability to work with athletes, as 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, specifically, and it’s those relationships that help 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”

  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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