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High Ankle Sprain

 

Definition
A "high" ankle sprain is an injury to the ligaments between the two major bones of the lower leg (Tibia and Fibula) at the level of the ankle.

Causes
A "high" (syndesmotic) ankle sprain is caused by an outward twisting of the foot and ankle. This is opposite of a typical ankle sprain where the foot and ankle are twisted inward. Football, soccer and basketball are the most common sports associated with a high ankle sprain. Proper stretching and training may help prevent some "high" (syndesmotic) ankle sprains.

Symptoms

  • Pain accentuated with external rotation (rotating out) of ankle

  • Inability to walk

  • Severe pain

  • Usually significant bruising

Considerations

A "high" (syndesmotic) ankle sprain is diagnosed when a patient has a history of an outward twisting motion to the ankle and pain just above the ankle joint. The patient initially may not be able to walk on injured leg. Squeezing the leg at the midpoint of the calf or gently moving the foot outward may reproduce the patient's pain. X-rays are taken to rule out fractures that can be associated with this injury. Occasionally, an MRI may be needed to confirm the diagnosis.

Treatment

An ankle sprain is named because the injury is above the level of the joint. It is a tearing of the syndesmotic ligaments of the tibia and fibula bones. 

An inversion injury, the most common cause of ankle sprains, occurs when the ankle rolls outward and the foot turns inward. It results in stretching and tearing of the ligaments on the outside of the ankle. In a "high" ankle sprain, a less common type of inversion injury, the ligaments at the top and outside of the ankle are also torn, increasing the sprain's severity and healing time. The high ankle sprain is different from a typical sprain because it is more severe and may, though rarely, require surgery early in the treatment course.

A "high" (syndesmotic) ankle sprain is diagnosed when a patient has a history of an outward twisting motion to the ankle and pain just above the ankle joint. The patient initially may not be able to walk on injured leg. 

Damage to the ligament varies from simply stretched or slightly torn to completely torn. Your doctor will grade your sprain accordingly.

  • Grade I is stretching or slight tearing of the ligament with mild tenderness, swelling, and stiffness. It is usually possible to walk with minimal pain.

  • Grade II is a larger but not complete tear with moderate pain, swelling, and bruising. The damaged areas are tender to the touch, and there is pain with walking.

  • Grade III is a complete tear of the affected ligament with severe swelling and bruising Walking is usually not possible because of the ankle gives out, and there is intense pain, although initial pain may quickly subside.

Nonoperative: Most "high" (syndesmotic) ankle sprains can be treated in a manor similar to typical ankle sprains with PRICE. P: Protection from further injury via a splint, R: Rest, I: Icing, C: Compression wrapping, E: Elevation (see sprained ankles). Syndesmotic sprains, however, will require much longer to heal and will also need more physical therapy to strengthen the muscles around the ankle.

Operative: Severe "high" (syndesmotic) ankle sprains with significant displacement of the bones (Tibia and Fibula) require surgical stabilization.

Call Immediately For Emergency Medical Assistance if
a) a broken bone is suspected or if there has been a serious injury or persistent pain.
b) there is an audible popping sound and immediate difficulty in using the joint.

How to Rehabilitate
Rehabilitation can begin a few days after the injury, when the swelling starts to go down. There are three goals to aim for in rehabilitation.

1. 
Restore motion and flexibility. Gently move the ankle up and down. After 5 to 7 days, start restoring motion to the hindfoot by turning the heel in and out.

You should also begin to restore flexibility to the calf muscles. One way to do this is to face a wall with one foot in front of the other and lean forward with your hands on the wall, bend the front leg while keeping the back leg straight and both heels on the floor. Lean forward until you feel a gentle stretch, and hold for ten seconds. Switch legs and repeat.

2.  Restore strength. After 60 to 70% of the ankle’s normal motion has returned, you can begin strengthening exercises using a rubber tube for resistance. Fix one end of the tube to an immovable object like a table leg, and loop the other end around the forefoot. Sit with your knees bent and heels on the floor. Pull your foot inward against the tubing, moving your knee as little as possible. Return slowly to the starting position. Repeat with the other foot.

You can also sit on the floor with your knees bent and the tube looped around both feet. Slowly pull outward against the tube, moving your knee as little as possible. Return slowly to the starting position. Repeat with the other foot.

3.  Restore balance. As strength returns, balance is restored by standing on the injured leg, hands out to the sides. You may want to warm the ankle before doing these exercises by soaking it in warm water. Warmed tissue is more flexible and less prone to injury. Use ice when finished with the exercises to minimize any irritation to the tissue caused by the exercise.

When Can I Return To Sports?

Return to sports only after you have met these goals:
1.  You have full range of motion in all directions (up and down, side to side, and in and out).
2.  You have good strength in all muscles around the ankle.
3.  You have good balance.
4.  You have no pain or swelling with exercise or activity.

How to bandage a sprain
1. Wrap a sprained ankles with a compression bandage in a figure 8 pattern. Make two loops around the instep, then stretch bandage diagonally across the foot.
2. Bring the bandage around the ankle to the front of the foot. Then wrap it diagonally across the foot.
3. Continue wrapping the bandage in figure 8 turns. Each turn should overlap the previous turn by about three fourths of the bandage’s width.
4. When the foot and ankle are wrapped, secure the bandage with a pin. Leave toes bare. If they become numb or discolored, the bandage is too tight.


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