High ankle sprain hurts!

Why does my ankle hurt after an injury?

An ankle sprain is one of the most common injuries worldwide. The mildest ankle sprains result in temporary pain and swelling. Most commonly, one of the lateral ankle ligaments can be partially or completely ruptured after a significant sprain. The mechanism of injury and the severity of the sprain can cause damage to different structures around the ankle joint such as cartilage, peroneal tendons, and ankle syndesmosis. Typically, the pain subsides after a period of nonsurgical treatment and rehabilitation. Incomplete healing of ankle ligaments and associated damage to other structures can lead to persistent pain and swelling.

What is a high ankle sprain?

A high ankle sprain is a general term for ankle syndesmotic injury. Ankle syndesmosis is composed of groups of ligaments keeping the Tibia and Fibula bone together as the top part of the ankle joint. A high ankle sprain can occur from an inversion injury or from external rotation force to the ankle. Most commonly, the thinner ligament in the front of the ankle syndesmosis ruptures first allowing the two bones to separate from each other. With more severe injuries, all the ligaments can be damaged together with bones around the ankle joint.

Patient suffering from a high ankle sprain usually suffers from pain in the front of the ankle joint, especially with weight-bearing. Swelling is also common. It usually takes twice the amount of time to return to function after a high ankle sprain compared to a normal lateral ankle sprain.

How is a high ankle sprain diagnosed?

The diagnosis of a high ankle sprain is quite simple. A good physical examination can help distinguish between a normal ankle, a lateral ankle sprain, and a high ankle sprain. The location of maximum pain and tenderness in the high ankle sprain is 2 cm more proximal than a normal ankle sprain. Unfortunately, X-rays are not sensitive enough to detect most high ankle sprains. Further investigation such as stress x-rays and MRI are very helpful in the confirmation of the diagnosis.

What is the best treatment for a high ankle sprain?

Conservative treatment using a walking boot, an ankle brace, and physical therapy can be successful in cases with mild injuries. Most of the patients with more severe injuries would benefit from a more definitive treatment. Arthroscopy plays a pivotal role in the management of patients with a possible syndesmotic injury. Arthroscopy is a minimally invasive tool that allows an accurate diagnosis of ankle syndesmotic injuries as well as other associated pain generators in the ankle joint. In some cases, a clean-up-only procedure using arthroscopy is sufficient to remove painful impingement at the ankle joint. Cases with more severe instability will require a surgical repair using screws, suture-button construct, or high-strength sutures alone.

What are the benefits and risks for a repair of a high ankle sprain?

Benefits: permanent treatment, anatomical restoration, pain relief, prevention of arthritis, quick recovery

Risks: Potential surgical complications, nerve irritation, wound healing issues, stiffness, persistent pain, irritation from hardware

What is the recovery after a surgical repair?

Recovery depends on the details of surgical repair, quality of soft tissue, adjunct procedures, and patient’s overall mobility. Typically, the patient is allowed to bear full weight on the affected ankle right away using a walking boot. Patients should use crutches or a walker for enhanced stability. For prolonged ambulation, a knee scooter may be considered. Ankle motion should start on the next day after surgery to prevent stiffness, especially in dorsiflexion. Patients can usually wean off from the boot by 6 weeks and gradually return to sports using a lace-up ankle brace.

Author: Phinit Phisitkul, MD