Ankle Sprains: Standard vs. High Ankle, Symptoms, Diagnosis, and Recovery

What is the difference between ankle sprain and high ankle sprain?

While both are injuries to the ankle's ligamentous structures, a "standard" ankle sprain (most commonly lateral) involves ligaments on the outer side of the ankle, typically from an inversion injury, whereas a high ankle sprain affects the syndesmotic ligaments connecting the tibia and fibula higher up, often resulting from external rotation and dorsiflexion forces.

Understanding the Ankle Joint Anatomy

To differentiate between these two common injuries, it's essential to first understand the complex anatomy of the ankle joint. The ankle is formed by the articulation of three bones: the tibia (shin bone), the fibula (smaller lower leg bone), and the talus (a bone in the foot). These bones are held together and stabilized by a network of strong, fibrous tissues called ligaments.

There are three primary groups of ligaments that are relevant to ankle sprains:

• Lateral Ligaments: Located on the outer side of the ankle, these include the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL). These are the most commonly injured in "standard" ankle sprains.
• Medial Ligaments: Known as the deltoid ligament complex, these strong ligaments are on the inner side of the ankle and are less frequently injured.
• Syndesmotic Ligaments: These are a group of ligaments that connect the distal ends of the tibia and fibula, forming the tibiofibular syndesmosis. They include the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), and the interosseous membrane (IOM) which runs along the length of the two bones. These are critical for maintaining the stability of the ankle mortise (the socket formed by the tibia and fibula that cradles the talus).

What is a "Standard" Ankle Sprain? (Lateral Ankle Sprain)

A "standard" ankle sprain, often simply referred to as an ankle sprain, overwhelmingly involves the lateral ligaments of the ankle.

• Mechanism of Injury: This injury typically occurs when the foot rolls inward, a motion known as inversion, forcing the sole of the foot to turn towards the other foot. This often happens during activities like running on uneven surfaces, landing awkwardly from a jump, or stepping into a hole.
• Affected Ligaments: The most frequently injured ligament is the anterior talofibular ligament (ATFL), followed by the calcaneofibular ligament (CFL) and, less commonly, the posterior talofibular ligament (PTFL).
• Symptoms:
  • Immediate pain on the outside of the ankle.
  • Swelling and bruising, often appearing quickly.
  • Tenderness to touch over the injured ligaments.
  • Difficulty bearing weight or walking, depending on severity.
  • Limited range of motion due to pain and swelling.
• Diagnosis: Diagnosis is primarily clinical, based on a physical examination. Imaging, such as an X-ray, may be used to rule out a fracture, especially if there's significant pain or inability to bear weight.
• Treatment: Initial treatment typically follows the RICE protocol (Rest, Ice, Compression, Elevation). This is followed by progressive rehabilitation focusing on restoring range of motion, strength, and proprioception (balance). Non-steroidal anti-inflammatory drugs (NSAIDs) may be used for pain and inflammation.
• Recovery Time: Recovery varies widely depending on the grade of the sprain (Grade I, II, or III), ranging from a few weeks for mild sprains to several months for severe, complete tears.

What is a High Ankle Sprain? (Syndesmotic Sprain)

A high ankle sprain is a less common but often more severe injury that involves the syndesmotic ligaments connecting the tibia and fibula.

• Mechanism of Injury: This injury typically results from a forceful external rotation of the foot relative to the lower leg, often combined with dorsiflexion (toes pointed upwards). It can also occur from a direct impact that forces the tibia and fibula apart. These mechanisms are common in contact sports like football, rugby, and skiing.
• Affected Ligaments: The primary structures involved are the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), and the interosseous membrane (IOM). Injury to these ligaments compromises the stability of the ankle mortise.
• Symptoms:
  • Pain located higher up on the ankle, often above the ankle joint line, between the tibia and fibula.
  • Pain is often worse with dorsiflexion and external rotation of the foot.
  • Less visible swelling and bruising compared to a lateral ankle sprain, as the injury is deeper.
  • Significant difficulty with weight-bearing, especially during push-off or cutting movements.
  • A feeling of instability in the ankle.
• Diagnosis: Diagnosis can be more challenging and may require specific clinical tests like the squeeze test (squeezing the tibia and fibula together above the ankle, which elicits pain at the syndesmosis upon release) and the external rotation stress test. Imaging, including stress X-rays and MRI, is often crucial to confirm the diagnosis and assess the extent of ligamentous damage and instability.
• Treatment: Treatment often involves a longer period of immobilization and protected weight-bearing. Surgical intervention (e.g., using a syndesmotic screw or suture button to stabilize the bones) may be necessary if there is significant instability of the ankle mortise. Rehabilitation is typically more prolonged and cautious.
• Recovery Time: Recovery from a high ankle sprain is notoriously longer and more complex than a lateral ankle sprain, often taking several months to a year, especially if surgery is required.

Key Differences Summarized

When to Seek Medical Attention

It's crucial to seek professional medical evaluation if you experience any of the following after an ankle injury:

• Inability to bear weight on the injured ankle.
• Severe pain, especially when touching the bone.
• Significant swelling or deformity.
• Numbness or tingling in the foot or toes.
• Symptoms that do not improve with initial self-care within a few days.

An accurate diagnosis by a healthcare professional is paramount to ensure appropriate treatment and a safe, effective recovery for both types of ankle sprains.

Prevention Strategies

While not all ankle injuries can be prevented, several strategies can reduce your risk:

• Strengthen Ankle Muscles: Exercises targeting the calf muscles and muscles surrounding the ankle (e.g., calf raises, resistance band exercises for inversion/eversion).
• Improve Proprioception and Balance: Incorporate balance exercises such as standing on one leg, using wobble boards, or performing single-leg Romanian deadlifts.
• Proper Footwear: Wear shoes that fit well and provide adequate support for your activity. Replace worn-out athletic shoes.
• Warm-up and Cool-down: Always perform a dynamic warm-up before activity and a static cool-down afterward.
• Taping or Bracing: Consider using ankle taping or bracing, especially if you have a history of ankle sprains or participate in high-risk sports.
• Listen to Your Body: Avoid pushing through pain, and allow adequate rest and recovery after intense activities.

Conclusion

Distinguishing between a standard (lateral) ankle sprain and a high ankle sprain is critical for accurate diagnosis, effective treatment, and appropriate rehabilitation. While the former affects the outer ankle ligaments and is typically an inversion injury, the latter involves the syndesmotic ligaments higher up, often from external rotation and dorsiflexion, leading to a more prolonged and complex recovery. Understanding these differences empowers individuals, trainers, and healthcare providers to manage these injuries optimally, facilitating a safe return to activity and preventing long-term complications.