- High ankle sprains involve the syndesmosis — the strong ligaments that hold the tibia and fibula together above the ankle.
- They're distinct from regular (lateral) ankle sprains and recover on a different timeline (slower).
- Stable injuries respond to bracing and progressive weight-bearing; unstable injuries need surgical fixation.
- Athletes routinely miss 4–8 weeks with a stable high ankle sprain and longer with surgical fixation.
- Misdiagnosis as a regular ankle sprain is common — slow recovery is the clue that prompts re-evaluation.
What are a high ankle sprain?
A high ankle sprain — properly called a syndesmosis injury — affects the strong ligaments connecting the tibia (shin bone) and fibula (smaller bone next to it) just above the ankle joint. These ligaments hold the two bones together and are critical for ankle stability when you twist or push off. They're stiffer and less commonly injured than the lateral ankle ligaments — meaning when they ARE injured, recovery is slower and the injury is often missed initially.
Mechanism is usually a forced external rotation of the foot relative to the leg — common in football, hockey, and skiing. The patient feels pain higher up the ankle (above the joint line) rather than at the typical sprain spot. Bearing weight is more uncomfortable than with a typical lateral sprain.
At NES we evaluate any "ankle sprain" that isn't recovering on the expected timeline for syndesmosis injury. Imaging (weight-bearing X-rays and sometimes CT or MRI) determines whether the injury is stable or unstable.
See it in motion
Animations licensed from ViewMedica · Swarm Interactive
What it feels like
High ankle sprains have a distinctive pain pattern:
- Pain ABOVE the ankle joint, often on the front of the leg near the inside of the ankle
- Pain with pushing off, climbing stairs, or running
- Less swelling at the ankle joint itself than with a regular sprain
- Pain reproduced by squeezing the leg bones together at mid-calf (squeeze test)
- A history of a twisting injury, often externally rotating the foot relative to the leg
- Slow recovery — pain still significant at 3–4 weeks
Why it develops
High ankle sprains have characteristic mechanisms:
- External rotation injury — foot planted, body twists outward (football tackles)
- Forced dorsiflexion — landing from a jump with the foot pushed up
- Ski boot injuries — the rigid boot transmits rotational force above the ankle
- Direct impact to the outside of the ankle while the foot is planted
How we diagnose a high ankle sprain
Diagnosis combines a careful physical exam (squeeze test, external rotation test) with weight-bearing X-rays. Subtle widening between the tibia and fibula confirms instability. CT scan and MRI are used when X-rays are equivocal or when surgical planning is needed.
Non-surgical care
Stable syndesmosis injuries are managed conservatively:
- Walking boot or rigid ankle brace for 4–6 weeks
- Crutches initially for pain management; transition to weight-bearing as tolerated
- Physical therapy starting with range of motion and progressing to strengthening
- No return to sport until pain-free strength and stability are restored
- Repeat weight-bearing X-rays at 2–4 weeks to ensure no late instability
Surgical care
Unstable syndesmosis injuries require surgical fixation.
- Syndesmotic screw fixation — one or two screws across the syndesmosis
- Suture-button (TightRope) fixation — a flexible fixation that preserves some motion
- Open reduction with internal fixation if associated with fracture
Post-surgical recovery: non-weight-bearing for 6 weeks, transition to walking boot at 6 weeks, supportive shoes at 10 weeks, return to running and sport at 4–6 months.
When to see a specialist
- Ankle pain that's above the joint line rather than on the side
- An "ankle sprain" that isn't healing on schedule (still painful at 4 weeks)
- Pain with the calf-squeeze maneuver
- A twisting ankle injury in a competitive athlete
High ankle sprains are treated by Dr. Todd Galle and Dr. Manny Moy (sports medicine), and surgically by Dr. Yama Dehqanzada, Dr. Thomas Melillo, and Dr. Ron Bowman (MD orthopedics) when fixation is needed.