High ankle sprains can be challenging with their unique recovery time and treatment options. Accordingly, these authors share insights from the literature as well as their experience to discuss evaluation, treatment and associated sequelae specific to high ankle sprains in football players.
Football players can endure a large amount of injuries throughout their career due to the high physical demands of practice and competition. Ankle sprains are some of the most common injuries but it is important to distinguish the difference between lateral ankle sprains and high ankle sprains due to the differences in treatment and recovery time.
A high ankle sprain is defined as injury to the anterior inferior tibiofibular ligament (AITFL), the deep and superficial posterior inferior tibiofibular ligaments (PITFL) and the tibiofibular interosseous ligament (IOL). The mechanism of injury involves external rotation and/or hyperdorsiflexion of the ankle.
In football, these injuries often occur during direct contact, such as blocking and tackling, as well as during pivoting motions. Osbahr and colleagues found that lineman and linebackers had the highest incidence of high ankle sprains in comparison to other positions.1 High ankle sprains are uncommon, accounting for approximately 24.6 percent of ankle injuries in athletes with an incidence of 2.09 out of 100,000 people in the general population.2,3 Often these sprains lead to longer recovery time, which is important to consider when treating athletes who need to return to activity as soon as possible. The average recovery time for high ankle sprains reportedly ranges between 15 to 46 days on average, which is significantly greater than the recovery time, 6.5 days on average, for common lateral ankle sprains.4
Essential Diagnostic Insights
One can diagnose high ankle sprains through a combination of clinical findings and advanced imaging. Clinically, patients may complain of pain along the distal anterolateral ankle with the pain radiating proximally. The clinical test with the greatest specificity (approximately 93.5 percent) for diagnosing syndesmotic injuries is the squeeze test. The provider squeezes the tibia and fibula together at the midportion of the lower leg. If one elicits pain along the syndesmosis, the test is positive (see first photo above). Clinicians can perform an external rotation test by externally rotating the foot with the patient’s hip and knee at 90 degrees. The exam is positive for a syndesmotic injury if one provokes pain at the syndesmosis (see second photo above).
Tenderness to palpation of the syndesmotic ligaments has the highest sensitivity for diagnosis of high ankle sprains. Clinicians can also perform a forced dorsiflexion examination, which is positive when one elicits pain along the syndesmosis with forced dorsiflexion of the ankle, and there is partial relief of pain with compression of the tibia and fibula.5 In 2012, Miller and colleagues reported a correlation between the height of the zone of injury and the recovery time after injury.6 They defined the zone of injury as the distance from the distal fibula to the highest point of tenderness along the interosseous membrane.6 Inability to perform a single leg hop and pain out of proportion to the apparent injury can also be key findings in the diagnostic process.
Clinicians should obtain radiographic images to evaluate for instability and other associated injuries. One can use the anteroposterior (AP) projection to identify syndesmotic and ankle instability. The tibiofibular overlap (TFO) is the distance between the medial border of the fibula and the lateral border of the anterior tibial tubercle. You can measure the tibiofibular overlap on both the AP and mortise views, one cm proximal to the tibial plafond. The normal value in the intact syndesmosis is an average of one mm on the mortise view and six mm on the AP view. The value will decrease in patients with an injured syndesmosis.
Another measurement that can aid in diagnosis is the tibiofibular clear space (TFCS), the distance between the medial border of the fibula and the lateral border of the peroneal incisura of the tibia one cm proximal to the tibial plafond. This distance has an average normal range of less than six mm. One can also utilize the medial clear space to indirectly assess the stability of the syndesmosis. This is the distance between the medial border of the talus and lateral border of the medial malleolus on the mortise view. The average value of a non-injured ankle is less than four mm or less than two to three mm difference in comparison to the contralateral limb. If a diagnosis is unclear, one can obtain stress radiographs but an accurate exam may be difficult in acute injury due to associated pain and swelling.
If radiographs are normal and the clinician still suspects instability, he or she should consider diagnostic ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI). Our preference for diagnostic imaging is MRI. Ancillary injuries may be a contributing factor to a prolonged recovery course, including osteochondral defects of the ankle that often act as pain generators. Clinicians must also consider secondary scar tissue and impingement syndrome when dealing with prolonged recovery after ankle injury. Advanced imaging can help diagnose the syndesmotic injury as well as any other associated pathology that may affect treatment and recovery.
Ultrasound may identify injury to the superficial structures, such as the anterior inferior tibiofibular ligament, and is useful for dynamic stress tests. However, the ultrasound is not as accurate at diagnosing high ankle sprains in comparison to CT or MRI. A CT can help identify a diastasis of two mm or more between the tibia and fibula, and is most accurate in diagnosing syndesmotic injuries when comparing injured and contralateral limbs.
Magnetic resonance imaging is an important tool to help identify the etiology of the injury, confirm the diagnosis and assess the severity of the injury. Magnetic resonance imaging findings for acute high ankle sprains would include the anterior inferior tibiofibular ligament and/or the posterior inferior tibiofibular ligament discontinuity at the level of the tibial plafond, a wavy or curved ligament contour or total absence of the ligament on the T1- and T2-weighted images (see third images above). On the T2-weighted image, one will observe signal intensity surrounding an injured anterior inferior tibiofibular ligament and posterior inferior tibiofibular ligament on the transverse image and/or fluid signal within the distal tibiofibular ligament, signifying a disruption in the syndesmosis.7 Determining the severity of the sprain and the presence of associated injuries is important when determining a treatment plan.8
Pertinent Treatment Options For High Ankle Sprains
Conservative treatment focuses on reducing inflammation and preventing further damage. One should attempt conservative care for less severe, stable injuries without significant diastasis. Treatment should start with rest, ice, compression, elevation and taping. Many physicians will allow weightbearing as tolerated or immobilization with progression to weightbearing as tolerated in a walking boot. Non-weightbearing and immobilization for three to five days after the injury can help resolve inflammation and edema.
Clinicians may utilize additional physical therapy modalities, such as massage, ultrasound, whirlpool, electrical stimulation and transcutaneous electrical nerve stimulation (TENS). Patients can utilize a lace-up ankle brace and partake in an intensive functional rehabilitative program four to six weeks after injury.7,8,9 With recalcitrant injuries, diagnostic and therapeutic injections may be indicated to help break the cycle of inflammation and assist in returning the athlete back to activity.
For more severe injuries with frank diastasis, one should consider surgical treatment. The goals of surgical treatment are to prevent future recurrence and decrease recovery time for unstable syndesmotic injuries. Surgical correction can include syndesmotic repair with screw or suture retention device fixation. There has been no definitive data stating which technique produces significantly better results.
When utilizing screw fixation, one should insert one or two screws 25 to 30 degrees to the coronal plane of the ankle, at least one cm above the ankle joint but preferably two to three cm proximal to the ankle joint. The surgeon can use a bone clamp to reduce and compress the syndesmosis but one should be careful to avoid over-compression or malreduction. Arthroscopic-assisted reduction can be beneficial for ensuring proper reduction of the syndesmosis and allowing for debridement of scar tissue that may prevent complete reduction. Be sure to cross a total of at least three to four cortices when using screw fixation. Remove screws at eight to 12 weeks post-op to avoid stiffness and hardware failure. One may also employ arthroscopy to evaluate the ligaments and syndesmosis.
Surgeons may also utilize dynamic fixation with a suture retention device to allow for micromotion of the syndesmosis, reduce the need for future hardware removal and potentially allow for earlier weightbearing in comparison to screw fixation. In their meta-analysis reviewing dynamic stabilization outcomes, Grassi and colleagues concluded that there is a decreased risk of inadequate reduction, recurrence and reoperation at a final follow-up of approximately two years.10 As with screw fixation, the surgeon can carefully utilize a bone clamp to compress the syndesmosis. One should place the suture button in a similar location and direction as we previously described with screw fixation. Surgeons may employ dynamic fixation independently or in combination with a screw or second dynamic fixation device.
Arthroscopy is an additional treatment method that one can perform for the treatment of high ankle sprains. It can allow for debridement of interposed tissue within the syndesmosis and help facilitate reduction. To help detect diastasis, insert a probe into the syndesmosis (see fourth images above). If one can pass a three mm or greater probe into the syndesmosis, there is a strong indication that the anterior inferior tibiofibular ligament, syndesmosis and/or posterior inferior tibiofibular ligament are injured.9 The surgeon can use arthroscopy to evaluate the ankle joint and look for any other pathology, such as osteochondral injuries, which may change the treatment options and expected recovery time.
In addition to the aforementioned techniques, one can imbricate or repair the anterior inferior tibiofibular ligament if the remnants are intact. The surgeon can also recreate the ligament with utilization of other tissue if the anterior inferior tibiofibular ligament is absent.11 Examples could include utilization of an autograft or incorporation of allograft tendon. One can perform syndesmotic fusion as a salvage procedure if other treatment options fail.
Our preferred technique is a hybrid construct utilizing one 4.5 mm screw through four cortices as well as implementation of a suture retention device to act as a dynamic stabilizing force when we remove the screw at three months. We place fixation under arthroscopic guidance with additional arthroscopic debridement as necessary (see fifth images above).
Determining Appropriate Return To Sport For Athletes With High Ankle Sprains
If surgical correction is not warranted, conservative treatment should begin immediately. One should determine the timing for return to sport based on the patient’s pain and functional ability. There are no specific guidelines in the literature. In the senior author’s experience, most clinicians will utilize the opinions and recommendations of the physical therapist. Start slow and if there is no pain, then advance the patient’s activity. If the athlete returns to activity too quickly, he or she can experience decreased performance and an increased likelihood of worsening the injury severity or reinjury.
If one performs surgical correction, return to sport depends on the procedures performed and any coexisting injuries. If the surgeon utilizes screws, return to sport may be delayed until screw removal, which usually occurs two to three months after placement in order to prevent hardware failure. In a systematic review looking at return to sport after ankle syndesmotic injuries, Vancolen and team noted that the average time to return to sport was 41.7 days for non-operative treatment and 55.2 days for operative treatment.4
What You Should Know About Possible Sequelae With High Ankle Sprains
If you attempt conservative care, the patient may continue to have functional limitation due to continued instability, heterotopic ossification and pain. This may happen if the syndesmosis is more severely damaged than originally thought, if there are other concomitant injuries or if the athlete attempts to return to sport too quickly. If this occurs, the patient will likely need to have surgical fixation and evaluation to determine the presence of other injuries such as synovitis or osteochondral lesions.12
Surgical treatment can fail or pose challenges as well. Complications from surgical treatment can include infection, hardware failure, malreduction, heterotopic ossification and arthritis. Malreduction can cause stiffness or result in further damage such as osteochondral lesions, synovitis and arthritis. A CT scan can help evaluate for malreduction which, if present, may require the patient to undergo more surgical procedures to remove hardware, correct the malreduction and address other injuries. If this is not corrected, further damage can occur with decreased likelihood of return to sport.
For both conservatively and surgically managed injuries, recurrence is a possible consequence of high ankle sprains. Approximately 9.8 percent of high ankle sprains that occur are recurrent injuries.12 In the case of an injury recurrence in football players, surgical management will likely be necessary with an extended rehabilitation course prior to return to sport, depending on the patient, associated injuries and previous treatment.12
The overall treatment goal for football players who experience a high ankle sprain is return to sport without limitations. One can achieve this goal through prompt diagnosis and determination of injury severity utilizing clinical and imaging evaluations. Based on the stability and severity of the injury, one should initiate conservative care methods early in all cases and ensure appropriate surgical consideration for those with severe injury.
Proper identification of the injury is paramount in the athlete. If complete disruption of the ligament occurs and is not treated, the athlete will be destined to degenerative arthrosis of the ankle. The clinician must perform anatomic stabilization of the syndesmosis when he or she has identified diastasis through clinical evaluation and imaging. The practitioner must be aware of the degree of injury and be able to identify if there is a need for surgical intervention.
Dr. Stack is a third-year resident at Highlands-Presbyterian/St. Luke’s Residency Program in Denver, CO.
Dr. Ng is a Past President of the American Board of Foot and Ankle Surgery and Fellowship Director of the Rocky Mountain Foot and Ankle Reconstructive Fellowship.
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