The Seahawks All-Pro cornerback Richard Sherman left  in the fourth quarter of the Super Bowl with an apparent ankle injury. He appeared to be writhing in pain on the ground after assisting on a tackle of Demaryius Thomas who had made a reception. It was the second time in the game Sherman had to leave the field because of an injury to his ankle. He was placed in a walker boot, and given crutches. It appears he sustained a high ankle sprain.

What is a High Ankle Sprain?

high ankle sprain is injury to the higher ankle ligaments, which are located above the ankle joint (closer to the knee with respect to the ankle).   Untitled

These high ankle ligaments connect the tibia (shin bone) to the fibula (outside leg bone). The injury involves the syndesmosis between the lower tibia and fibula just above the ankle joint.The syndesmosis is a fibrous joint where the two leg bones are connected together by ligaments or connective tissue and usually have very little mobility. High ankle sprains are much less common but are more disabling than a traditional lower ankle sprain. They must be diagnosed at an early stage and appropriate treatment initiated. Treatment of high ankle sprains differs from a lower ankle sprain.


What Causes a High Ankle Sprain?

High ankle sprains most commonly occur when the foot is planted on the ground and then an excessive outwards twisting of the foot occurs. Untitled.2

High ankle ligaments can also sprain when the ankle is loaded severely and pushed into excessive dorsiflexion. This often occurs in football tackles as with Richard Sherman.


What are the Symptoms of a High Ankle Sprain?

High ankle sprains occur following a traumatic ankle injury. Patients often report:

  • Pain felt above the ankle that increases with outward rotation of the foot.
  • Pain with walking and often significant bruising and swelling across the higher ankle rather than around the malleolus.

The severity of symptoms will depend on the grade of ankle sprain: mild, moderate, and severe. Patients with a high ankle sprain without fracture may be able to bear weight, but will have pain over the junction between the tibia and fibula just above the level of the ankle. This is higher than the more traditional sprains.


How is a High Ankle Sprain Diagnosed?

If high ankle sprain is suspected an X-ray, CT scan or MRI maybe ordered to confirm the diagnosis, after performing a physical examination.

What is the Usual Treatment for a High Ankle Sprain?

The vast majority of high ankle sprains are treated conservatively (non-operatively) with splinting of the ankle to reduce motion of the painful joint. Elevation and icing to the ankle is helpful to reduce swelling. Non-steroidal anti-inflammatory medications are usually prescribed to aid in pain control and swelling. Crutches may be necessary to assist with ambulation.

Once the acute inflammatory phase is over, physical therapy is prescribed. Gentle range of motion exercises are begun as tolerated. This is followed by strengthening exercises to the muscles of the lower leg. Graduated, sport-specific exercises are then initiated with the goal to return the athlete to sports when he or she is able to run, jump, cut, and pivot without pain. An ankle brace or taping of the ankle may help reduce the risk for recurrent injury once the athlete returns to sports.

Surgery is rarely necessary for high ankle sprains and is indicated only if there is significant injury to the ligaments around the ankle resulting visible separation of the tibia and fibula bones. In this situation, an orthopedic surgeon will place one or two screws across the two bones to restore their normal anatomic relationship.

syndesmotic screw placement


When Can Athletes Return to Sports Following a High Ankle Sprain?

Despite the fact that most athletes who experience a low ankle sprain can return to sports within one to three weeks following the injury, those players who sustain a high ankle sprain are often out of sports for four to six weeks depending upon the injury severity. Sports that involve cutting and pivoting, such as football, are especially difficult to play in the setting of a high ankle sprain. The player’s position may also dictate the length of recuperation as running backs or linebackers who have to quickly change direction are often the most disabled with this injury. For those athletes who require surgery, sports activity can usually be resumed in approximately four months. Therefore, surgery for this injury typically results in an inability to return the same season. Once an athlete sustains an ankle sprain, he or she, unfortunately, is more prone to future injuries.