Ankle Bone Connected to the… Syndesmosis?

The high ankle sprain: It is what it is but it ain’t what you think.

Who invented the “high” ankle sprain, anyway? It seems like only a decade ago that an ankle sprain was an ankle sprain, and we didn’t discuss whether they were high, low, or in between. At some point in the last few years the concept of the high ankle sprain has entered the lexicon of sports injuries, but in many cases it seems to cloud rather than clarify the picture. What is meant by a “high” ankle sprain, and what are the implications for recovery time and a player’s overall effectiveness once he does return?

Ankle sprains are an extraordinarily common occurrence. Essentially, everyone has “rolled” their ankle at some point, whether playing sports or in the course of everyday life. What we would consider a routine ankle sprain usually involves the lateral ligaments of the ankle ‒ the anterior talofibular ligament and the calcaneofibular ligament. These are injured in an inversion type of ankle sprain, which is the most common – when the ankle rolls to the outside, with the sole of the foot turning toward the inside.

Less frequently, the ligaments on the inside of the ankle, the deltoid ligaments, can be injured. Both of these injuries are more common than “high” ankle sprains, and while they can be a source of significant time lost for an athlete, they tend to be relatively predictable in terms of recovery and return to action.

“High” ankle sprains are actually an injury to a separate anatomic structure, the syndesmosis. The syndesmosis is actually a number of different ligaments, including the anterior-inferior tibiofibular ligament, interosseous ligament, and posterior-inferior tibiofibular ligaments. As a whole, these are responsible for maintaining the relationship of the tibia to the fibula and thereby maintaining the stability of the ankle.


While the lateral and medial ligaments of the ankle are usually injured when the ankle is “rolled,” the syndesmosis is put at risk with more rotational injuries. Imagine a player’s foot being planted and someone tackles them in such a way that their lower leg rotates around the stationary ankle. A relatively recent and high-profile example of this was Rob Gronkowski being turned into an oversized decoy for Super Bowl XLII when his syndemsosis was shredded by noted Patriot-killer and likely puppy-kicker Bernard Pollard in the AFC Championship Game that same year. Not that I’m bitter…

This picture illustrates this mechanism of injury very well. Gronkowski’s left foot is just coming up off the ground, but it is still turned to the left in exaggerated fashion after being planted while he was tackled.

Photo Credit

His left leg rotates inward, causing the ankle to rotate externally, which sprained or tore the syndesmosis. While he still played in the Super Bowl, his mobility was definitely affected adversely. Gronk ultimately underwent postseason surgery to address the injury.

What are the implications for a player’s return to the field after a syndesmotic injury? Our overall experience shows that the time required is almost always longer than with standard, “low” ankle sprains; several studies have shown average recovery durations for high-ankle sprains to be approximately two weeks, but in more severe cases even those non-operatively treated may result in patients being sidelined 6 to 8 weeks. Typically when players come back from this injury they will not have any ongoing symptoms – as long as they are fully healed. There have been numerous examples, however, of players attempting to come back too soon and re-aggravating a high ankle sprain – Dee Milliner of the Jets is a recent case in point.

On occasion, this may be a surgical problem – when the ligaments are fully torn, they are stabilized and allowed to heal by inserting screws between the fibula and tibia.

This necessitates 8 to 12 weeks of limited weight-bearing followed by removal of the screws and a long course of rehabilitation. While these athletes may have occasional pain and stiffness, most will come back at full strength after 6 to 8 months.

In summary, high ankle sprains are a more severe injury than a run-of-the-mill ankle sprain, resulting in a longer times out of action and on some occasions requiring season-ending surgical intervention. If recognized and managed properly, however, most players will return in two to six weeks with no significant lingering effects.

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