High Ankle Sprain
Fall and winter collision sports like football, hockey, and even soccer, pose unique threats to the bodies of its participants. The foot and ankle are common sites of injury. This article will focus on the current evidence-based assessment and management of one of the more troublesome ankle injuries.
“Syndesmotic ankle sprain” or “high ankle sprain” follows damage to the ligaments and tissues that hold the tibia and fibula together at the ankle mortise joint. Syndesmotic sprains are much less common than their lateral counterparts (representing less than 10% of all ankle sprains) but are more difficult to assess and manage with significantly longer recovery times. (1-3)
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Joint Anatomy
The ankle mortise joint is comprised of the (slightly concave) tibia and the (slightly convex) fibula, which rest on the talus. (4,5) These three bones are held together by three ligaments: the anterior tibiofibular ligament (AITFL), the posterior tibiofibular ligament (PITFL), and the interosseous membrane. The triangular-shaped AITFL begins with a broad origin on the anterolateral tibia and runs obliquely to a point on the anterior aspect of the lateral malleolus. (5-7) The more horizontally oriented PITFL is comprised of a superficial band and a deeper component (inferior transverse ligament) that together connect the posterior aspects of the tibia and fibula. (5,7) Finally, the interosseous membrane connects the medial aspects of the tibia and fibula along their entire length. (4) The distal termination of the interosseous membrane consists of a fibrotic thickening, called the interosseous ligament, which further stabilizes the joint. (6,9)
The primary function of the syndesmotic ligaments is to prevent excessive widening of the ankle mortise by holding the fibula tight to the tibia. (10) During normal ankle dorsiflexion, the wider anterior aspect of the talus wedges and spreads the tibia and fibula by 1-2 millimeters. (10,11) Additionally, ground reactive forces cause approximately 5 degrees of external rotation of the talus, which forces the fibula laterally. (10) The distal fibers of the interosseous membrane act in a spring-like fashion to accommodate this separation during dynamic loading.
The Injury
Disruption of the syndesmosis occurs from forces that cause excessive mortise widening, particularly external rotation (pushes the fibula laterally) and hyperdorsiflexion (wedge effect). (11,13-17) Isolated external rotation injuries produce a predictable pattern of damage, commensurate to the force involved. First, the deltoid ligament is ruptured (or the medial malleolus is avulsed), followed by progressive tearing of the AITFL, the PITFL, and finally, the interosseous membrane. (18) Particularly forceful injuries may terminate in a spiral fracture to the proximal fibula (Maisonneuve fracture). (18)
Symptoms
Patients typically present following an athletic injury that involves external rotation of the tibia on a planted dorsiflexed foot. (13) Syndesmotic sprains are common in collision sports, like football, hockey, and soccer. (12,14,19,20) Snow skiers may be predisposed from excessive rotational stress. (15) Symptoms may mimic those of other types of ankle sprain, but the pain of a syndesmotic injury is typically located slightly higher, just above the ankle. (21,22) Patients with severe injuries will not be ambulatory, and those able to bear weight will usually report pain when standing or walking. Dorsiflexion or outward rotation of the foot will likely intensify symptoms. Significant bruising or swelling is possible. Clinicians should suspect neurovascular compromise in patients complaining of numbness, paresthesias, or a cold foot. (23)
Palpation will likely demonstrate tenderness and swelling over the AITFL, but focal tenderness does not necessarily indicate injury to that ligament since AITFL tenderness is a common finding in any ankle sprain. (24) Tenderness that begins over the AITFL and extends proximally is a more noteworthy finding. The length of tenderness as measured from the distal tip of the lateral malleolus (Syndesmotic Tenderness Length) directly correlates with injury severity and disability for syndesmotic sprains. (25) Range of motion testing will demonstrate pain on dorsiflexion or external rotation. Passive external rotation with the ankle neutral or slightly dorsiflexed (External Rotation Test) widens the ankle mortise joint and will likely reproduce symptoms of syndesmotic injury. (14,25) A positive Eversion Stress Test may suggest Deltoid ligament involvement. Anterior and Posterior Drawer Tests may help assess for instability.
Tests
The Fibular Squeeze Test is a classic (but non-specific) assessment for syndesmotic injury that consists of compressing the mid-portions of the tibia and fibula to create sheer strain on the distal syndesmosis. (21,25,26) The test is considered positive when compression causes pain over the distal syndesmosis. A self-service version of the Fibular Squeeze Test called the Crossed Leg Test, is performed by having the patient cross the mid portion of the affected leg over the opposite knee while applying a compressive downward force over the proximal tibia. (27) The Syndesmotic Stabilization Test consists of applying athletic tape around the distal syndesmosis and having the patient perform the provocative activity, including standing, toe raising, heel raising, squatting, and jumping. Diminished pain with the ankle stabilized suggests syndesmotic injury. (25,28) Additional orthopedic assessments include translating the talus medially and laterally (Cotton Test) or sheering the fibula in an anterior to posterior fashion (Fibular Translation Test). (13,29-31)
Clinicians should assess for the possibility of neurovascular compromise by palpating the dorsalis pedis and posterior tibial pulses and testing sensation, particularly over the distribution of the sural and peroneal nerves.
Radiology
The Ottowa ankle rules are a well-established standard for determining the need for radiographs following trauma. (32-34) The Ottowa rules suggest that radiographs are appropriate following injury when there is point tenderness over the medial or lateral malleolus, navicular, and/or base of the fifth metatarsal or the instability to bear weight for at least four steps. Employing the Ottowa rules allows clinicians to exclude fractures with nearly 99% accuracy. (32-34) These rules were intended for adults, but have since been shown to be accurate for children as young as two years. (33,34)
Radiographic views would include AP, lateral, and ankle mortise views. Clinicians should observe for osseous avulsions on the anterior or posterior aspects of the tibia, which are present in up to half of all true syndesmotic injuries. (35) Stress radiographs, performed in a single-leg, weight-bearing position, may demonstrate widening of the ankle mortise joint. (25) Gapping of greater than 5 mm as measured on an AP or mortise view is considered “diastasis,” i.e., a pathologic separation of the ankle mortise joint. (7) This space is termed the “talofibular clear space.” Syndesmotic injuries may occur without diastasis, with diastatis that occurs under stress (i.e. weight-bearing radiographs), or frank diastasis. (36,37) A study on NHL hockey players demonstrated that only one out of 14 syndesmotic injuries demonstrated diastasis on stress radiographs. (38) MRI will definitively demonstrate ligamentous injury. Diagnostic ultrasonography can demonstrate ligamentous damage as well.
Highly suspicious cases, or those that do not respond to a short trial of conservative therapy, may require advanced imaging. (35,40) Advanced imaging is helpful to determine the grade of injury and to rule out alternate diagnoses, including osteochondral lesion or tumors. (10) A CT or bone scan may help detect subtler bony abnormalities (stress fracture, osteochrondral defect, etc.) (41) Dynamic ultrasound has been shown to reliably visualize AITFL tears or abnormal mortise widening. (10)
The differential diagnosis for syndesmotic sprain includes fracture (talar dome, calcaneous, malleolus, osteochondral, avulsion, etc.), intraarticular meniscoid (impingement syndrome), complex regional pain syndrome (RSD), tendinopathy (tibialis posterior, flexor hallucis longus, Achilles, peroneal, etc.), medial or lateral sprain, inflammatory arthoropathy, peripheral neuropathy, or osteochondritis dissecans.
Treatment
While ankles demonstrating diastasis or instability will likely require surgical intervention, most uncomplicated Grade I syndesmotic sprains will respond to conservative care. (42-48) However, syndesmotic ankle sprains heal more slowly than their medial and lateral counterparts. (49) In fact, recovery of a syndesmotic sprain may require a treatment period twice as long as a Grade III lateral ankle sprain. (10,38) Sports-specific disability can last up to four months with an average recovery time lasting between 2-7 weeks. (50)
Early Rehab
Early progressive rehab may help improve lymphatic drainage, enhance proprioception, restore ligament strength, and minimize fibrosis and atrophy. (25) The initial goals of treatment include suppressing pain, inflammation, and swelling while preserving joint mobility and muscle strength. (51-52) A brief period of non-weight bearing may be required to minimize undue stress on the injured syndesmotic ligaments. (25,54) An ankle stirrup does little to prevent external rotation or dorsiflexion, so a boot may be required to minimize these provocative movements. (51) Patients may begin gentle active range of motion and proprioceptive exercises as tolerated. (55) Isometric exercises should be employed in the early phase to minimize muscular atrophy. Ice, compression, elevation, and anti-inflammatory modalities or medications may provide benefit. (51,52,56)
Progression of rehab is dependent upon the severity of the injury and the patient’s response to therapy. When the patient is able to perform full weight bearing, including stairs, rehab may progress to include stretching and light resistance exercise. (51) The goal of this subacute phase is to restore pain-free function during basic activities of daily living. Stationary cycling or aquatic therapy may be useful during this stage. Proprioceptive training may reduce the recurrence of re-injury and may include an air cushion, rocker board, or BAPS board. (57-59)
Joint Mobilization
Stretching exercises should be directed at the gastroc and soleus. (55) Strengthening exercises should target the ankle stabilizers (peroneals, tibialis anterior, etc) (60) Clinicians should address hip abductor weakness to minimize excessive sway. (60) The judicious application of joint mobilization may help release restrictions and improve the range of motion. (61-65) Soft tissue techniques, including myofascial release and IASTM may be appropriate.
The final phase of rehab includes functional drills, including running, figure 8 running, jumping, plyometrics, and sports-specific drills. Dribbling, cutting, and shooting begin as tolerated and eventually progress to game speed. (51) When the patient is able to perform sports specific tasks without symptoms, they may be cleared to return to activity. (51)
The literature regarding Grade II and Grade III syndesmotic injuries is sparse, with no clear standard to guide management. (48,66-72) Diastasis of greater than 5 mm suggests ligament disruption, which precludes the ability to push off, propel, or cut. (73) Diastasis requires surgical fixation with screws to stabilize the ankle. (73)
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