High ankle sprains – syndesmosis injury

It is only too fitting to be talking about syndesmosis injuries with Jack Gunston from Hawthorn working hard to get back for this weeks preliminary final in the AFL 2 weeks post injury.

As per a previous post, ankles are the most commonly injured body part in a wide variety of popular Australian sports.

If you hurt your ankle, an important injury not to miss is the ‘high ankle sprain’, or syndesmosis injury.

Your 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 your traditional lower ankle sprain. They must be diagnosed early stage and appropriate treatment initiated, which do differs from a lower ankle sprain.

Syndesmosis injuries account for approximately 11% of all ankle injuries, with a higher occurrence in sporting activities that involve twisting or cutting manoeuvres.

This is where the diagnosis is important – high ankle sprains can lead to long term instability and weakness of the ankle complex if not treated right – including pain from extra movement and longer term complications such as arthritis.

The most common way to injure these ligaments is through an external rotation mechanism (where the foot is turned away from the body), or with excessive dorsiflexion (the movement at the ankle where the shin moves forward over the fixed foot in weight-bearing).

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 bone on the side of the ankle).
• A high ankle sprain, if on its own, will usually have less swelling than with a classic lateral ankle sprain.

As with any soft tissue injury, it is important to get the right management underway straight away.

• Rest the injured ankle, and stay away from aggravating activities until directed. Use crutches to off-load the injured ankle if it is painful to walk.
• Ice the injured ankle. Cooling the injured area (every 2hours in the first 48 hours after initial injury) will decrease inflammation and swelling, and speed up the recovery process.
• Compress the swollen area with elastic bandaging to aid with swelling control.
• Elevate the ankle to decrease the swelling symptoms
• Diagnosis – Book in an appointment at a Physiotherapist, to get a clear diagnosis and management plan for your high ankle sprain injury. The diagnosis is particularly important here, as continued weight-bearing on a high ankle sprain can delay healing whereas walking with a lateral ankle sprain can actually promote healing.

There are specific tests that your physiotherapist will carry out to confirm or deny a high ankle sprain – and if suspicious a stress x-ray is required to see if the ankle is stable or not when a force is applied.

If instability is noted on the x-ray, an MRI may be required to determine the extent of damage to the ligaments – a MRI will also show up any bone bruising, which can affect how your rehab progresses.

Through the use of history taking, clinical tests, and relevant imaging, it will be determined if surgery is required or not.

Unstable high ankle sprains may require a ‘syndesmotic screw’ – a screw between the two long bones of the lower leg, which generally requires 6 weeks of no weight on the foot after surgery, and a general return to sport time of 3-4 months. The screw can be later removed.

If no surgery is required, a comprehensive conservative rehab programme will be put in place by your physiotherapist.

This will generally involve a period of non-weightbearing on crutches – as with high ankle sprains weight through the ankle can continually stress the damaged ligaments as they are initially healing.

An aircast ‘boot’ will help stabilize the joint but still allow you to maintain range of motion.

As your rehab progresses, stretches and activities will be put in place to return the mobility, strength, and balance reactions of your injured ankle.

As a general rule, high ankle sprains of a lower grade can take up to 6-8 weeks to recover, or twice as long as a classical ankle sprain.

However, there are no set rules for return to running, training, and sport – as each injury is different and our physios will manage your progress closely.

So, will Jack Gunston be able to play this week? What about for the Grand Final if Hawthorn make it through?

Lifecare Prahran Sports Medicine is close to suburbs including Malvern, South Yarra, Toorak, Armadale, St Kilda East, Caulfield, Richmond and Hawthorn, and has early and late appointments for all your sports medicine and physiotherapy needs.