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Ankle Ligament Injury

High Ankle Sprain

Minute Read


Posted 1 year ago


Last updated: 03/12/2022


by James McCormack

High Ankle Sprain: Anatomy

The two common types of ankle ligament injuries are a high ankle sprain and a low ankle sprain. Low ankle sprains involve the ligaments on the inside and outside of the ankle while a high ankle sprain involves the ligaments connecting the tibia and fibula together along with the syndesmosis. These ligaments are the Anterior Inferior Tibiofibular Ligament (AiTFL, the Posterior Inferior Tibiofibular ligament (PiTFL), and the interosseous membrane.

The AiTFL is located at the front of the ankle, the PTFL at the back of the ankle, and the interosseous membrane is a large sheet of membrane that connects the tibia and fibula together along the shin, providing additional stability.

Sprained Ankle Diagram

High Ankle Sprain: Symptoms

Injury to the high ankle ligaments causes pain at the front of the ankle and in severe cases can cause pain at the back of the ankle and on the middle of the shin. Severe cases of high ankle sprains involve compromise to all 3 key structures and can lead to instability of the ankle with movement. there is often an audible pop or crack when a high-grade sprain occurs to the high ankle. Activities such as climbing stairs, running and hopping can be very painful while there may not be a lot of visible bruising or swelling, even in severe cases.


High Ankle Sprains are caused by sudden twisting or turning motions of the foot and ankle. Planting of the foot in dorsiflexion with forced external rotation of the ankle from trauma like a tackle in sport can lead to more severe ligaments tears. High ankle sprains can also be the secondary outcome of an ankle fracture or ankle dislocation. It is often seen in the following sports:

  • Rugby
  • Basketball
  • Football
  • Wrestling
  • Ice Hockey
  • Skiing
  • Running

Diagnosis of High Ankle Sprains

High Ankle Sprains are a complex injury that is often misdiagnosed in severity due to the complex nature of the injury. As a result, it is important to see an experienced Physical Therapist in ankle injuries for a clinical examination. This form of examination is often sufficient for a clinical diagnosis in mild or Grade 1 high ankle sprains but in higher grade sprains a scan is often required to establish the complexity of the injury.

High Ankle Sprain Diagram

Physical Examination

A clinical examination will contain two special tests; the Squeeze test where the proximal end of the tibia and fibula are squeezed together with pain provocation indicating a positive test.


Secondly, the patient is positioned prone with their knee bent. The therapist takes their ankle into dorsiflexion and external rotation (Kleigers Test). If there is pain in the anterolateral ankle, it is a positive result.


An MRI is the gold standard scan for high ankle sprains. It will provide information on any soft tissue damage such as a ligament tear or compromise to the syndesmosis.


In addition to this, it can detect any bony injuries such as a fracture to the tibia and/or fibula


An ultrasound is a cost-efficient alternative to an MRI and will provide live feedback on the status of the AiTFL & PiTFl. Although it can detect bony injuries, it is not as sensitive as an MRI scan.


An x-ray is unable to detect the integrity of ligaments but it can be useful for ruling out other conditions.

High Ankle Sprain Treatment

In the early stages, 0-3 days it is important to protect the joint as much as possible. Home remedies during this period compression taping, keeping the ankle elevated and applying ice to help with pain relief. In severe cases that involve compromise to the syndesmosis, it is recommended to immediately use a walker boot with crutches to protect the ankle joint.

Treatment with a Physical Therapist should begin as soon as possible. Physical therapy may involve soft tissue massage to restore range of motion. Rigid ankle taping may be applied to support the ankle and this can help to normalise walking gait. Some Therapists may use KT Tape to help decrease swelling.

Progressive strengthening exercises alongside balance and proprioception exercises are part of a standard rehabilitation program. A Physical Therapist specialises in knowing when and how to progress these exercises throughout the recovery process.

When entering the later stages of rehabilitation, change of direction exercises, hopping protocols, and sport-specific exercises are added to rehabilitation.

In severe cases where the high ankle ligaments are completely ruptured or clinically insufficient, surgery may be required. This typically involves a surgical fixation using a screw and/or wire to provide stability to the joint. This is followed by a rehabilitation program.

Picture of James McCormack doing a FHL Strengthening Exercise

picture of james mccormack doing a Single Leg Balance on Wobble Cushion exercise

Physiotherapy with James McCormack

This is not medical advice. We recommend a consultation with a medical professional such as James McCormack. He offers Online Physiotherapy Appointments for £45.

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