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Physical Therapy for a High Ankle Sprain

Physical therapist treating high ankle sprain with manual therapy.

Treating High Ankle Sprain with Physical Therapy 

High ankle sprains, also known as a Syndesmotic injury, are much less common but far more disabling than traditional ankle sprains. High ankle sprains are the result of tearing and damage of the ligaments that are located above the ankle joint that connect the tibia to the fibula – including the anterior tibiofibular ligament, transverse ligament, posterior inferior tibiofibular ligament, and interosseous ligament. Accurate diagnosis and appropriate treatment by a qualified physical therapist can ensure that your ankle heals correctly.

Cause of High Ankle Sprains

High ankle sprains most commonly occur due to rotational forces. However, they can also occur when there is excessive load placed on the ankle and the foot is forced into dorsiflexion.

High ankle sprain can occur in conjunction with an ankle fracture, and in some cases the deltoid ligament, which is on the inside of the ankle can be torn. When this occurs, the force of the injury passes from the deltoid ligament to the high ligaments of the ankle, and up toward the fibula. This results in a fracture of the fibula at a very high level, known as a Maisonneuve fracture.

Signs and Symptoms of a High Ankle Sprain

Symptom severity varies depending on the grade of the ankle injury, and often includes:

-       Pain above the ankle that increases when the foot is placed in outward rotation

-       Pain with walking

-       Significant bruising and swelling across the higher part of the ankle

-       Deltoid ligament tenderness (if a Maisonneuve facture is present)

Treatment Options for a High Ankle Sprain

There are three phases to treatment for a high ankle sprain. Your physical therapist at Blue Hills Sport & Spine Rehabilitation will observe you and progress you through the phases of rehabilitation properly.            

Phase 1

Goals of treatment in phase 1 include decreasing inflammation, restoring range of motion (both active and passive), and maintaining strength and cardiovascular endurance.

Treatment options in phase 1:

- Protect, rest, ice, compress and elevate (PRICE) to help control pain and inflammation

- Active ankle range of motion exercises

- Restricted weight-bearing

- Mobilizations of the ankle

- Passive range of motion exercises

- Soft tissue massage

- Upper extremity pedaling or stationary bike (if patient is able to tolerate it)

Once pain and inflammation are under control and the patient is able to walk with minimal limping, progression to phase 2 of rehabilitation is recommended.            

Phase 2

Goals of treatment in phase 2 include increasing strength and proprioception, and improving gait. In phase 2, the patient should start to perform basic skills such as jogging, hopping, and pivoting around obstacles.            

Treatment options in phase 2:

- Resisted ankle range of motion exercises, using theraband

- Lower body strength exercises such as squats and lunges

- Proprioceptive exercises, such as single leg stance

Progressing strength and proprioceptive exercises should be to patient tolerance. Progressing exercises too quickly can have a negative effect and increase rehabilitation time.

Strengthening exercises in phase 2 should be started with lower weight and higher repetition sets followed by progression to higher weight and lower repetition sets. Proprioceptive exercises can be progressed once the patient is able to perform the single leg stance without difficulty. A foam pad or pillow can be added to make the exercise more challenging; additionally, the single leg stance can be progressed by having the patient perform single leg mini squats or by adding in a ball toss.

Once the patient is able to hop repeatedly without difficulty, they can progress to phase 3 of rehabilitation.            

Phase 3

Goals of treatment in phase 3 include getting the patient back to their normal level of functioning.            

Treatment options in phase 3:

- Aggressive strengthening exercises

- Sport specific drills

- Leaping, jumping, and side to side and backwards movements

- Plyometrics (added in the later part of phase 3 to increase power)

In addition to progressing you through the three phases of rehabilitation, your physical therapist may use modalities to control pain and inflammation, including:

- Ice to decrease inflammation and pain throughout your rehabilitation program

- Transcutaneous electrical simulation (TENS) and/or Interferential therapy (IFC) for pain relief in the early phases of rehabilitation

Conservative treatment, such as physical therapy, is beneficial in most mild to moderate cases of high ankle sprains. However, in some cases, involving syndesmosis tears, or those that are complicated with a fracture, surgical repair may be needed.

Recovery from a high ankle sprain can take quite a bit longer than traditional ankle sprains. For many athletes it can take six to seven weeks before they’re able to return to play.


If you think you’ve suffered a high ankle sprain contact one of the physical therapists at Blue Hills Sport & Spine Rehabilitation to evaluate your ankle and start appropriate treatment to help decrease your pain and get you back to your normal activities as quickly as possible.