"High" Ankle Injuries in Soccer
Soccer is classified as a dynamic, aerobic, impact sport. Injuries are inevitable and lower extremity injuries are the most common musculoskeletal injuries reported among male and female soccer players of all ages and levels of competition and participation.
Ankle sprains are one of the most common musculoskeletal injuries in the United States among both athletes and non-athletes and the disability caused by these injuries and the time spent recovering can impact both work and sports/recreation participation.
Approximately 10% of all ankle injuries are recurrent injuries.
Medically speaking, ankle injuries can be classified in many ways. In general, ankle injuries can be described as ‘common’ or ‘high’ ankle injuries.
This blog helps athletes better understand the general difference between the two and focuses attention on the mechanism, symptoms and recovery associated with the ‘high’ ankle sprain among footballers—though most of this information can be applied to any sport.
The Lower Leg
Below the knee joint, the lower leg is composed of two long bones—the tibia which is the strong, thick ‘shin’ bone and the thinner, largely non-weight-bearing bone on the outer aspect of the lower leg called the fibula. Even though the fibula does not 'do' much in terms of supporting body weight, it plays an important role in stabilizing the lower leg and the ankle. These two bones are kept in close proximity to one another by a series of ligaments that make up a tough band of tissue called the syndesmosis.
The syndesmosis is the site of injury in ‘high ankle’ sprains.
The Ankle Joint
The ankle is not a bone, but it is an anatomical location where 3 bones come together (articulate) and are stabilized and held together by tendons (the ends of muscle that connect to bone) and ligaments (tissue that connects bones to one another). These bones are the tibia, the fibula, and the talus. When the joint is functioning properly, the ankle is able to move dynamically and withstand forces 3 or more-times a footballers’ total body weight.
Common Ankle Injuries
The ankle cannot be ‘broken’ per se, and medically, ankle fractures are described in terms of the bone(s) involved as well as other grading systems and descriptive terms. Ankle fractures are far less common than tendon (strains) and ligament (sprains) injuries.
Common ankle sprains most often involve inversion injuries where the ankle suddenly ‘twists’ inwardly. Athletes often call this ‘rolling’ their ankle. The most common ligament injured in the common ankle sprain is the anterior talofibular ligament (ATFL), though sprains can involve one or more ligaments. It is also important to note that virtually all ankle sprains also involve an element of tendon (strain) injury.
It is just a a lot to say "I sprain-strained my ankle", so we typically simply call it a sprain.
Some injuries that produce discomfort in or around the ankle joint aren't ankle injuries at all.
One of the most common examples is an injury to the Achille's tendon which is actually a lower leg injury that involves the foot because the gastrocnemius (calf) muscle originates in the lower leg and attaches to the back of the heal.
Common Ankle Injuries | Symptoms & Findings
- account for about 85% – 90% of ankle sprains
- pain, swelling, bruising and pain involving the ankle joint and foot
- pain is often worsened with attempting to walk, step, run or hop
- athlete recovery and full return to unrestricted participation typically takes 6 to 12 weeks with a structured rehabilitation program—longer without
‘High’ Ankle Injuries
Because ‘high’ ankle injuries involve different lower leg structures, the signs, symptoms and examination findings are different. ‘High’ ankle injuries involve the syndesmosis of the lower leg—the strong ligamentous band of tissue between the tibia (shin) and fibula).
While the ATFL is an important stabilizing ligament of the ankle joint, the syndesmosis is an important stabilizer of the shin and fibula. Walking, running, twisting, jumping and sudden changes in direction exert tremendous force on the lower leg and the syndesmosis helps keep the tibia and fibula from being spread apart too far. When you bear weight on the leg, the tibia and fibula experience high forces that spread them apart.
While common ankle sprains involve ‘rolling’ the ankle, ‘high’ ankle sprains more commonly involve eversion (outward movement) or a movement called dorsi-flexion—where the foot bends suddenly and forcefully toward the shin.
'High' Ankle Injuries | Symptoms & Findings
- account for up to 5% to15% of ankle sprains
- pain and swelling to the ankle joint is far less common, often sparing the foot entirely
- pain that radiates upward towards the shin, particularly when attempting to weight-bear or pivot on the foot
The Lower Leg Examination
A proper examination of an injured ankle will start with obtaining a history from the patient of how the injury occurred (timing and mechanism), initial symptoms, home care and treatment and any other clinical evaluation (from a primary care physician, emergency department, urgent care or athletic trainer).
Next, the examiner will perform a complete evaluation of the knee, lower leg, ankle and foot.
The exam will start with a general inspection—looking for deformity, bruising, swelling, warmth and other wounds such as lacerations (cuts) or abrasions (scrapes) and previous surgical scars.
Next, the function and stability of the muscles, tendons and ligaments and joints will be evaluated—including assessing the range-of-motion and the ability to bear-weight (stand and move on the injured leg). Both restricted and abnormally-increased range of motion (called joint laxity) may be an indication of injury.
The examination will also include an evaluation of the circulation (blood flow) and pulses as well as an assessment of the nerve function.
After the physical examination, the examiner may decide to obtain imaging (plain xrays, CT imaging or MRI)
Diagnosis of ‘High’ Ankle Sprain
- History and mechanism of injury
- Physical Exam findings including a fibular compression test also called the high ankle sprain test or the syndesmosis squeeze test
- many times, particularly in elite-level athletes or in those with persistent symptoms or significant deformity or exam findings, imaging studies (X-ray, CT, MRI) may help in diagnosis and treatment decisions
Treatment of ‘High’ Ankle Sprain
- Initial treatment typically includes ‘PRICER’ (Protect, Rest, Ice Compress, Elevate, Re-evaluate), modified weight-bearing
- Protect & Rest: limit use/weight-bearing, crutches, walking boot, splinting
- Ice: apply ice to injured area to reduce pain and/or inflammation
- Compress: appropriate use of ace bandage wrap for comfort and inflammation
- Elevate: at rest, elevating the injured ankle will reduce pain/swelling
- Re-evaluate: follow-up evaluation prior to resuming unrestricted activities
- Early, limited weight-bearing—evidence suggests that the duration of immobilization and/or limited weight-bearing may be twice as long as that for common ankle sprains.
Recovery Timeline
Every footballer is different and thus there is no specific, hard-and-fast rule for the recovery duration from a ‘high’ ankle sprain.
In general, however, the recovery time for ‘high’ ankle sprains that do not require surgery is 6-8 weeks, though as many as half of athletes will reports symptoms for as long as 6 months following injury.
Guided rehabilitation from trained athletic trainer or physical therapist has been clearly shown to improve recovery and in some cases, shorten recovery time
Advanced imaging my be required in athletes where there is any evidence of potential ligament instability
A small percentage of lower extremity injuries (including common and 'high' ankle injuries) may require surgery to fix which will impact recovery time.
Elements that Impact Recovery & May Reduce Injury Risk
- Neuromuscular activation training which ‘connects’ the brain to the musculoskeletal system and focuses on balance, coordination and sport-specific movement patterns
- Evidence suggests that regular, proper neuromusculoskeletal activation may reduce the rate of ankle injuries by as much as 30%
- Proper movement mechanics are essential to an optimally stable joint
- Sleep, adequate recovery between training and competitive events, hydration and balanced nutrition all can positively impact musculoskeletal function
- injuries that impact participation and performance may also impact mood which, in turn, can negatively impact healing and recovery
Athletes may struggle socially-emotionally while recovering from injury. Part of the recovery process should include creating 'safe' spaces for open communication about these elements no different than conversations about physical pain/discomfort.
It is important for footballers to be properly evaluated following any musculoskeletal injury—particularly those that require removal from training or competition.
Early and proper diagnosis and the initiation of guided rehabilitation are important to getting the injured footballer back on the pitch safely.
Christopher T. Conti, MD is the Founder and Owner of Steel City Direct Care, LLC., a Pittsburgh, PA-based medical practice specializing in the care of athletes and aviators. He is an emergency medicine physician with additional training in sports and concussion health. He is currently a Team Physician for the US Soccer Federation (USSF), U14-U17 Youth National Team player pools, Medical Advisor for the PA West Soccer Association, a local affiliate of the United States Youth Soccer Association and the Medical Advisor for the Woodland Hills School District in suburban Pittsburgh, PA. Dr. Conti serves as Medical Advisory Board Member for SportGait and is also a Credentialed ImPACT Consultant (CIC) for sports concussion care. Dr. Conti is a designated Senior Aviation Medical Examiner (AME) for the Federal Aviation Administration (FAA)
Disclaimer
The information, opinions and content presented do not necessarily represent the policies or opinions of USSF, the FAA, PA West Soccer, USYS, FIFA, ImPACT, SportGait, the Woodland Hills School District or Steel City Direct Care, LLC.
None of the information presented should be construed as formal medical advice, nor should it be considered an acceptable substitute for a formal virtual or in-person encounter with an appropriately trained and licensed healthcare professional. None of the above-listed entities, including Steel City Direct Care, LCC, are responsible for any adverse outcome associated with this content.
If you would like to schedule a virtual or in-person visit with Dr. Conti, please contact Steel City Direct Care
Steel City Direct Care is a Direct Patient Care (DPC) practice that provides targeted & specialized in-person and virtual care for aviators and athletes of every age and level of skill and participation.
Ankle sprains are one of the most common musculoskeletal injuries in the United States among both athletes and non-athletes and the disability caused by these injuries and the time spent recovering can impact both work and sports/recreation participation.
Approximately 10% of all ankle injuries are recurrent injuries.
Medically speaking, ankle injuries can be classified in many ways. In general, ankle injuries can be described as ‘common’ or ‘high’ ankle injuries.
This blog helps athletes better understand the general difference between the two and focuses attention on the mechanism, symptoms and recovery associated with the ‘high’ ankle sprain among footballers—though most of this information can be applied to any sport.
The Lower Leg
Below the knee joint, the lower leg is composed of two long bones—the tibia which is the strong, thick ‘shin’ bone and the thinner, largely non-weight-bearing bone on the outer aspect of the lower leg called the fibula. Even though the fibula does not 'do' much in terms of supporting body weight, it plays an important role in stabilizing the lower leg and the ankle. These two bones are kept in close proximity to one another by a series of ligaments that make up a tough band of tissue called the syndesmosis.
The syndesmosis is the site of injury in ‘high ankle’ sprains.
The Ankle Joint
The ankle is not a bone, but it is an anatomical location where 3 bones come together (articulate) and are stabilized and held together by tendons (the ends of muscle that connect to bone) and ligaments (tissue that connects bones to one another). These bones are the tibia, the fibula, and the talus. When the joint is functioning properly, the ankle is able to move dynamically and withstand forces 3 or more-times a footballers’ total body weight.
Common Ankle Injuries
The ankle cannot be ‘broken’ per se, and medically, ankle fractures are described in terms of the bone(s) involved as well as other grading systems and descriptive terms. Ankle fractures are far less common than tendon (strains) and ligament (sprains) injuries.
Common ankle sprains most often involve inversion injuries where the ankle suddenly ‘twists’ inwardly. Athletes often call this ‘rolling’ their ankle. The most common ligament injured in the common ankle sprain is the anterior talofibular ligament (ATFL), though sprains can involve one or more ligaments. It is also important to note that virtually all ankle sprains also involve an element of tendon (strain) injury.
It is just a a lot to say "I sprain-strained my ankle", so we typically simply call it a sprain.
Some injuries that produce discomfort in or around the ankle joint aren't ankle injuries at all.
One of the most common examples is an injury to the Achille's tendon which is actually a lower leg injury that involves the foot because the gastrocnemius (calf) muscle originates in the lower leg and attaches to the back of the heal.
Common Ankle Injuries | Symptoms & Findings
- account for about 85% – 90% of ankle sprains
- pain, swelling, bruising and pain involving the ankle joint and foot
- pain is often worsened with attempting to walk, step, run or hop
- athlete recovery and full return to unrestricted participation typically takes 6 to 12 weeks with a structured rehabilitation program—longer without
‘High’ Ankle Injuries
Because ‘high’ ankle injuries involve different lower leg structures, the signs, symptoms and examination findings are different. ‘High’ ankle injuries involve the syndesmosis of the lower leg—the strong ligamentous band of tissue between the tibia (shin) and fibula).
While the ATFL is an important stabilizing ligament of the ankle joint, the syndesmosis is an important stabilizer of the shin and fibula. Walking, running, twisting, jumping and sudden changes in direction exert tremendous force on the lower leg and the syndesmosis helps keep the tibia and fibula from being spread apart too far. When you bear weight on the leg, the tibia and fibula experience high forces that spread them apart.
While common ankle sprains involve ‘rolling’ the ankle, ‘high’ ankle sprains more commonly involve eversion (outward movement) or a movement called dorsi-flexion—where the foot bends suddenly and forcefully toward the shin.
'High' Ankle Injuries | Symptoms & Findings
- account for up to 5% to15% of ankle sprains
- pain and swelling to the ankle joint is far less common, often sparing the foot entirely
- pain that radiates upward towards the shin, particularly when attempting to weight-bear or pivot on the foot
The Lower Leg Examination
A proper examination of an injured ankle will start with obtaining a history from the patient of how the injury occurred (timing and mechanism), initial symptoms, home care and treatment and any other clinical evaluation (from a primary care physician, emergency department, urgent care or athletic trainer).
Next, the examiner will perform a complete evaluation of the knee, lower leg, ankle and foot.
The exam will start with a general inspection—looking for deformity, bruising, swelling, warmth and other wounds such as lacerations (cuts) or abrasions (scrapes) and previous surgical scars.
Next, the function and stability of the muscles, tendons and ligaments and joints will be evaluated—including assessing the range-of-motion and the ability to bear-weight (stand and move on the injured leg). Both restricted and abnormally-increased range of motion (called joint laxity) may be an indication of injury.
The examination will also include an evaluation of the circulation (blood flow) and pulses as well as an assessment of the nerve function.
After the physical examination, the examiner may decide to obtain imaging (plain xrays, CT imaging or MRI)
Diagnosis of ‘High’ Ankle Sprain
- History and mechanism of injury
- Physical Exam findings including a fibular compression test also called the high ankle sprain test or the syndesmosis squeeze test
- many times, particularly in elite-level athletes or in those with persistent symptoms or significant deformity or exam findings, imaging studies (X-ray, CT, MRI) may help in diagnosis and treatment decisions
Treatment of ‘High’ Ankle Sprain
- Initial treatment typically includes ‘PRICER’ (Protect, Rest, Ice Compress, Elevate, Re-evaluate), modified weight-bearing
- Protect & Rest: limit use/weight-bearing, crutches, walking boot, splinting
- Ice: apply ice to injured area to reduce pain and/or inflammation
- Compress: appropriate use of ace bandage wrap for comfort and inflammation
- Elevate: at rest, elevating the injured ankle will reduce pain/swelling
- Re-evaluate: follow-up evaluation prior to resuming unrestricted activities
- Early, limited weight-bearing—evidence suggests that the duration of immobilization and/or limited weight-bearing may be twice as long as that for common ankle sprains.
Recovery Timeline
Every footballer is different and thus there is no specific, hard-and-fast rule for the recovery duration from a ‘high’ ankle sprain.
In general, however, the recovery time for ‘high’ ankle sprains that do not require surgery is 6-8 weeks, though as many as half of athletes will reports symptoms for as long as 6 months following injury.
Guided rehabilitation from trained athletic trainer or physical therapist has been clearly shown to improve recovery and in some cases, shorten recovery time
Advanced imaging my be required in athletes where there is any evidence of potential ligament instability
A small percentage of lower extremity injuries (including common and 'high' ankle injuries) may require surgery to fix which will impact recovery time.
Elements that Impact Recovery & May Reduce Injury Risk
- Neuromuscular activation training which ‘connects’ the brain to the musculoskeletal system and focuses on balance, coordination and sport-specific movement patterns
- Evidence suggests that regular, proper neuromusculoskeletal activation may reduce the rate of ankle injuries by as much as 30%
- Proper movement mechanics are essential to an optimally stable joint
- Sleep, adequate recovery between training and competitive events, hydration and balanced nutrition all can positively impact musculoskeletal function
- injuries that impact participation and performance may also impact mood which, in turn, can negatively impact healing and recovery
Athletes may struggle socially-emotionally while recovering from injury. Part of the recovery process should include creating 'safe' spaces for open communication about these elements no different than conversations about physical pain/discomfort.
It is important for footballers to be properly evaluated following any musculoskeletal injury—particularly those that require removal from training or competition.
Early and proper diagnosis and the initiation of guided rehabilitation are important to getting the injured footballer back on the pitch safely.
Christopher T. Conti, MD is the Founder and Owner of Steel City Direct Care, LLC., a Pittsburgh, PA-based medical practice specializing in the care of athletes and aviators. He is an emergency medicine physician with additional training in sports and concussion health. He is currently a Team Physician for the US Soccer Federation (USSF), U14-U17 Youth National Team player pools, Medical Advisor for the PA West Soccer Association, a local affiliate of the United States Youth Soccer Association and the Medical Advisor for the Woodland Hills School District in suburban Pittsburgh, PA. Dr. Conti serves as Medical Advisory Board Member for SportGait and is also a Credentialed ImPACT Consultant (CIC) for sports concussion care. Dr. Conti is a designated Senior Aviation Medical Examiner (AME) for the Federal Aviation Administration (FAA)
Disclaimer
The information, opinions and content presented do not necessarily represent the policies or opinions of USSF, the FAA, PA West Soccer, USYS, FIFA, ImPACT, SportGait, the Woodland Hills School District or Steel City Direct Care, LLC.
None of the information presented should be construed as formal medical advice, nor should it be considered an acceptable substitute for a formal virtual or in-person encounter with an appropriately trained and licensed healthcare professional. None of the above-listed entities, including Steel City Direct Care, LCC, are responsible for any adverse outcome associated with this content.
If you would like to schedule a virtual or in-person visit with Dr. Conti, please contact Steel City Direct Care
Steel City Direct Care is a Direct Patient Care (DPC) practice that provides targeted & specialized in-person and virtual care for aviators and athletes of every age and level of skill and participation.
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