High Ankle Sprain: Understanding Syndesmotic Injuries
Updated: 3 days ago
Medically reviewed by Dr. Baraa Alnahhal, MD · Last reviewed: October 2026
Quick Answer
A high ankle sprain, medically called a syndesmotic injury, is damage to the ligaments connecting the lower leg bones above the ankle. It usually happens from twisting the ankle while the foot is flexed upward, often in a collision while running or jumping. Recovery takes six to eight weeks or longer, and treatment includes R.I.C.E., bracing and physical therapy. [1]
What the research says
In collegiate football, high ankle sprains are mostly contact injuries and rarely need surgery. Across five NCAA football seasons, the incidence was 0.24 per 1,000 athlete exposures and high ankle sprains made up 24.6% of all ankle sprains. Players were nearly 14 times more likely to be injured in games than in practice, 75.2% of injuries involved contact with another player, and fewer than 3% needed surgery. Complete injuries cost more time than partial ones (31.3 vs 15.8 days). (Hunt et al., Clin J Sport Med, 2013)
No single physical test is both highly sensitive and highly specific. In a meta-analysis of six studies (512 participants, 13 tests), palpation had the highest sensitivity (92%, 95% CI 79–98%), while the squeeze test (85%, 95% CI 81–89%) and external rotation test (78%, 95% CI 73–82%) had the highest specificity. These tests cannot reliably separate stable from unstable injuries, so imaging or arthroscopy may be needed to guide treatment. (Netterström-Wedin & Bleakley, Phys Ther Sport, 2021)
Severe injuries in elite athletes can have an unpredictable recovery. In a cohort of 13 professional male rugby players, most injuries came from tackles and were often unstable. Median return to training was 97 days and median return to play was 112 days (IQR 54), and injury severity, complications, delayed diagnosis and associated injuries could prolong recovery. This was a small study. (Wever et al., J ISAKOS, 2022)
What Is a High Ankle Sprain?
A high ankle sprain involves damage to the ligaments above the ankle joint. These high ankle ligaments, known as the syndesmosis, connect the two bones of the lower leg: the tibia (shin bone) and the fibula (the thinner outer bone). They keep the leg bones properly aligned as you move. [1]
When these ligaments are stretched, torn partially or torn completely, the injury is called a syndesmotic injury. High ankle sprains are less common than traditional ankle sprains, but they are often more serious and take longer to heal. [1]
High Ankle Sprain vs. Low Ankle Sprain
The main differences are where the injury happens and how. Low ankle sprains are what most people picture when they hear "sprained ankle," and they do not involve the high ankle ligaments. [1]
Feature | High ankle sprain | Low ankle sprain |
Location | Above the ankle joint (syndesmosis) | Below the ankle joint (lateral ligaments) |
Mechanism | Foot flexed upward and then twisted, usually in a collision | Ankle rolls inward or outward |
Severity | Generally more severe, with longer healing | Often less severe, with faster healing |
Weight bearing | Often very difficult or not possible | Often possible with some discomfort |
Anatomy: Ligaments Involved
Three main structures can be damaged in a high ankle sprain: [1]
Anterior inferior tibiofibular ligament: Found in front of the tibia and fibula.
Posterior inferior tibiofibular ligament: Found at the back of the tibia and fibula.
Interosseous membrane: A membrane in the space between the two bones that helps stabilize the lower leg.
Any of these structures can be stretched, torn partially or torn completely.
Common Symptoms and Causes
A high ankle sprain happens when the foot is flexed upward and then twisted inward or outward. It almost always follows a collision rather than a simple rolling motion, and it usually happens while running or jumping. It is seen most in athletes who play football, basketball, wrestling, ice hockey, skiing or soccer. [1]
Symptoms to watch for
Inability to bear weight: Walking or climbing stairs may be difficult or impossible.
Pain higher up: Pain above the ankle, which may travel up the leg.
Delayed bruising: Bruising may not appear until days after the injury.
Swelling: Some swelling around the upper ankle.
Difficulty walking on your toes: An inability to push off the ground with your toes.
How Doctors Diagnose the Injury
Your provider will ask about your injury and medical history, then do a physical exam with tests that stress the syndesmosis. [1]
Syndesmosis squeeze test: The provider squeezes the tibia and fibula together. Pain in the area of the syndesmosis, just above the ankle, suggests a high ankle sprain.
External rotation test: With the knee bent and the foot hanging down, the provider pushes the foot up and twists it slightly outward. A lot of pain suggests a high ankle sprain, and this test may be repeated a few days after the injury.
Imaging: X-rays can help rule out broken bones. MRI is the best test for a high ankle sprain, and CT or ultrasound may also be used.
No single physical test is both highly sensitive and highly specific, so doctors usually combine several tests and may use imaging to decide whether the injury is stable. [3]
Treatment and Recovery Timeline
Most high ankle sprains are treated without surgery, using rest and rehabilitation. [1]
The initial phase (about the first 3 to 5 days)
Treatment begins with the R.I.C.E. approach: [1]
Rest: Avoid putting weight on the ankle. Crutches may be needed.
Ice: Apply ice to help with swelling.
Compression: Use a bandage to limit swelling.
Elevation: Keep your foot raised.
Over-the-counter NSAIDs can help with pain and swelling. Your provider may also recommend a brace, tape or a cast to keep the ankle from bending upward. [1]
The rehabilitation phase
Once the initial pain eases, physical therapy is important. It may include exercise bands, exercising in water (which reduces the weight your ankle has to bear), and balance training to prevent re-injury. [1]
How long does recovery take?
Recovery may take six to eight weeks or longer, and athletes may need more time before returning to play. Surgery is unlikely unless the damage is very severe or the ankle stays unstable. [1] Research in athletes shows that recovery can be unpredictable for severe injuries. [2][4]
Conclusion
A high ankle sprain is a significant injury that takes patience and proper care. Knowing how it differs from a common ankle sprain helps you follow the right recovery path. If you have hurt your ankle and cannot put any weight on your foot, call your provider or go to an emergency room to check for broken bones and begin treatment. [1]
Need help with your recovery? Visit Rinnit.com for expert health guides.
Frequently Asked Questions
Is a high ankle sprain worse than a regular one?
Generally, yes. High ankle sprains affect the ligaments that hold the two lower leg bones together, and they typically take longer to heal than low ankle sprains. [1]
Can I walk with a high ankle sprain?
Many people find it very difficult to bear weight right after the injury, and climbing stairs can be hard. Crutches are often needed. If you cannot put any weight on your foot, see a provider or go to an emergency room to check for broken bones. [1]
Do I need a cast for a high ankle sprain?
Sometimes. Your provider may recommend a brace, tape or a cast to keep the ankle from bending upward while the ligaments heal. [1]
How do I know if it's a high ankle sprain?
Pain above the ankle joint, difficulty bearing weight, and pain when the two lower leg bones are squeezed together can all point to a high ankle sprain. Only a clinical exam, and often imaging, can confirm it. [1][3]
What is the syndesmosis?
The syndesmosis is the group of ligaments (the "high ankle ligaments") that connect the tibia to the fibula just above the ankle joint. [1]
Can a high ankle sprain cause long-term problems?
The outlook is good and most people recover without surgery, but you may be more prone to injuring your ankle again and may have joint stiffness later. [1]
Why do high ankle sprains take so long to heal?
The high ankle ligaments help hold the two leg bones together and are stressed with every step, so the ankle needs protection and gradual strengthening while they heal. Recovery is often six to eight weeks or longer. [1]
Are high ankle sprains common in non-athletes?
High ankle sprains are less common than low ankle sprains and often happen in sports with collisions, running or jumping. They can also happen in any fall or accident in which the foot is planted and twisted. [1]
What is proprioception training?
Proprioception training involves exercises that improve your brain's ability to sense where your joints are positioned. It is part of balance and may help reduce the risk of re-injury. [1]
Should I use heat or ice?
Ice, as part of R.I.C.E. (rest, ice, compression and elevation), is used in the first three to five days to help with swelling. Ask your provider or physical therapist before using heat. [1]
When can I return to sports?
Recovery often takes six to eight weeks or longer, and athletes may need more time. In a small study of 13 professional rugby players with syndesmosis injuries, median time to return to play was 112 days. Return to sport should be guided by your clinician or physical therapist. [1][4]
Can a high ankle sprain be prevented?
Accidents cannot be prevented completely, but strength and flexibility exercises, balance (proprioception) training and protective equipment such as braces or tape may make an injury less likely. [1]
Does a high ankle sprain require surgery?
Surgery is unlikely unless the damage is very severe or the ankle stays unstable. In one large collegiate football study, fewer than 3% of syndesmosis injuries needed surgery. [1][2]
What medications help with the pain?
Over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can help with pain and swelling. They come as pills or as topical lotions, creams or sprays. [1]
What is the interosseous membrane?
The interosseous membrane is a membrane in the space between the tibia and fibula that helps stabilize the two bones. [1]
Related Reading
Sprained Ankle: Symptoms, Causes, Treatment & Complete Guide explains common low ankle sprains and how they are treated.
Broken Ankle: Symptoms, Causes, Treatment & Complete Guide covers ankle fractures that can occur with high ankle sprains.
Understanding Ankle Ligaments: Anatomy, Function, and Injury Prevention explains the ligaments that hold the ankle together and how they get hurt.
Fibula Fracture Guide: Understanding Symptoms, Causes, and Treatment explains breaks in the thin lower leg bone near the syndesmosis.
References
Cleveland Clinic. High Ankle Sprain. Cleveland Clinic. Last updated December 8, 2021. https://my.clevelandclinic.org/health/diseases/22249-high-ankle-sprains
Hunt KJ, et al. Epidemiology of syndesmosis injuries in intercollegiate football: incidence and risk factors from National Collegiate Athletic Association injury surveillance system data from 2004-2005 to 2008-2009. Clin J Sport Med. 2013;23(4):278-282. PMID 23339895. https://doi.org/10.1097/JSM.0b013e31827ee829
Netterström-Wedin F, et al. Diagnostic accuracy of clinical tests assessing ligamentous injury of the ankle syndesmosis: A systematic review with meta-analysis. Phys Ther Sport. 2021;49:214-226. PMID 33774464. https://doi.org/10.1016/j.ptsp.2021.03.005
Wever S, et al. Syndesmosis injuries in professional rugby players: associated injuries and complications can lead to an unpredictable time to return to play. J ISAKOS. 2022;7(4):66-71. PMID 36189472. https://doi.org/10.1016/j.jisako.2022.03.001
Medical disclaimer
This article is for general educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have about a medical condition. Never disregard professional medical advice or delay seeking care because of something you have read here. If you think you may have a medical emergency, call your doctor or emergency services immediately.
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