High ankle sprain vs. low ankle sprain: What are the key differences?

Michael VanPelt, D.P.M., Kshitij “KJ” Manchanda, M.D. Orthopaedic Surgery Football fans collectively held their breath when two of the NFL’s most dynamic stars hobbled off the field during the 2023 divisional playoff round. Kansas City Chiefs quarterback Patrick Mahomes and Dallas Cowboys running back Tony Pollard both were tackled from behind and suffered what is becoming an all-too-familiar injury in football: the high ankle sprain. Unlike the most common sprains, which usually occur when the lower portion of the ankle rolls inward, high ankle sprains are more significant rotational injuries, stressing the syndesmotic ligaments above the ankle that hold the shin bones together. After getting X-rays in the locker room, Mahomes was cleared to return to the game and would eventually lead his team to victories in the AFC championship game and, two weeks later, Super Bowl LVII. But Pollard was carted off the field with his leg in an air cast and was later diagnosed with a season-ending fracture in his fibula – the smaller bone on the outside of the shin. The rules in football have changed in recent years to reduce hits to the head and neck, but one unintentional consequence has been the increase in alternative tackling forms like the “hog tie” or “hip drop” – when a defender grabs a ball carrier by the waist or legs from behind, twisting with force and using body weight to pull them to the ground. When the defender lands on the offensive player’s leg(s), it can cause a painful high ankle sprain. You don’t have to be a pro football player to be at risk for this type of injury. In our Dallas, Frisco, Las Colinas, and Richardson Sports Medicine and Orthopaedic Surgery centers, most of our patients with high ankle sprains have been injured playing soccer, basketball, rugby, or participating in other high-velocity activities such as trampolining and ice skating, which create potential for severe ankle trauma.

How to tell if you have a high ankle sprain

About 80% of low ankle sprains are inversion sprains, when the ankle rolls inward and the tendons within the joint are strained. These can happen when you step wrong and are the most common sports injury. A high ankle sprains occurs when the ankle and leg turn outward, involving the ligaments above the ankle in an external rotation injury. Like low ankle sprains, high ankle sprains typically have visible bruising and some swelling that appears higher on the leg. But they typically take at least twice as long to heal – about three weeks to four months or longer in severe cases. That’s because the high ankle ligaments have a heavier load to lift:

• The tibia (inside shin bone) and fibula try to separate every time a person stands, and the syndesmotic ligaments hold the bones in place.
• Damage to the syndesmotic ligaments can destabilize the leg and ankle, rather than just the ankle like in a lower sprain.
• Improper healing can cause scar tissue or chronically loose ligaments that increase the risk of future sprains.

To assess ligament function following an ankle sprain, we’ll perform a physical exam that may include moving your foot and applying pressure to your shin, ankle, and calf. It’s uncomfortable but necessary so we pinpoint if and where any ligament damage occurred. We may also order diagnostic imaging such as X-rays, MRI, or a CT scan to check for fractures and other signs of injury. Ankle sprains are graded according to severity, with Grade 1 being the mildest:

• Grade 1: Slight ligament stretching with some damage to fibers.
• Grade 2: Partial ligament tear with an abnormally loose ankle joint.
• Grade 3: Fully torn ligament with ankle joint instability.

Treating high ankle sprains

For Grade 1 or 2 high ankle sprains, we typically begin treatment with the RICE method:

• Rest: Avoid weight-bearing exercise until your doctor says it’s OK to resume.
• Ice: Apply an ice pack for 15-20 minutes, three times a day for the first few days after the sprain to reduce pain and swelling.
• Compress: Wrap the injured area firmly with an elastic bandage to control swelling. If the skin lower than the wrap gets cold, tingly, or blue, loosen the wrap to avoid reducing circulation.
• Elevate: Raise and prop up the ankle higher than the heart several times a day to reduce swelling and pain.

Over-the-counter pain relievers like ibuprofen and acetaminophen are often enough to manage pain. We may also recommend crutches or an immobilizing boot to prevent further injury. Professional athletes will likely have access to advanced, intensive therapies such as hyperbaric chambers and altered-gravity treadmills to maintain muscle tone while immobilized. UT Southwestern offers leading-edge treatments, such as platelet-rich plasma injections and shockwave therapy or extracorporeal pulse activation therapy (EPAT). For the average athlete, working with a physical therapist is plenty to help you regain strength and mobility once the swelling goes down.

When to consider ankle surgery

For more serious Grade 2 and Grade 3 sprains, a doctor may recommend surgery to repair damaged ligaments or ankle instability. Ankle surgery can help restore the ligaments to a more taut and normal length, providing stability and reducing the risk of additional injury. During surgery, we use a small camera to look inside the ankle joint. The orthopedic surgeon removes any loose pieces of bone or cartilage and repairs the torn ligament with stitches or a tissue graft. In some cases, we use a braided polyethylene cord rather than rigid surgical screws to stabilize the leg and restore the original position of the bones for faster healing. Recovery from surgery involves immobilization with a cast or boot and physical therapy to help rebuild strength and range of motion. Total recovery times vary and can range from six weeks to four months or longer for complex repairs.

Getting back in the game

Tony Pollard is recovering from surgery and is expected to be ready for next season. Patrick Mahomes took the field on Sunday, Feb. 12, for Super Bowl LVII – just three weeks after his initial injury. Late in the second quarter, he re-aggravated the injured ankle but was able to power through the pain and lead his team to a comeback win, 38-35 over the Philadelphia Eagles. Even though he wasn’t playing pain-free, Mahomes scrambled for several crucial first downs during the second half. Now, with a second Super Bowl MVP trophy in hand, he has a full offseason to let his ankle ligaments heal. Meanwhile, the NFL has announced it will review the “mechanics” of league-approved tackling styles like the hip drop to determine whether it causes more injuries and should potentially be banned, much like the “horse-collar” tackle – grabbing the back or side of the jersey or pads by the inside collar, side, or at the nameplate or higher. Whether you’re elite athlete, weekend warrior, or a trampoline enthusiast, ankle injuries are common – don’t hesitate to get them checked out when they happen. An untreated high ankle sprain can cause joint instability, which can lead to ongoing pain, swelling, and eventually arthritis. But with specialized care and proper rehabilitation, you can get back to the activities you love in a relatively short amount of time. To talk with one of our orthopaedic or ankle specialists, call 214-645-8300 or request an appointment online.