High Ankle Sprain

A high ankle sprain is the one that fools people. It looks like a routine roll but takes two to three times longer to come back from. Our Burlington team helps you sort out which one you have, and what the recovery should look like.

The Sprain That Sits Above the Joint

A high ankle sprain involves the syndesmosis, the tough connective tissue that holds the two bones of the lower leg, the tibia and fibula, together just above the ankle joint. That structure has a different job than the ligaments on the outside of the ankle that get hurt in a regular lateral ankle sprain. The lateral ones stop the foot from rolling. The syndesmosis stops the two leg bones from spreading apart every time you push off, plant, or pivot. When it gets stretched or torn, almost every step asks something of it, which is why these injuries take so much longer to settle.

The mechanism is usually a forced outward rotation of the foot while the leg is loaded, what happens when a foot gets caught and the body keeps rotating over top. We see them often in hockey, football, soccer, skiing, and mountain biking. The pain typically sits higher than a normal sprain, often a few inches above the joint line, and shows up most when you push off, twist, or load the leg in any way that asks the syndesmosis to do its job. For deeper anatomy and the imaging side of things, our article on the high ankle sprain goes further into the structures involved and what shows up on assessment.

The big practical difference is recovery time. A grade one lateral ankle sprain might be back to sport in a couple of weeks. A grade one high ankle sprain often takes six to eight, and a more significant one can take three months or longer. People underestimate it, push through, and end up with a slower and more frustrating recovery than they needed.

How the Syndesmosis Gets Caught Out

Most high ankle sprains we see trace back to a combination of these:

A foot getting planted or caught while the body keeps rotating over top
Contact sports where the leg gets hit while the foot is fixed (football tackles, hockey collisions)
A skier or snowboarder catching an edge while the binding holds the foot in place
A landing from a jump where the foot lands turned out and the leg twists inward

A previous lateral ankle sprain that left the joint mechanics off, putting unusual stress on the syndesmosis
Cleats or boots that lock the foot in place while the leg is free to rotate above it
Cutting, pivoting, or planting on a surface with high friction (turf, court, ice)
A heavy fall onto a dorsiflexed foot, jamming the talus up between the tibia and fibula

Telling a High Sprain Apart From a Routine One

The first job is to figure out which structures are involved, because a high ankle sprain often shows up alongside a lateral one and the mix changes how we manage it. The conversation covers the mechanism, where you felt the pain at the time of the injury, whether you could weight-bear afterward, and what activities provoke it now.

The exam includes specific tests that load the syndesmosis directly: squeezing the lower leg above the ankle, externally rotating the foot, and palpating the area between and above the malleoli. Tenderness that extends well above the joint line is a useful clue. We also screen for fractures, particularly of the fibula, because a high-energy mechanism can produce both a syndesmosis injury and a bony injury that needs imaging.

If the assessment suggests a higher-grade injury or there are red flags for a fracture or a more significant separation between the tibia and fibula, we coordinate imaging before pushing into rehabilitation. Most lower-grade syndesmosis injuries can be diagnosed clinically and managed conservatively, but missing a more serious one early creates avoidable problems later.

Physiotherapist examining patient ankle injury at Burlington sports therapy clinic

Giving the Syndesmosis the Time and Loading It Needs

Why This One Cannot Be Rushed

Early on, the focus is protection. The syndesmosis needs a period of reduced load to begin healing, and that often means a walking boot, crutches, or modified weight-bearing for the first one to three weeks depending on the grade. This is one of the few injuries where we are more conservative early than we are with most sprains, because the structure is mechanically loaded with every step in a way that lateral ligaments are not.

As pain settles, we start restoring range of motion and bringing load back gradually. Manual therapy helps with the joint stiffness that builds up during the protected phase, and soft tissue work on the calf, peroneals, and lower leg keeps things from getting locked down. Active Release Technique and shockwave therapy can both have a role when the recovery is slow or when scar tissue is contributing to ongoing symptoms.

The middle and later phases are where progressive loading earns its keep. The calf, the foot intrinsics, the hip, and the core all need to handle the demands you are returning to, and the joint itself needs to tolerate twisting, push-off, and impact in that order. You can’t go wrong with strong, and a syndesmosis injury is a clear example of why: the tissue heals best when it is asked to handle progressively more force, not when it is rested until pain disappears. Returning to sport too early is the most common reason these injuries become chronic. A grade one tends to take six to eight weeks, a grade two eight to twelve, and a grade three can be three to six months or require surgical consultation if there is significant separation.

High Ankle Sprain Treatment in Burlington

Recovery from a high ankle sprain works best when each part of the rehabilitation is doing its specific job and the pieces line up in the right order. Our team handles the joint and tissue work, the strength and balance rebuild, and the muscular tightness that builds up while the joint is protected.

Chiropractic Treatment

Our chiropractors assess the joint mechanics through the ankle, foot, and lower leg, and treat the surrounding soft tissue that gets restricted during the protected phase. Active Release Technique can target the calf, peroneals, and tibialis posterior that tighten up around an injured syndesmosis, and Graston Technique can help with the chronic tissue changes that show up in slower recoveries.

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Massage Therapy

Our massage therapists release the tightness that builds up in the calf, peroneals, and lower leg while you are walking in a boot or compensating around the injury. This makes it easier to restore normal movement at the ankle as load returns. Acupuncture may be added for pain management when needed.

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Physiotherapy

Our physiotherapists build the progressive loading program that takes the ankle from protected weight-bearing all the way back to cutting and push-off. Calf, hip, and core strengthening, balance work, and graded return-to-sport drills are the core of it. Shockwave therapy and laser therapy may support the tissue side when recovery is slower than expected.

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From Protected Walking to Full Push-Off

A high ankle sprain progresses through clearly defined stages. The temptation is to skip ahead once it stops hurting in a straight line, but the syndesmosis has to be tested under twisting and push-off load before it is genuinely ready.

Protected Healing

Load is reduced through a boot, crutches, or modified weight-bearing for the first one to three weeks depending on grade. The job here is to let the syndesmosis settle without shutting the rest of the leg down. Pain-free range of motion and gentle muscle activation start as soon as they are tolerated.

Reintroducing Load

Weight-bearing returns to normal, the boot comes off, and walking becomes pain-free in a straight line. Manual therapy and mobility work address the stiffness from the protected phase, and basic strength work for the calf, foot, and hip starts taking over from passive recovery.

Loading the Twist

The harder loading goes in here: heavier calf and hip work, single-leg balance, then progressing into change of direction, light hopping, and push-off drills. This is where most chronic high ankle sprains are made, because skipping the rotational and push-off loading leaves the joint untested for what it has to do.

Returning to Sport

Full return to cutting, planting, contact, or whatever the sport demands. Strength and balance work continues in the background as a maintenance habit, and bracing or taping may be used during the first few games or weeks back as a temporary support.

High Ankle Sprain Questions That Come Up at the Clinic

Most people who land at the clinic with a high ankle sprain have a similar set of questions, especially in the first couple of weeks when the recovery is moving more slowly than they expected. Here are the ones that come up most.

Every high ankle sprain is graded and managed individually. The information below covers the patterns we see most often, and the right plan for your specific injury comes out of the assessment.

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How is a high ankle sprain different from a regular ankle sprain?

The location and the structures involved are different. A regular ankle sprain involves the ligaments on the outside, inside, or front of the ankle joint. A high ankle sprain involves the syndesmosis, which sits above the joint and holds the tibia and fibula together. The mechanism is usually rotational rather than a roll, the pain sits higher up, and recovery generally takes two to three times longer.

How do I know which one I have?

Symptom location is the first clue. High ankle sprain pain usually sits a few inches above the ankle joint, gets worse with twisting or push-off, and is reproduced by specific tests we run during the assessment. A regular ankle sprain is typically lower, on the outside of the joint, and triggered by inversion-type stress. The two can also occur together, which is part of why an assessment is worth booking.

How long does a high ankle sprain take to heal?

Six to eight weeks for a grade one, eight to twelve for a grade two, and three to six months for a grade three. Some grade three injuries with significant separation between the tibia and fibula need surgical consultation. The biggest factor in recovery time is whether the loading progression is followed properly. People who try to short-cut it almost always end up taking longer overall.

Do I need to wear a boot?

Most high ankle sprains benefit from a period in a walking boot or with crutches early on, particularly grade two and grade three. The exact duration depends on how the joint responds to load. Grade one injuries can sometimes be managed without a boot if normal walking is pain-free from the start, but that decision should come out of an assessment, not a guess.

When can I get back to sport?

Return to sport is the last stage, not the first time the pain is gone. The joint needs to tolerate single-leg loading, change of direction, push-off, and the demands of the specific sport in that order. For most people that is somewhere between two and four months depending on grade, sport, and how cleanly the rehabilitation went. Bracing or taping for the first few games back is common.

When should I book an assessment?

Sooner rather than later, particularly if the pain is higher than a typical ankle sprain, came from a twisting or rotational mechanism, or is not responding to the first week of basic care. Early identification of a high ankle sprain changes the management. It is also one of the more commonly misdiagnosed ankle injuries, so getting it sorted out early saves a lot of time later.