Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.
What Is a High Ankle Sprain? For specialized treatment, see our ankle instability treatment at Balance Foot & Ankle.
A high ankle sprain—also called a syndesmotic sprain—is an injury to the syndesmosis, the fibrous joint complex that holds the tibia and fibula together just above the ankle. The syndesmosis consists of four ligaments: the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), the interosseous membrane, and the interosseous ligament. These structures maintain the precise spacing between the tibia and fibula that allows the ankle mortise to grip the talus during weight-bearing. When they are torn, the mortise widens, and the ankle joint becomes unstable in a mechanically different (and more consequential) way than a typical lateral ankle sprain involving only the ATFL or CFL.
High ankle sprains account for roughly 10–15% of all ankle sprains but are significantly more disabling and slower to heal than standard lateral sprains. They are common in contact sports (football, hockey, soccer, rugby) and skiing, typically occurring with external rotation of the foot or a direct blow that forces the tibia and fibula apart. Athletes who sustain high ankle sprains miss substantially more playing time than those with lateral sprains.
Symptoms and How to Tell It Apart from a Lateral Sprain
High ankle sprains cause pain above and in front of the ankle joint—at the AITFL location just proximal to the ankle mortise—rather than below and in front of the lateral malleolus where lateral sprains hurt. The squeeze test (compressing the fibula toward the tibia at mid-calf) reproduces pain at the syndesmosis in high ankle sprains; it does not in lateral sprains. The external rotation stress test (stabilizing the tibia and externally rotating the foot) also reproduces syndesmotic pain. Point tenderness along the anterior ankle just above the joint line, pain with weight-bearing that seems disproportionate to swelling, and pain when climbing stairs or pushing off with the foot are characteristic features. Swelling may be less dramatic than in lateral sprains, which often leads to underestimation of severity.
Imaging: standard ankle X-rays are essential to rule out fibula fracture and assess tibiofibular clear space (widening suggests significant syndesmotic disruption). Stress X-rays (external rotation stress view) can demonstrate instability not apparent on neutral films. MRI provides definitive evaluation of syndesmotic ligament integrity and is indicated when surgical decision-making is needed or clinical examination is equivocal.
Treatment: Conservative and Surgical
Stable high ankle sprains (no diastasis on stress X-rays, intact mortise) are managed conservatively: immobilization in a walking boot for 4–6 weeks, non-weight-bearing or protected weight-bearing during acute phase, followed by aggressive physical therapy focusing on proprioception, peroneal strengthening, and functional retraining. Return to sport is typically 6–10 weeks for stable injuries—significantly longer than the 2–4 weeks typical for grade I-II lateral sprains. Rushing return before the syndesmosis has healed leads to chronic instability and persistent pain.
Unstable high ankle sprains—with widening of the tibiofibular clear space on stress X-rays, or associated fibula fracture (Maisonneuve fracture is the classic high-energy variant)—require surgical stabilization. The syndesmosis is reduced and fixed with suture-button devices (TightRope) or screws. Suture-button fixation has largely replaced solid screws because it allows physiologic motion at the syndesmosis without requiring hardware removal. Recovery after surgical repair is 3–4 months before return to sport. Inadequately treated unstable high ankle sprains lead to syndesmotic malreduction, early ankle arthritis, and chronic pain.
Frequently Asked Questions
How long does a high ankle sprain take to heal?
Stable high ankle sprains typically take 6–12 weeks to heal sufficiently for return to sport—two to three times longer than comparable lateral ankle sprains. The syndesmotic ligaments heal slowly because of their location, limited blood supply, and the continuous mechanical demand placed on them during any weight-bearing. Returning to activity too early before the syndesmosis has adequate stability risks recurrence, chronic instability, and early ankle arthritis. Surgical cases typically require 3–4 months before sport return. Full resolution of soreness and restoration of full function often takes 4–6 months even in conservative cases. Patience and complete rehabilitation are critical—many athletes attempt to return before they are truly ready and sustain setbacks.
Can you walk on a high ankle sprain?
Walking with a high ankle sprain depends on severity. Mild stable injuries may allow protected weight-bearing in a boot with pain as the limiting factor. Moderate to severe injuries, especially those with any suggestion of mortise instability, should be evaluated before resuming weight-bearing to rule out an unstable syndesmotic disruption or associated fracture. Walking on an unstable high ankle sprain risks worsening the diastasis (widening between tibia and fibula), which converts a potentially non-surgical injury into one requiring surgery. When in doubt, use crutches and seek orthopedic or podiatric evaluation. The absence of dramatic swelling does not rule out a severe high ankle sprain—these injuries frequently have less visible swelling than lateral sprains while being more serious structurally.
What is the difference between a high ankle sprain and a regular ankle sprain?
A regular (lateral) ankle sprain injures the ligaments on the outer side of the ankle—primarily the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL)—through an inversion mechanism (foot rolling inward). A high ankle sprain injures the syndesmosis, the ligament complex connecting the tibia and fibula above the ankle joint, through external rotation or direct trauma. The practical differences: regular ankle sprains are more common (85% of ankle sprains), heal faster (2–6 weeks), rarely require surgery, and hurt below and in front of the lateral malleolus. High ankle sprains are less common but more serious, heal slower (6–12+ weeks), may require surgery if unstable, and hurt above the ankle joint at the tibiofibular junction. Both require proper evaluation and rehabilitation—but high ankle sprains demand more caution about premature return to activity.
Medical References & Sources
- PubMed Research — Syndesmotic Ankle Sprain Treatment Outcomes
- American Orthopaedic Foot & Ankle Society — Ankle Sprains
- PubMed Research — Suture-Button Fixation for Syndesmotic Injuries
Dr. Tom Biernacki, DPM is a board-certified podiatric surgeon at Balance Foot & Ankle in Howell and Bloomfield Hills, Michigan. He evaluates and treats ankle sprains including syndesmotic injuries, with conservative management and surgical stabilization when indicated.
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Medically Reviewed by: Dr. Tom Biernacki, DPM — Board-Certified Podiatrist, Balance Foot & Ankle Specialists
Suffered a High Ankle Sprain?
High ankle sprains (syndesmosis injuries) are more serious than typical ankle sprains and require different treatment. Our podiatrists diagnose these injuries accurately and ensure proper recovery to prevent long-term problems.
Clinical References
- Williams GN et al. “Syndesmotic ankle sprains in athletes.” American Journal of Sports Medicine, 35(7):1197-1207, 2007.
- Nussbaum ED et al. “Prospective evaluation of syndesmotic ankle sprains without diastasis.” American Journal of Sports Medicine, 29(1):31-35, 2001.
- Lin CF et al. “Comparison of different treatments for the rehabilitation of high ankle sprains.” Clinical Rehabilitation, 22(12):1060-1068, 2008.
Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.
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