Physical Therapy for a High Ankle Sprain

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A high ankle sprain injury can cause a significant amount of pain and can dramatically impact your ability to stand, walk, or exercise. This is because this type of sprain causes symptoms like stiffness, soreness, and instability in your lower leg. 

While some types of high ankle sprains may require surgery, many can be properly treated with physical therapy (PT) alone. This article will give a detailed look at what PT for a high ankle sprains entails, as well as discuss alternative treatment options.

Occupational therapist treating man's ankle

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High Ankle Sprain Overview

High ankle sprains occur when the tough, fibrous connective tissue (ligaments) just above the ankle (collectively referred to as the syndesmosis) is stretched and torn.

These structures, which include the ligaments that hold the leg bones together (the interosseous ligament and the anterior inferior tibiofibular ligament, or AITFL), the ligament that runs along the outside of the ankle (the posterior inferior tibiofibular ligament, or PITFL), and the ligament that run across the front of the ankle (the transverse ligament), provide significant stability to the lower portion of the shin bone (the tibia).

High Ankle Sprain vs. Lateral Ankle Sprain

A high ankle sprain is different than the more common lateral ankle sprain, which affects the ligaments on the outside part of the foot.

The most common type of high ankle sprain occurs when the foot is forced in the outward direction while the lower leg is relatively stable. This type of injury is especially prevalent in high-contact sports like football, soccer, or hockey and is frequently accompanied by a fracture of the smaller leg bone behind the shin (the fibula).

In more significant high ankle sprains, the excessive twisting force may cause a widening of the space between the two lower leg bones (called diastasis) and may even impact the deltoid ligaments on the inside of the ankle.

High ankle sprains can cause a wide variety of symptoms, including:

  • Pain just above the ankle joint
  • Swelling
  • Difficulty walking or bearing weight through the leg
  • Instability or giving way of the leg


The first step to treating your high ankle sprain is getting it properly diagnosed. Your physician or physical therapist will usually palpate (touch) the area just above the ankle to assess for tenderness and will ask you questions about how the injury occurred. Several special tests, designed to evaluate the damage to the ligaments of the syndesmosis, may also be performed.

Depending on your symptoms, your medical provider may also order imaging to properly assess the injury. X-rays are often needed to help visualize the bones in the lower leg and evaluate for any fractures. In some cases, an MRI (magnetic resonance imaging) scan or CT (computed tomography) scan may also be necessary to assess damage to the ligament and whether there is separation between the tibia and fibula.

After your doctor’s exam, the following scale is traditionally used to classify your high ankle sprain:

  • Grade 1: Tearing of the AITFL without instability or widening of the syndesmosis.
  • Grade 2: Tearing of the AITFL and interosseous ligament. Typically, this results in instability but not separation of the tibia and fibula. The inner (deltoid) ligament of the ankle is usually also torn. 
  • Grade 3: Tearing of the AITFL, interosseous ligament, and PITFL. This injury results in instability, separation of the two lower leg bones, deltoid ligament tearing, and usually a fibular fracture (broken fibula).

Physical Therapy

In the case of grade 1 and some grade 2 high ankle sprains, conservative treatment with physical therapy is often effective at reducing your symptoms and restoring your function. PT is commonly broken into several specific categories, each with its own unique treatments.

Acute Phase

After being diagnosed, your physician typically places you in a boot for several weeks to protect the torn ligaments. During this time, PT usually focuses on gentle mobility and strengthening exercises designed to keep the ankle moving without causing further damage to the ligament.

Several different modalities, including electrical stimulation (a therapy that involves electrical impulses being directed toward the muscles) or vasopneumatic compression (an inflatable garment is wrapped around an area of the body and used to apply pressure), may also be used to reduce your pain and swelling. This phase typically lasts for several weeks depending on the severity of your injury.

Subacute Phase

During this stage, your therapist will assist you with weaning out of the boot into a shoe and help you regain a normal walking pattern. Rehab during this time typically focuses on carefully restoring your ankle's range of motion (the extent it can move), improving your balance, and increasing the strength in your injured

Toward the end of this phase, quicker agility exercises are sometimes used to help the foot adjust to more demanding activities. This stage of rehab normally takes six weeks or more to progress through.

Return-to-Activity Phase

The last portion of PT focuses on gradually phasing in higher-level activities like running or jumping. These movements are typically initiated slowly and progresses based on your comfort and pain levels.

Before your doctor clears you to return to more strenuous exercising or athletics, your therapist may put you through a series of jumping tests to assess how your injured ankle handles the high amounts of force associated with these activities. 

Surgical Considerations

In the case of grade 3 (and certain grade 2) high ankle sprains, surgery is typically needed to restore the stability of the syndesmosis and to fix any accompanying fractures that occur. In this procedure, the surgeon places a screw through the tibia and fibula bones to stabilize the high ankle area.

Unfortunately, this method of correction usually requires you to not bear weight on the affected side for a long period of time afterward. And, ultimately, a second surgery will be needed to remove the screw.

A newer procedure called the suture-button, or tightrope fixation, has become more common. In this technique, the surgeon places a flexible implant in your anke to stabilize the syndesmosis. It typically allows you to begin walking earlier afterward than traditional surgery. In addition, the tightrope technique does not require additional surgery, making it a popular alternative for patients.

Related: When Is It Safe to Start Running After an Ankle Fracture?

Following either procedure, PT usually is required to restore your previous level of function. This rehab process is similar to the typical physical therapy stages, but rehabilitation may take a bit longer. It's not unusual for surgically corrected high ankle sprains to take six months or more to fully heal.

A Word from Verywell

A high ankle sprain can temporarily rob you of your independence and can make everyday activities like walking feel like a chore. Fortunately, in many cases, physical therapy can help reduce the symptoms associated with this injury and restore your function.

If you are dealing with this type of injury, be sure to speak to your physician about whether a referral to PT is appropriate. Being properly evaluated is an important first step on your road to recovery.

5 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. American Orthopaedic Foot and Ankle Society. Highankle sprain (syndesmotic injury).

  2. Sman AD, Hiller CE,Rae K, et al. Diagnostic accuracy of clinical tests for ankle syndesmosis injuryBr J Sports Med. 49(5):323-329. doi: 10.1136/bjsports-2013-092787

  3. Calder JD, Bamford R,Petrie A, McCollum GA. Stableversus unstable grade ii high ankle sprains: a prospective study predicting theneed for surgical stabilization and time to return to sports. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 32(4):634-642. doi: 10.1016/j.arthro.2015.10.003

  4. Sanford Health. High ankle sprain rehabilitation guideline.

  5. Zhang P, Liang Y, HeJ, Fang Y, Chen P, Wang J. Asystematic review of suture-button versus syndesmotic screw in the treatment ofdistal tibiofibular syndesmosis injury. BMC Musculoskelet Disord. 18(1):286. doi: 10.1186/s12891-017-1645-7

By Tim Petrie, DPT, OCS
Tim Petrie, DPT, OCS, is a board-certified orthopedic specialist who has practiced as a physical therapist for more than a decade.