Beware of this uncommon and dangerous ankle sprain…

by Benjamin Ho | Jun 21, 2020 | Ankle Pain

Many of us roll our ankles throughout our lives. An ankle sprain seem to be a common occurrence in life. Whether that be through playing sport, recreational hobbies like hiking or even just stepping off the sidewalk wrong… It’s a natural and normal part of our lives.

However, one specific ankle sprain requires more attention that most. If it’s managed poorly, it could have profound effects on your livelihood and outcomes in the future. 

Case Study: Poor Management of a Ankle Sprain

The history: 

A ~30 year old female suffered an ankle sprain after being intoxicated and stepped off the sidewalk poorly.

• Initially thought it was a simple ankle sprain – Basic RICE principles (rest, ice, compression and elevation) applied 
• Doctor review after 2 weeks when it wasn’t getting better.
• X-ray was performed that ruled out all fractures 
• The doctor provided pain medication and told her to rest her ankle.
• Physiotherapy consultation at 4 week mark due to worsening ankle pain

The examination:

• Ankle felt unstable and had increased laxity on testing
• Was unable to pivot on foot due to pain
• Decreased ability to put weight on foot and walk
• Decreased balance on affected foot
• Pain in the middle of ankle on touch
• Positive physiotherapy stress tests including: Side-to-side, external rotation and weight bearing lunge test

The treatment: 

Immediate referral to a new GP, which created a cascade of events including:

• Emergency X-Ray and MRI which revealed a Syndesmosis injury with tibiofibular diatasis (which the previous GP missed)
• Referral to orthopaedic specialist from GP
• Immediate booking for ankle surgery to stabilise the ankle joint
• Surgery performed and referred to physiotherapy for routine post-op care.

Ankle Sprain: Syndesmosis

For the more astute clinicians or health practitioners, many would know that I’m immediately referring to a syndesmosis injury – otherwise known as a high ankle sprain. This case was poorly managed, as the follow-up with the doctor should have included further investigation. Especially because the ankle pain wasn’t resolving. Usually, recommendations should be made to see a physiotherapist before a doctor for most simple ankle sprains. 

Unfortunately for this individual, had the right assessments been completed and monitored over weeks, a surgery would have been avoided. The individual would have been able to recover in a earlier time period and eventually would have returned to her daily gym and sport routine. 

Epidemiological data suggests as many as 1-2 out of 10 people will suffer a syndesmosis ankle sprain (Williams & Allen, 2010). Although it’s an injury that largely occurs in athletic populations, there have been many cases – like the one above – where syndesmosis injuries happen in every day life.

The Basics: Anatomy 

The syndesmosis joint comprised of a few structures, primarily: 

• Distal tibia and fibula 
• The ‘syndesmosis’ itself (interosseous tibiofibular ligament connecting the fibula and tibia together) 
• The many ligaments supporting it (anterior-inferior tibiofibular ligament (AITFL), posterior-inferior tibiofibular ligament (PITFL) and transverse tibiofibular ligament (TTFL)).

In a syndesmosis sprain; we are worried about the connection between the two shin bones (tibia and fibula) being pushed apart. Disruption of the ligamentous structures holding these bones can cause the ankle to have excessive movement and mobility through the bones. This is extremely detrimental to all facets of life including walking, running and any form of lower limb exercises. Therefore, recommendations to stay away from excessive weight and pain is imperative, as it allows the ligaments to heal back into it’s natural positions. 

Long-term complications including chronic ankle instability and recurrent ankle sprains can arise if this is not treated properly. Other long term complications can include chronic pain in the ankle, loss of strength and range of motion in the ankle. 

Common Signs of a High Ankle Sprain

• Mechanism of injury (The how of the injury): Forceful external rotation of the ankle (knee turns outwards relative to the ankle)
• Swelling around the middle and outer edges of the ankle
• Tenderness directly over the middle of the ankle
• Positive physiotherapy stress tests, including: external rotation , fibular translation and squeeze test

Therefore, the following few symptoms are indicators you should get your ankle checked ASAP by a qualified health professional:

1. Pain that increases when your knees go past your toes (i.e lunging, up stairs) 

2. Pain with pivoting on foot

3. Your ankle feels loose and unstable 

4. Unable to point your toes 

5. Unable to put full weight on ankle

Timeline for Recovery for the Syndesmosis Ankle Sprain

The following guidelines for recovery are based on the recommendations suggested by Williams & Allen (2010). These are only ‘guidelines’ and do not reflect the recovery that you or anyone else may experience. A host of individual factors can influence the speed in which you recover back to your baseline and must be considered in any injury.

First 6 weeks – Protecting the Ankle

• A combination of moonboot / crutches to reduce weight bearing and protect ankle
• Gentle ankle movement exercise to reduce stiffness
• Prevention of re-injury
• Pain management, including: medication, ice or heat therapy and gentle massage

Progression to next stage when: Able to fully put weight onto affected leg and walk stairs and uneven ground with minimal discomfort.

6 – 12 weeks – Normalising walking and movement

• Gait retraining
• Calf and foot strength exercises 
• Balancing exercises such as single leg stands, tandem stance.
• Ankle stretches and range of motion exercises (pain free) 

Progression to next stage when: Hopping and running has minimal discomfort.

12 weeks + Return to sport or hobbies

• Reintroduce lateral plane movements 
• Begin gentle sport specific activities (i.e. agility drills, controlled training drills) 
• Conditioning and steady-state movement (i.e. jogging and running, jumping rope)

Steadily build on your fitness and strength in the ankle, as well as progress your sport specific activities. When you are able to train pain-free and minimal discomfort, then a return to sport level activity should be warranted.

Caution Signs: 

A few warning signs to be wary of include:

• Unable to put any weight on your ankle
• Feeling severe pins and needles in your feet
• Severe pain that is intolerable

The recommendation to go to the emergency department or your local GP is emphasised. During this stage, you must rule out an ankle fracture otherwise this will have profound long term consequences on your recovery. 

This specific ankle injury can potentially have serious consequences on your long-term ankle function. If you are unsure about the severity of your ankle sprain, please seek professional advice from a healthcare professional. 

Conclusion

This blog post is intended to make the viewer aware that a more serious type of ankle sprain exists. Syndesmosis sprains cannot be managed like a ‘usual’ ankle sprain and can take longer to heal. The main messages for this post are to contact a medical professional if:

• You exhibit any of the Caution Signs
• The pain doesn’t seem to be improving
• You are concerned about your ankle sprain or pain

Like any other injury, syndesmosis sprains can heal. However, proper management and a structured rehabilitation program is necessary to make sure a favourable outcome is made.

References 

• Bleakley, C. M., McDonough, S. M., & MacAuley, D. C. (2008). Some conservative strategies are effective when added to controlled mobilisation with external support after acute ankle sprain: a systematic review. Australian Journal of Physiotherapy, 54, 7 – 20
• Physiopaedia. (2020). Tibiofibular Diatasis. Retrieved from: https://www.physio-pedia.com/Tibiofibular_Diastasis
• Williams, G. N., & Allen, E. J. (2010). Rehabilitation of Syndesmotic (High) Ankle Sprains. Sports Health, 2(6), 460 – 470.