High (Syndesmotic) Ankle Sprain

A high ankle sprain is a tear of the ligaments that hold the two lower-leg bones together just above the ankle joint. It causes pain, swelling, and significant difficulty putting weight on the foot, and it typically takes much longer to recover from than the more familiar outer-ankle sprain. For many people it means weeks away from sport, physical work, or simply walking without pain. Most people recover well and return to their previous level of activity. How well and how quickly depends on whether the injury is stable or unstable, and on how much the ankle is asked to do.

The ankle is formed where the shinbone (tibia) and the calf bone (fibula) meet at the top of the foot. These two bones run side by side down the lower leg, and at their lower ends they are bound tightly together by a set of strong ligaments called the syndesmosis. This connection forms a bony socket, and the ankle bone (talus) fits inside it. The syndesmotic ligaments keep the two leg bones from spreading apart under the forces of walking, running, and jumping.

Farther down and on the outside of the ankle, a separate set of ligaments stabilizes the joint against rolling inward. Those are the structures injured in a common lateral ankle sprain. A high ankle sprain is above that level, in the syndesmosis itself.

A high ankle sprain is a tear, partial or complete, of the syndesmotic ligaments that hold the tibia and fibula together just above the ankle. The injury may also involve the interosseous membrane, the tough tissue that runs between the two bones along the length of the lower leg. Because the syndesmosis holds the ankle socket together, a significant tear changes how the ankle distributes load and puts the joint at risk of widening during activity.

The same force that tears the syndesmosis can also fracture the fibula higher up the leg, sometimes well above the ankle. This is called a Maisonneuve fracture. Because the break is far from the ankle, it can be missed unless X-rays include the full length of the fibula.

The most important distinction for treatment is whether the injury is stable, meaning the gap between the tibia and fibula has not widened, or unstable, meaning the bones have separated. That single finding determines whether surgery is needed.

High ankle sprains happen when the foot is forcefully twisted outward or pushed upward, stressing the syndesmotic ligaments. The mechanism is different from the inward roll that causes most outer-ankle sprains.

Contact and collision sports. American football, rugby, and ice hockey account for many of these injuries. High-speed cutting and pivoting combined with tackle-type collisions can twist the foot outward with enough force to tear the syndesmosis.

Skiing. Stiff ski boots anchor the foot firmly while the body continues to rotate, transmitting rotational force directly to the syndesmosis.

Falls and awkward landings. Any fall or landing where the foot is planted and the leg twists over it can produce a high ankle sprain, in sport or in everyday activity.

These injuries happen across age groups and fitness levels. They are more common in competitive athletes who move at speed or make contact, but they are not limited to that population.

Pain from a high ankle sprain sits higher than pain from a common outer-ankle sprain, along the front and outer side of the lower leg between the two bones, above the ankle joint itself. Walking is noticeably more painful, and swelling tends to appear higher up the leg rather than around the outer ankle bone.

Rotating the foot outward or pushing off through the ball of the foot typically reproduces the pain. Unlike a lateral ankle sprain, which often settles within a short time, a high ankle sprain lingers. Many people describe a deep ache that worsens when they try to cut, pivot, or accelerate.

When the syndesmosis is unstable, the ankle may feel as though it gives way or cannot support the forces of pushing off and changing direction.

A focused physical exam of the ankle checks for tenderness above the ankle along the outer lower leg and assesses whether the syndesmosis is stable under stress. Tenderness along the fibula higher up the leg is also checked, because a Maisonneuve fracture can accompany the syndesmotic injury.

X-rays are the starting point. Standing X-rays of both ankles together allow comparison of the gap between the tibia and fibula on each side and help identify subtle widening. X-rays covering the full length of the fibula are needed to rule out a Maisonneuve fracture. MRI and CT can confirm the extent of ligament injury and detect widening that plain X-rays may underestimate.

Nonsurgical treatment is appropriate when the syndesmosis is stable and the gap between the two leg bones has not widened. The goal is to protect the healing ligaments and gradually restore ankle strength and control.

High ankle sprains take significantly longer to recover from than a common outer-ankle sprain. Returning to activity before the ligaments are fully healed increases the risk of developing a chronically unstable ankle.

When the gap between the tibia and fibula has widened (called diastasis), the ankle is unstable and needs surgery. Without stabilization, the ankle heals with the bones in a permanently separated position, which alters how weight is distributed through the joint and leads to early arthritis.

Surgery holds the tibia and fibula in their correct position while the ligaments heal. The most common approaches use either a screw through both bones or a flexible suture-button device that holds the bones together while allowing a small amount of natural motion. If a Maisonneuve fracture is present, the fibula may need to be repaired as well.

After surgery, recovery follows a similar path to nonsurgical care: an initial period of protection, then progressive rehabilitation. The overall timeline is longer than for a stable injury treated without surgery.

Most people with a high ankle sprain recover well and return to their previous level of activity. Stable injuries treated with protection and rehabilitation heal over a period of weeks to months. Unstable injuries treated with surgery also do well when the repair is solid and rehabilitation is followed through, though the total timeline is longer.

The main risk from undertreating the injury or returning to activity too soon is chronic ankle instability, where the ankle continues to give way because the syndesmosis never fully stabilized. A small number of people develop lingering pain or stiffness in the ankle even after appropriate treatment.

Return to high-demand activity such as competitive sport takes longer than return to everyday walking. Following the rehabilitation plan and allowing the ankle enough time are the most important factors in a good outcome.

External patient-education references and related pages for additional background:

• Sprained Ankle — AAOS OrthoInfo (accessed June 2026)