The story was told to me a couple of months after this happened.
An unlicensed person who was loosely affiliated with the team went through the back door of the dressing room when he saw a player was injured.
The AT had taken him off the ice, helped him into the room and went to get the team doctor.
When the doctor walked in, he immediately threw his hands up in the air and said he would have no part of this.
This unlicensed person was vigorously massaging an acute high ankle sprain.
I was a student at the time and the rest of the medical staff were trying to impress upon me why they always tried to keep the care of all the players in house.
Although it wasn’t the point of the story all I could think was: “what the hell is a high ankle sprain?”
Massage Assessment And Grading Of A Syndesmosis Sprain
I remember through college talking and learning all about ankle sprains.
The difference between an inversion and an eversion sprain, how the deltoid ligament is so strong it usually prevents an eversion injury, that the anterior tibiofibular ligament is the most commonly injured, since it happens with inversion injuries.
I don’t remember ever learning about a “high ankle sprain” (which is partially why I was so bewildered the first time I heard the name).
A “high ankle sprain” is an injury to the distal tibiofibular syndesmosis. The injury is caused by the foot being dorsiflexed and externally rotated which widens the ankle joint, stressing the syndesmosis.
Initially it can be hard to determine the difference between a typical sprain or a high ankle sprain, but mechanism of injury can be one thing to help differentiate. There are four other tests that help prove the difference:
- Passively moving the ankle into dorsiflexion.
- Pressing the tibia and fibula together while asking about pain level (squeeze test).
- Palpating the syndesmosis ligament.
- Externally rotating the ankle while stabilizing the leg (external rotation test).
Acutely this can be managed like any other ankle sprain depending on degree of injury.
The injury is graded from I-III according to it’s severity.
- There is injury to the anterior deltoid ligament and palpation of ATFL is quite tender.
- Causes disruption to the other deltoid ligaments and tearing of the syndesmosis.
- Complete disruption of medial ankle ligaments, possible fracture to the fibula and separation of the syndesmosis. In this case the mechanism of injury is a possible hint to the extent of the injury, since the external rotation and abduction will be pretty severe.
Fortunately in the acute stages, management of this injury should be pretty straightforward if you’re working the sidelines at a sporting event.
As with any acute injury we want to take the swelling down at the start, so implementing a R.I.C.E protocol will be necessary. Then we need to figure out how severe the injury is. Using the testing noted above will help, but a much easier way is to just check out the stability of the joint. If the joint seems unstable at all, then the injury is a Grade II or III. Another sign is that pain will be felt through the lower half to one-third of the leg (thus the term high ankle sprain).
If your patient is experiencing any of this, you need to immobilize the ankle with proper splinting and remove any weight bearing on the ankle by assisting with crutches.
Then refer them to more advanced medical care.
Massage And Rehab Guides For High Ankle Sprain
It’s tough to find any research (at least it was for me) indicating the best approach as far as Massage Therapy to treat a high ankle sprain.
Most of what I could find deals with the exercise end of things as opposed to the actual treatment of the ankle. Starting the person on progressive resisted exercise and then challenges on balance and sport specific drills is the most common forms of treatment.
I can remember having one of the players on our team years ago having to deal with a high ankle sprain. One of the exercises the AT would do is hold up a hockey stick between him and the player, they would both hold the stick and the AT would essentially wrestle against the player pushing him back and forth in order to draw his attention away from the ankle, but still have him moving and strengthening it in the process.
Unfortunately it can take up to 12 weeks to completely heal depending on the degree of injury. And will obviously be different if surgery is involved. There is debate over whether a grade II should be a surgical repair, but without surgery it can be difficult for an athlete to return to play.
Because the injury involves a widening of the ankle joint between the fibula and tibia, keeping inflammation down will be important in order to allow the joint to return to proper function again. Depending on the degree of separation and wether the ankle had to be splinted for any length of time will also shape your treatment.
If the leg has been splinted, watch for any muscle wasting compared to the opposite leg and start strengthening once swelling has come down.
Working in some passive and active range of motion will help to keep the joint moving. Because pain is felt further up the leg, working the muscles through the entire area will help in the recovery process. Treating gastrocs/soleus and tibant will help with ankle mobility, but you may have to work further up the leg into the quads, hamstrings and glutes because of the change in gait due to the injury. Be patient with the treatment because it’s a long healing process, especially once activity or return to sport happens. Sometimes athletes can start activity again in six weeks, but can have symptoms for six months. Above all, whether its acute or subacute your assessment is going to tell you what you need to do. Make sure to touch base with their doctor or surgeon in the cases of grade II & III injuries and get a little guidance from them if necessary. And for god’s sakes, please don’t vigorously Massage any acute injuries!
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