Foot & Ankle

High Ankle Sprains and Regenerative Therapies

By October 23, 2019 No Comments

Maybe you came down too hard when you jumped to catch a ball. Perhaps you stepped into a hole and twisted your foot. If so then you might be one of an estimated 25,000 ankle injuries which occur each day in the United States.

Anatomy of the Ankle

The ankle is a large joint made up of three bones:

  • The shin bone (tibia)
  • The thinner bone running next to the shin bone (fibula)
  • A foot bone that sits above the heel bone (talus)

The ankle joint allows up-and-down movement of the foot. The subtalar joint sits below the ankle joint and allows side-to-side motion of the foot. Numerous ligaments (made of tough, moveable tissue) surround the true ankle and subtalar joints, binding the bones of the leg to each other and to those of the foot.

Symptoms

Symptoms happen when the ligaments in your ankle tear or get stretched too far. You will typically feel pain that radiates up your leg from the ankle. Each step you take may be quite painful, and the pain is usually even worse if you move your foot in the same way as when the injury occurred. 

Other symptoms include:

  • Pain when pressing in on the tibiofibular ligament at the front of the ankle. This is the ligament which joins the tibia and fibula at the bottom of the leg/top of the ankle.
  • Swelling and bruising at the front and outside of the ankle.
  • Difficulty walking.
  • Pain is reproduced by rotating and dorsiflexing the ankle (external rotation test). This means rotating your ankle with toes and foot pushed upwards.

High Vs. Normal Sprain

There are two different types on ankle sprains. A more common lower ankle sprain and a high ankle sprain. People who suffer high ankle injuries will have more pain and a longer rehabilitation period when compared to a low ankle injury. 

A high ankle sprain is an injury that involves a different set of ligaments than in the common ankle sprain. These ligaments are located above the ankle joint and between the tibia and fibula. They form what is known as the ankle syndesmosis (a slightly movable fibrous joint). 

When you bear weight on the leg, the tibia and fibula experience high forces that spread them apart. The ligaments of the syndesmosis serve as shock absorbers, preventing the tibia and fibula from spreading too far apart. When you run, and especially when you run and quickly change direction, these ligaments of the syndesmosis experience very high forces.

Causes

Most ankle sprains happen when you’re playing sports. Within athletics, it’s the most common injury. This ligament is typically injured when a large compression force impacts the ankle, such as jamming the ankle into the ground when landing. Combine this with rotational stress, in which the foot is turned outside in respect to the leg, and you have a recipe for a high ankle sprain. This is especially true for games where there’s a lot of jumping or a chance of stepping on someone’s foot. 

Yet it’s also just as easy to sprain your ankle by stepping off a curb the wrong way or taking a walk on the beach. You also may have a greater chance for an ankle sprain if you’ve had one before.

Diagnosis

In order to determine if you have a high ankle sprain your doctor will ask you what motion you were performing when your injury took place, assess your symptoms, and conduct a physical exam. The exam may include a fibular compression test, also sometimes called a “high ankle sprain test” or “syndesmosis squeeze test”. For this test, your doctor will place hands on each side of your lower leg and squeeze the tibia and fibula together in a few different spots. If this causes pain that radiates down your leg, this suggests a high ankle sprain. However, additional tests for example, X-rays, may also need to be conducted to be sure you do not have a fractured fibula or compartment syndrome.

Treatments

The standard high ankle sprain treatment is the same “RICE” protocol used for the common ankle sprain:

  • Rest – Keep your weight off the affected leg. The amount of rest required to permit healing is usually much longer than for the common ankle sprain – nearly twice as long, according to most studies.
  • Ice – During the first couple of days after the injury, apply ice for about 15 minutes every few hours to reduce inflammation and swelling.
  • Compression – Wrap the lower leg with an elastic bandage to minimize swelling, but not tight enough to cut off circulation.
  • Elevation – Sit or lie down with your foot elevated to a position above the level of your heart to reduce swelling and pain

A doctor, physiotherapist or other sports medical professional may prescribe anti-inflammatory and painkilling medication such as ibuprofen. This will help reduce pain and swelling after a High ankle sprain. Doctors also can use cortisone steroid injections, most commonly in sports. However, cortisone is effective only as a means of decreasing pain and swelling. It does little to treat the underlying injury. For many athletic injuries, cortisone is actually falling out of favor. Its anti-inflammatory properties likely stop or slow down the very inflammatory process these tissues need to heal.

Surgery

For severe high ankle sprains, or in cases where a ligament is torn through completely, surgery may be suggested. The standard procedure is to insert one of two screws between the tibia and fibula to hold the two bones together, which relieves pressure and allows the syndesmotic ligament to scar and heal. 

Because the syndesmosis is a ligament, it should be able to move small amounts. After healing of the ligament has occurred, some surgeons will remove the screws so the bones can move normally again. Other surgeons recommend leaving the screws in place. However, they do often break as a result of repetitive stress. After surgery, high ankle sprain recovery time varies. Some people are able to return to their sports within six weeks, but about 50% will experience symptoms for as much as six months.

Regenerative therapy

Regenerative therapy is the name given to a set of injections which may help to reconstruct damaged tissues. The therapies themselves are very simple. First, tissues are extracted from the patient. Next, these tissues are processed in order to isolate the active ingredients (either platelets or stem cells). Finally, the isolated cells are reinjected into the site of injury using special imaging technologies.

 (PRP) injections use platelets from the patient’s blood to encourage healing of damaged tissue. PRP injections are effective because they have a stimulating effect on the stem cells within the targeted area. The introduction of PRP stimulates the stem cells in the injection site to work harder to heal damaged tissues. PRP therapy can be effective for ankle sprains and injuries that are not too severe. The procedure helps heal damaged tissues and tighten lax ligaments due to the sprain.

Stem Cell Therapy functions much the same way. Adipose tissue is extracted from a patient whereupon the stem cells are processed into pseudo stem cells known as “mesenchymal” stem cells. Once reinjected into the site of injury, these cells not only promote healing, but also create an environment suitable for the healing to happen. Stem cell procedures can be used for a wide range of conditions and are the tool of choice for injuries such as a high ankle sprain and other conditions that may be more significant than what may be treated with PRP therapy.

Depending on the extent of injury, doctors may combine stem cell therapy with platelet-rich plasma therapy which amplifies the others reaction to an injury. Not only do they treat the pain caused by the injury, but they also treat the underlying cause of it, thereby providing longer lasting results than conventional treatment options such as surgery or rest. Recent studies also found that patients receiving PRP experienced significantly less pain during recovery. PRP can reduce the typical 6-week recovery period after surgery for a torn ligament from an ankle sprain to just 2-3 weeks.

Conclusion

We all rely heavily on our lower body for everything we do. The ankles are an essential ligament that connects our lower leg to our foot. It allows for us to walk, run and jump. High ankle sprains are very common and not only for athletes. Simply being mobile on your feet presents potential for a sprain. While conventional treatments may help to reduce the pain and recover, they do not treat the underlying causes of it. By rebuilding damaged tissues, regenerative therapies offer not only a treatment for the pain, but also help to promote new tissue growth. This is especially important for high ankle injury patients due to the higher chances of re-injury. If you would like to learn more about regenerative therapies and how they may help your ankle injury, contact the CELLAXYS offices today.

Dr. Matthew HC Otten

Dr. Matthew HC Otten

Director of Orthopedic & Orthobiologics
Fellowship-trained & Board Certified in Sports medicine
Director Angiography at Harvard Clinical Research Institute
Michigan Stage University Alumni