Rehabilitation of syndesmotic (high) ankle sprains

Abstract

Context: High ankle sprains are common in athletes who play contact sports. Most high ankle sprains are treated nonsurgically with a rehabilitation program.

Evidence acquisition: All years of PUBMED, Cochrane Database of Systematic Reviews, CINAHL PLUS, SPORTDiscuss, Google Scholar, and Web of Science were searched to August 2010, cross-referencing existing publications. Keywords included syndesmosis ankle sprain or high ankle sprain and the following terms: rehabilitation, treatment, cryotherapy, braces, orthosis, therapeutic modalities, joint mobilization, massage, pain, pain medications, TENS (ie, transcutaneous electric nerve stimulation), acupuncture, aquatic therapy, strength, neuromuscular training, perturbation training, and outcomes.

Results: Level of evidence, 5. A 3-phase rehabilitation program is described. The acute phase is directed at protecting the joint while minimizing pain, inflammation, muscle weakness, and loss of motion. Most patients are treated with some form of immobilization and have weightbearing restrictions. A range of therapeutic modalities are used to minimize pain and inflammation. Gentle mobilization and resistance exercises are used to gain mobility and maintain muscle size and strength. The subacute phase is directed at normalizing range of motion, strength, and function in activities of daily living. Progressive mobilization and strengthening are hallmarks of this phase. Neuromuscular training is begun and becomes the central component of rehabilitation. The advanced training phase focuses on preparing the patient for return to sports participation. Perturbation of support surfaces, agility drills, plyometrics, and sport-specific training are central components of this phase.

Conclusion: The rehabilitation guidelines discussed may assist clinicians in managing syndesmotic ankle sprains.

Keywords: ankle rehabilitation; distal tibiofibular sprain; syndesmosis ankle sprain; syndesmosis instability.

Figure 1.

An acute ankle injury including a tibiofibular syndesmosis sprain. Note the edema and ecchymosis in the region of the distal tibiofibular syndesmosis and extending up the leg. Acute tenderness to palpation was present over the syndesmosis, and it extended approximately 6 in. (15 cm) superiorly over the interosseous membrane.

Figure 2.

Taping used in the syndesmosis stabilization test. Patients perform heel raises, walking, running, and vertical hopping (if possible) before and after 1.5-in. (3.8-cm) athletic tape is circumferentially applied over the tibiofibular syndesmosis to provide joint stability. The test result is positive if the patient’s complaints of pain and/or instability in the region of the distal syndesmosis are relieved with the taping.

Figure 3.

A sample progression of neuromuscular training exercises in the subacute phase of rehabilitation: A, double-leg balance on a balance board; B, single-leg balance on an air cushion; C, single-leg balance on a balance board; D, single-leg resistive cord exercises in which perturbation is applied via resisted movement of the opposite leg; E, double-leg weight shifts on a balance dome; F, throwing a weighted ball against a rebounder while balancing on one leg on an air cushion.

Figure 4.

An example progression of functional/agility training exercises in the advanced training phase of rehabilitation: A, jumping over hurdles; B, hopping over hurdles; C, timed figure-8 running; and D, timed 4-square hop test.