Hey everyone.

Welcome to PTs Snacks podcast.

This is Kasey your host, and if you're tuning in for the very first time, first of all, welcome.

But what you need to know is that this podcast is meant for physical therapists and physical therapists, students who are looking to grow your fundamentals and vice ice segments of time.

Now today what we're gonna do is talk about high ankle sprains.

But before we do, if you've listened to the show at least three times and you found it to be beneficial, if you wouldn't mind leaving a review wherever you listen to podcasts, please do and to those who have already done so, thank you so much.

I really do appreciate you'cause these make a big difference.

Now in today's episode, we're going to be differentiating.

What exactly a high ankle sprain is.

So really to do that we have to review some anatomy and that's good to review.

Anyways, we're gonna talk about how it happens, how we test for it, and what we do about it.

So with that being said, let's dive in.

So covering anatomy, essentially when we're talking about a high ankle sprain, we can also use the words syndesmotic, ankle sprain.

This is essentially just an injury to the syndesmotic ligaments that connect the tibia and fibula, and usually happens from forceful foot external rotation or dorsiflexion of the ankle.

This is different than a lateral ankle sprain that affects the ligaments on the outside of the ankle.

Medial ankle sprain, of course.

So with that, we've gotta really get an idea of our anatomy in our head.

We have the tibia and fibula, and together these kind of create the mortis of the talocrural ankle joint.

We also have our interosseous membrane, the anterior inferior tibia fibular ligament, the posterior inferior tibia, fibular ligament, interosseous ligament, and transverse tibial liga tibio fibular ligament.

So all these help to stabilize and instruct all of these components help to stabilize and support the mortice of the talocrural ankle joint, the joint that is responsible for more so dorsiflexion and plantar flexion.

Now the anterior and posterior tibial fibular ligaments are.

The anterior and posterior inferior tibia, fibular ligaments say that five times fast are pretty strong stabilizers of the distal tibia fibular joint.

In terms of the other ligaments that I mentioned, we have our interosseous tibia fibular ligament.

It's basically a thickening of the interosseous membrane, about 10 to 15 millimeters proximal to the crural joint.

Some people think it CS like a spring, which allows for a little bit of medial to lateral splaying of the toibin fibular during things like movement and loading.

For some, the jury's still out, but just be aware of that.

Then lastly, we have our transverse tibia fibular ligament, which is basically a deep portion of the posterior inferior tibial fibular ligament and posterior capsule that has a fibro cartilaginous appearance.

Honorable mention here, deloid ligament is a secondary stabilizer to the distal ankle syndesmosis and can sometimes be injured in conjunction.

So just to be aware.

Now, here's the takeaway from this, other than the anatomy.

These are, this is pretty strong, so it requires some high loads to actually injure this.

So when we're considering is this involved, these are the types of structures that we should be taking a look at and understanding how it all works together so that we know when things don't seem to be working well, we can further dive into what specifically isn't and how do we fix it.

So to start with, we have to consider what the mechanism of injury typically is.

So most often it's gonna be some sort of force, forceful external rotation and dorsiflexion of this joint, especially when the foot is planted and leg twists outward.

We see this a lot of times in contact and collision sports with a direct blow that puts, forces someone into this position so their leg is planted thing sports like football, wrestling, ice hockey or it could even be a lateral blow to the ladder.

A direct blow to the lateral heel while the foot is planted.

Other less commonly would be with hyper dorsiflexion.

So maybe rapid pivoting on a planted foot.

If you picture someone trying to split a log, they might drive some sort of peg into it and then hammer over top.

Now, if we are picturing this joint, this is essentially the Ali's talus is positioned in the mortis, and a high velocity force causes the talus to separate the distal tibia and fibula.

It's like splitting wood.

So that's what happens here, essentially with this mechanism.

Biggest risk factors, as you could probably guess, collision, sports, also activities or sports that require rigid boots, skiing, hockey activities like that.

You're creating a fixed environment on the lower segments, and so the higher ankle sprain is usually the next thing to go.

And then flat foot is also mentioned here, mainly because.

Someone's foot is relatively externally rotated when the foot is planted just with this flat foot position.

So when we're looking at this, your patient was walking in, what do you do about it?

Now essentially this person is probably already gonna have a hard time ambulating without crutches.

They probably have a good amount of pain and instability when they're pushing off their foot or pivoting inward when their foot is planted.

There may be edema.

The more extensive the injury is, the more swelling they're gonna have.

And as you're evaluating them, obviously you're still looking above them.

You're still looking at them as a person comparing side to side, checking things like their range of motion, their strength, things like that.

But some standout features here would be tenor to palpation over the anterior and posterior inferior tibia fibular ligaments.

So it's important to know where those are which could extend even up the leg if the neuro osseous membrane is involved.

It and fun fact how far up this tenderness, how far up this pain goes is associated with how much time away this athlete might be away from competition or from whatever activity it is.

Also important to keep in mind, you wanna assess for a potential fracture of the fibula and tibia just to make sure we're rolling out everything that needs to be.

And then there's a few stress tests that you can do to really stress this.

This ankle complex.

So some that I'm gonna mention I'll try and describe, but you may wanna look up a video on YouTube.

So we have our cotton test, that's where the talus is translated medial to lateral in the ankle mortes.

So positive.

If there's excessive motion or pain, we have our cross legged test.

So this is something that your patient could do themselves if you're seeing them virtually.

They would basically sit with the injured leg on the opposite knee and apply medial as and apply pressure to the medial aspect of their proximal tibia and fibula at or near the knee to apply a sheer force.

And it would be positive if they have pain distal.

So it's like a functional squeeze test by a physical therapist, which.

A squeeze test is essentially where the tibia and fibular compressed midway up the leg to apply a shear strain to the distal syndesmosis ligaments.

Positive.

If pain at distal tibia, fibular ligament, some others, you can take'em into extra rotation with their knee.

At 90 degrees of flexion, you're basically stabilizing their leg midway of the tibia and applying an external rotation force.

Remember we talked about the mechanism of injury, you're bringing them into that same position to see if it hurts.

They have a lot of laxity, things like that.

And then you can check fibular translation, fibula, applying a anterior posterior direction force, applying a anterior posterior directional force to the fibula.

And if it's painful, positive.

With these patients, it's generally recommended to get an X-ray to also assess for bony integrity and stability of the ankle mortiz joint.

So a lot of times these views will be in weightbearing in an AP position.

Mortis view, mortise view, and the lateral view.

An MRI, of course, is gonna be more sensitive and specific and can catch things like other lesions.

Anterior talo, fibular, ligament sprains, bone bruises, and osteochondral lesions.

So can definitely be beneficial as well, especially with a pretty acute, painful patient.

Now, in terms of potential differential diagnoses there are several fractures that can be associated Weber fractures, B and C.

A mason, new fracture, deltoid ligament sprain and lateral ankle sprain.

Now this brings us to the question, okay, maybe we have identified that this person has a syndesmotic or high ankle sprain.

What do we do about it?

So if someone has very frank instability, this is probably gonna call for surgery.

But if physical therapy seems appropriate, generally there's gonna break down into three broad stages, acute, subacute, and more advanced.

And obviously this is not.

A treatment session.

So you need to individualize this to the patient that's in front of you.

But the main themes would be in the acute phase, you're helping to protect the joint.

Some, whether it's immobilization, avoiding extra rotation in enraged, dorsiflexion, painful positions, helping them transition from if they are non-weight bearing or partial weight bearing to full weight bearing as appropriate and helping them to get.

Mobility back gentle exercises, helping them to be able to walk.

In full weight bearing on different types of surfaces, things like that.

And then in our subacute phase, we're starting to more so normalize mobility and strength neuromuscular control, getting them back into their ADLs or activities of daily living.

Maybe they're starting to do more heel raises, step ups, up and down calf press.

More balanced training, working towards a little bit more impact, jogging, hopping, that kind of stuff.

And then in our more advanced space, we are really working on return to sport.

They're doing a good amount of strain training, not just in the foot and ankle, but the, their entire lower extremity complex.

Starting to work on more plyo, maybe things like running jump rope.

Change of direction, strain, sport specific in no particular order.

But essentially helping them to make sure that what they need to do, if it's in a sport or activity, you are going through it and you're helping them to prepare and build tissue resilience towards those activities.

That's the main theme, so it's helpful to.

Look at their end goal and kind of work back backwards from there.

And then utilizing your understanding of tissue healing timeline and monitoring your patient's progress, actually testing to see if they're ready for these things.

That can all be really helpful.

Now in terms of prognosis, this is less common high ankle sprains than lateral ankle sprains, but often associated with much longer recovery times and a higher risk of chronic ankle instability or arthritis.

If they're not managed well, they tend to have patients with this tend to have a longer period away from sport.

And yes, there is potential surgical intervention, but it all really depends on the degree of instability that there is.

If you have any questions at all, feel free to reach out at PTs Snacks podcast@gmail.com and I am more than happy to answer your questions to the best of my abilities.

And if you are by chance, trying to renew your license or you're studying for your OCS or SCS or anything like that, med Bridge is actually offering listeners over a hundred dollars off their year subscription.

And with that includes tons of courses on all sorts of topics, specialty exam prep and some of their, they even have an exercise builder and some other.

One of their subscriptions even has an exercise builder where you can put together videos and there's a ton of videos on there and print those off, write in your rep sets, all that kind of stuff, give'em to your patient.

And your patient can either use the printed version or they can go online and watch how to do the exercises.

So really awesome.

But check out the show notes for that promo code.

And if you're a student, you get an even better deal.

So use the student specific one for that.

But that's it for today, guys, and until next time.