Recovering from a High Ankle Sprain: That’s Hockey Tough

My son injured his ankle avoiding a check near the boards and his skate blade caught a rut in the ice. His athletic trainer told us he has a high ankle sprain. What does that mean and how long is my kid going to be out of hockey?

– Rob H, Chicago

High ankle sprains are a common injury in ice hockey compared to other sports. 

Why? Well, ice skates are very stiff and can provide support to the foot and lower ankle, but they also limit the ankle’s range of motion. This increased stiffness leads to increased forces and pressure to the higher ankle during sharp lateral movements and sudden stops on the ice. High ankle sprains are tears of the ligaments that connect the two leg bones together (these bones are called the tibia and fibula) at the level of the ankle.  

These ligaments form what is known as the ankle syndesmosis. The role of the syndesmosis is to hold the two leg bones together and allow for only a small amount of movement with activity. When the syndesmosis is injured, this allows for more movement between these two bones and this extra motion is painful for the athlete. Injury to the ankle syndesmosis usually occurs when the foot is twisted outwards and flexed upwards. The pain is usually located right above the ankle joint.

Unlike routine ankle sprains, which some players can return to the ice quickly from, a high ankle sprain can frustrate a player, parent, coach and physician. Unfortunately, it takes longer to recover from a high ankle sprain. The blood supply to this area is not robust and while normal activities such as walking may not be hard, skating can be very difficult. The repetitive twisting and turning maneuvers required to push off on the edges or to do crossovers directly impact the ankle syndesmosis. Furthermore, if these skating maneuvers are initiated too quickly, this can cause recurrent tearing and injury to the area—slowing overall recovery.  

It will take a hockey player 6 to 12 weeks to return to the ice following a high ankle sprain in most instances. In some severe cases, surgery may be recommended to repair the damaged syndesmosis to restore the appropriate tension in the ligament.

Here is a three-step recovery plan that can help expedite a player’s return to the ice. Progression through each phase of the recovery typically takes between 2-4 weeks. 

 

Phase One: Reduce the swelling and inflammation

The initial treatment phase involves the use of a tall walking boot, ice and elevation. This is a good time to also use a daily NSAID (Non-Steroidal Anti-Inflammatory) such as over the counter naproxen or ibuprofen to help with the pain and swelling. The goal of this first phase is to reduce the pain and swelling and to protect the ankle from additional injury.

I recommend crutches until the player can walk in the boot without pain. As the swelling subsides and the player feels better, we start incorporating range of motion exercises and use of the stationary bike. 

 

Phase Two: Build back up the strength and restore normal motion and function

The goal of the second phase of the recovery is to restore normal motion and gait while building back up strength of the ankle. This phase of the recovery should ideally be done with the help of a physical therapist. The player should be walking normally and have no pain with exercises such as a single leg hop. 

The focus in physical therapy should be on strengthening the muscles on the outside of the ankle (the peroneal muscles) to help minimize the risk of re-injury with the use of resistive bands. This is also the appropriate time to initiate and emphasize balance board exercises. 

 

Phase Three: Transition back to the ice 

This involves ramping up the activity level with the specific goal of first returning to the ice and then progressing to practice and live game play. The player should not have pain with pushing off their edges and doing mohawks (transitioning from forward to backwards skating). If the player has pain and weakness with these on ice activities, more time in Phase Two is required. 

During the return to play, I am a strong advocate for taping the ankle or using a lace up ankle brace on the ice. 

High ankle sprains can be a challenge to recover from and managing expectations is important because of the longer recovery time. Immediate recognition and treatment with a logical progression through the three phases of recovery gives the player the best chance to return at the previous level of play with a low risk for re-injury.

Issue: 
2024-06

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