High Ankle Sprain Exercises: Syndesmosis Injury Rehabilitation

A high ankle sprain (syndesmosis injury) affects the ligaments connecting the tibia and fibula above the ankle joint—different from the common lateral ankle sprain. These injuries are notorious for taking longer to heal and requiring more careful rehabilitation. Rushing recovery often leads to chronic problems and prolonged disability.

Understanding High Ankle Sprains

Anatomy

The syndesmosis consists of:

• Anterior inferior tibiofibular ligament (AITFL) - Front
• Posterior inferior tibiofibular ligament (PITFL) - Back
• Interosseous membrane - Between the bones
• Transverse ligament - Lower portion

These structures hold the tibia and fibula together, maintaining the ankle mortise (the "socket" the talus sits in).

Mechanism of Injury

High ankle sprains occur when:

• Foot is planted and rotated outward (external rotation)
• Forceful dorsiflexion with rotation
• Direct blow forcing bones apart

Common in: Football, hockey, skiing, soccer, basketball

Why They Take Longer

Unlike lateral sprains:

• Weight-bearing stresses the syndesmosis with every step
• The ligaments must hold bones together under load
• Healing requires the fibula to stay properly positioned
• Rushing causes chronic instability and pain

Healing Timeline

• Grade 1: 4-6 weeks
• Grade 2: 6-12 weeks
• Grade 3 (with diastasis/surgery): 3-6 months

Phase 1: Protection Phase (Week 1-3)

Goals

• Protect healing ligaments
• Reduce swelling
• Maintain fitness where possible
• Begin gentle motion (if cleared)

RICE Protocol

Essential in early phase:

• Rest: Non-weight bearing or limited as directed
• Ice: 15-20 minutes, multiple times daily
• Compression: ACE wrap or compression sleeve
• Elevation: Above heart level

Toe Curls and Spreads

Maintain intrinsic foot strength:

1. Sit with foot flat on floor
2. Curl toes, gripping surface
3. Spread toes wide apart
4. Alternate between movements

Perform: 20 reps each, 3-4 times daily

Towel Scrunches

1. Place towel flat under foot
2. Use toes to scrunch towel toward you
3. Spread towel back out
4. Repeat

Perform: 10-15 scrunches, 3 sets

Hip and Core Work

Maintain fitness while protecting ankle:

Seated Leg Raises:

1. Sit in chair
2. Straighten injured leg
3. Hold 5 seconds, lower

Glute Bridges:

1. Lie on back, knees bent
2. Lift hips toward ceiling
3. Don't push through injured ankle

Upper Body Work: Continue normal upper body training

Perform: Normal sets and reps for maintenance

Gentle Dorsiflexion (If Cleared)

Only if provider approves:

1. Sit with knee bent
2. Gently pull toes toward shin
3. Avoid rotation
4. Hold 10-15 seconds

Perform: 5-10 reps, 2-3 times daily

Phase 2: Early Mobility (Week 3-6)

Goals

• Restore range of motion
• Begin controlled weight bearing
• Progress strength exercises
• Maintain cardiovascular fitness

Ankle Alphabet

Controlled ROM in all directions:

1. Sit with leg extended or elevated
2. Trace letters A-Z with big toe
3. Move only at ankle
4. Keep movements smooth

Perform: Full alphabet, 2-3 times daily

Calf Stretches (Gentle)

1. Stand facing wall, hands on wall
2. Injured leg back, heel on floor
3. Lean forward until stretch in calf
4. Keep foot pointed straight ahead (no rotation)

Perform: Hold 30 seconds, 3-4 reps, 2-3 times daily

Isometric Resistance

Build strength without movement:

Dorsiflexion:

1. Sit with foot against wall
2. Push top of foot into wall (like pulling toes up)
3. Hold 10 seconds

Plantarflexion:

1. Place ball of foot against wall
2. Push into wall (like pointing toes)
3. Hold 10 seconds

Inversion/Eversion:

1. Cross ankles, push against each other
2. Alternate which foot is on top
3. Hold 10 seconds each direction

Perform: 10 reps each direction, 3 sets

Stationary Bike

Excellent low-impact cardio:

1. Start with foot flat on pedal
2. Use primarily uninjured leg
3. Gradually increase injured leg effort
4. Avoid pointed toe position

Perform: 15-20 minutes daily

Weight Shifting

Progress to controlled loading:

1. Stand with support available
2. Shift weight onto injured leg
3. Hold 10-20 seconds
4. Progress to more weight over time

Perform: 10-15 shifts, 3 sets

Single-Leg Balance (Uninjured)

Maintain balance on good leg:

1. Stand on uninjured leg
2. Practice various challenges
3. Maintains neuromuscular function

Perform: 30-60 seconds, 3-4 times

Phase 3: Strengthening (Week 6-10)

Goals

• Progressive resistance training
• Improve functional strength
• Begin proprioception training
• Progress weight-bearing activities

Resistance Band Exercises

Dorsiflexion:

1. Loop band around foot, anchor to sturdy object
2. Pull toes toward shin against resistance
3. Control return

Plantarflexion:

1. Loop band around foot, hold ends
2. Push foot down against resistance
3. Control return

Eversion (Important for syndesmosis):

1. Sit with legs extended, band around both feet
2. Push feet apart against resistance
3. Control return

Perform: 15-20 reps each direction, 3 sets

Heel Raises

Progress gradually:

Bilateral:

1. Stand with both feet on floor
2. Rise onto toes
3. Lower with control

Single Leg (When cleared):

1. Stand on injured leg
2. Rise onto toes
3. Lower slowly

Perform: 15-20 reps, 3 sets

Step-Ups

1. Stand facing 4-6 inch step
2. Step up with injured leg
3. Control descent
4. Progress step height

Perform: 12-15 reps, 3 sets

Squats

1. Feet shoulder-width apart
2. Squat to comfortable depth
3. Keep weight in heels
4. Avoid compensating with injured side

Perform: 15-20 reps, 3 sets

Balance Training

Begin proprioception work:

Single-Leg Stance:

1. Stand on injured leg
2. Hold 30-60 seconds
3. Progress: eyes closed, unstable surface

Perturbations:

1. Stand on injured leg
2. Partner gently pushes from different angles
3. Maintain balance

Perform: 3-5 reps, 30-60 seconds each

Walking Program

Progress duration and intensity:

Week 6-7: Flat surfaces, 10-15 minutes Week 7-8: Increase to 20-30 minutes Week 8-10: Add gentle inclines

Phase 4: Return to Function (Week 10+)

Goals

• Sport-specific training
• Plyometric progression
• Cutting and pivoting
• Full return to activity

Single-Leg Exercises

Single-Leg Deadlift:

1. Stand on injured leg
2. Hinge at hip, reaching opposite hand to floor
3. Keep back flat
4. Return to standing

Single-Leg Squat:

1. Stand on injured leg
2. Squat to 60-70 degrees
3. Keep knee aligned
4. Return with control

Perform: 10-12 reps, 3 sets

Plyometric Progression

Start low-level, progress carefully:

Two-Leg Hops:

1. Small forward hops
2. Land softly
3. Progress to side-to-side

Single-Leg Hops (When ready):

1. Start with small hops forward
2. Progress to lateral hops
3. Stick each landing before next hop

Box Jumps:

1. Low box initially
2. Land softly with bent knees
3. Step down initially

Perform: 8-12 reps, 2-3 sets

Running Progression

Week 1: Walk-jog intervals (90 sec walk, 30 sec jog)

Week 2: Jog 50% intervals, walk 50%

Week 3: Continuous jogging 10-15 minutes

Week 4: Add gentle curves and turns

Week 5: Figure-8 running

Week 6: Cutting drills at reduced speed

Cutting and Pivoting

Progress slowly—syndesmosis is stressed by rotation:

1. Start with wide, slow cuts (45 degrees)
2. Progress to sharper angles
3. Increase speed gradually
4. Add sport-specific movements

Key: If pain occurs with rotation, back off and continue strengthening

Sport-Specific Drills

Tailored to your activity:

• Agility ladder work
• Cone drills
• Sport-specific movements at reduced intensity
• Full practice situations when cleared

Important Considerations

Signs of Improper Healing

Watch for:

• Pain that persists beyond expected timeframes
• Swelling that returns with activity
• Clicking or catching sensation
• Feeling of instability
• Pain with rotation

When Surgery May Be Needed

• Grade 3 with widening (diastasis)
• Failed conservative treatment after 12 weeks
• Combined fractures
• Athlete with high-level demands

Post-Surgical Rehabilitation

If surgery performed:

• Non-weight bearing typically 6-8 weeks
• Hardware removal may be needed before full rotation
• Timeline extended 2-3 months beyond conservative
• Follow surgeon's specific protocol

Taping and Bracing

For return to sports:

• Figure-8 taping provides rotational stability
• Lace-up braces offer support
• May be used for months after return
• Gradually wean as confidence builds

Exercises to Avoid

Throughout Recovery:

• External rotation under load
• Deep squats with rotation
• Cutting/pivoting before cleared
• Any exercise causing pain above ankle joint
• Aggressive calf stretching with rotation

Early Phases:

• Running or jumping
• Single-leg activities
• Resisted rotation
• High-impact activities

Sample Schedule (Phase 3)

Daily:

• Ankle alphabet
• Calf stretches: 3x30 sec
• Resistance band (all directions): 3x15

Monday/Wednesday/Friday:

• Heel raises: 3x15
• Step-ups: 3x12
• Squats: 3x15
• Single-leg balance: 3x45 sec

Tuesday/Thursday:

• Stationary bike: 20-30 minutes
• Walking program
• Hip and core strengthening

Prevention After Recovery

Once healed:

• Continue ankle strengthening
• Maintain balance training
• Use appropriate footwear
• Consider prophylactic taping for high-risk sports
• Address any biomechanical issues

Key Takeaways

High ankle sprains require patience:

1. They take longer - Don't compare to lateral sprains
2. Rotation is the enemy - Avoid twisting under load until healed
3. Strength before speed - Build foundation before cutting/pivoting
4. Pain is your guide - Back off if pain occurs above ankle
5. Rushing = chronic problems - Protect your long-term function

High ankle sprains have a reputation for "taking forever" because athletes often return too soon. Invest the time in proper rehabilitation—your ankle will thank you.