Last Updated on Thursday, 18 October 2012 11:48
By Dr. Rob LaPrade
http://drrobertlaprademd.com
Question: One of my skates got twisted outwards during a collision and now I have pain just above my ankle. I don’t have any fractures on x-rays, but I have been told I have a high ankle sprain. What is this and when can I get back to playing hockey?
Answer: High ankle sprains are stretches or tears of the ligaments and membrane connecting the two leg bones (tibia and fibula) at the level of the ankle. The ligaments involved are also referred to as a syndesmosis, so a syndesmotic injury to the ankle is another term for high ankle sprain. High ankle sprains are far less common and located above the ligaments involved in a traditional ankle sprain, which are on the outside of the ankle. When intact, the syndesmosis allows for only a small amount of movement between the leg bones when subject to high stresses during walking and running, and even more so with skating. High ankle sprains occur most often in contact sports when the foot is twisted outwards, and cause pain or tenderness just above the ankle. Proper assessment may include ankle x-rays to look for ankle fractures, which often occur due to a similar injury mechanism and can have similar symptoms.
It can be very difficult to quickly return to on-ice activity for hockey players following a high ankle sprain. While traditional ankle sprains can usually be taped and fit into a tight skate, with a rather quick return to skating once the pain and swelling have resolved, it takes a much longer time to recover from high ankle sprains. The blood supply to the syndesmosis is poor, slowing down the rate of healing. Additionally, twisting or turning maneuvers that are common in hockey result in recurrent tearing of this area that can further delay healing. For these reasons, high ankle injuries can take up to six weeks or longer to heal.
The initial treatment for high ankle sprains is to follow the standard RICE protocol. This consists of a program of Rest, Icing, Compression, and Elevation. In our experience, we have found that immediate application of these basic treatments can decrease the recovery time for even the most severe ankle sprains. Conversely, if the ankle is allowed to swell up after the injury and the athlete loses ankle motion, their ability to return in a timely fashion will be jeopardized.
During recovery, athletes who have high ankle sprains may be able to walk fairly normally or even jog on level ground, but should not be allowed to skate due to the stresses from pushing off or twisting on the skate edges. Once the ankle has quieted down and swelling is minimized, the athlete is started on a program of ankle strengthening. The outside ankle (peroneal) muscles are a focus of strengthening exercises to help protect the ankle from being reinjured by twisting again. We usually use exercise bands or rubber tubing to apply resistance during ankle eversion exercises. In addition, exercises such as balancing help the supporting muscles to regain recognition of the appropriate time to contract to prevent a reinjury. These exercises are important to help the athlete return to function safely and quickly.
Once an athlete has minimal swelling and has appropriate strength, a functional on-ice evaluation needs to be performed to assess readiness for return to play. This is especially important for high ankle sprains because an athlete should not try to play through pain because of risk for reinjury. If they find that they cannot push off on their edges and have difficulty with transitioning from forward to backward skating, the return to on-ice activities should be delayed.
In conclusion, the treatment of high ankle sprains is more complex and requires more recovery time than for low ankle sprains. Immediate measures to reduce swelling are beneficial, and athletes need to have resolution of their symptoms prior to returning back to skating to minimize the chance of reinjury.
Robert F. LaPrade, M.D., Ph.D. is a complex knee surgeon at The Steadman Clinic in Vail, Colorado. He is very active in research for the prevention and treatment of ice hockey injuries. Dr. LaPrade is also the Chief Medical Research Officer at the Steadman Philippon Research Institute. Formerly, he was the team physician for the University of Minnesota men’s hockey team and a professor in the Department of Orthopaedic Surgery at the U of M. If you have a question for the Hockey Doc, e-mail it toeditor@letsplayhockey.com.
