Fairhope High School’s remarkable Riley Leonard made Duke football must-see TV this fall. But the pride of the Pirates had us on the edge of our seats not just for his QB exploits but what we all could see as a gruesome ankle injury in the last seconds of a primetime game against Notre Dame. Fortunately, what could have been a season-ending fracture instead was diagnosed as a high ankle sprain and expected to heal in a matter of weeks.  We all breathed easier with that news.

So what exactly is a high ankle sprain? 

Let’s start with the basics.

Ankle injuries are extremely common in sports, especially those that involve cutting or on fields with uneven ground.   

Ankle sprains involve the lateral ligaments on the outside of the ankle, and occur when the foot and ankle are twisted unexpectedly.  We grade sprains based on the amount of tearing. Grade 1: mild with microscopic tearing of the ligament fibers. Grade 2:  moderate with partial tearing of the ligament and some laxity of the ankle with examination maneuvers.  Grade 3: severe damage to the ligament with more instability on exam.

Two Types of Ankle Sprains

We see two types of ankle sprains defined by the ligaments injured: high ankle sprains and low ankle sprains.  

Low ankle sprains are the most common and involve an inversion injury to ligaments that typically can heal without surgery. With rehab, an athlete is back on the field typically within a few weeks. Without quick attention and therapy, a sprain can potentially weaken the ankle and lead to re-injury.  Repeated ankle sprains can lead to chronic ankle pain, arthritis, and ongoing ankle instability.

In contrast, high ankle sprains are typically the result of an external rotational injury to the ankle, often involving additional fractures around the ankle. Depending on the degree of injury, surgery is often used to keep the ankle joint in its current position while the ligaments heal.  A memorable example was former Alabama QB Tua Tagovailoa’s 2018 high ankle injury repaired in a surgery technique with “tightropes.”

This type of sprain involves enough force or damage placed through the foot and ankle that injury occurs to the ankle ligaments along with a forceful separation between the tibia and fibula in the lower leg.  High ankle sprains are one of the most common injuries football players may suffer during their careers, due to the twisting, turning, or cutting motion while running, jumping or falling. In fact, ankle sprains are the number one reason for missed participation with all athletes. (AAOS)

Recovery from Ankle Sprains

Fortunately, most sprains including a complete tear can be treated successfully without surgery. Recovery may take 2 weeks for mild sprains or 6-12 weeks or longer for more severe sprains.     

  • Phase 1: rest, protect the ankle and reduce swelling with ice
  • Phase 2: restoring motion, strength, and flexibility
  • Phase 3: strength and balance exercises and gradual return to sport and activities.   

Gulf Orthopaedics’ Grant Shell, MD is fellowship trained in foot and ankle injuries with a focus on the same non-surgical solutions favored by elite athletes. One of these options is orthobiologics, which can support and enhance the body’s natural healing process when injected into the body. Released chemicals stimulate growth and draw additional cells for regeneration of tissue to speed recovery.

Clearly, recovery from a severe sprain is a challenge for elite athletes whose job involves just the kind of motion that puts stress on an ankle.  We all wish Riley – and his protective offensive line – healthy days and winning games ahead!

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