High Ankle Sprain vs. Lateral Ankle Sprain: What’s the Difference?

Kathy Ryan-Ceisel, PT MHS | Algonquin Sports PT

Overhead Throwing Expert-Athletic Edge and Wellness Edge

Not all ankle sprains are created equal. When an athlete says, "I rolled my ankle," many people immediately think of the common lateral ankle sprain involving the ligaments on the outside of the ankle. But there is another type of ankle injury that deserves special attention: The high ankle sprain, or syndesmotic sprain.

High ankle sprains involve the ligaments that connect the tibia and fibula above the ankle joint. They are less common than lateral ankle sprains but can be significantly more difficult to diagnose and often require a longer rehabilitation period.

For athletes, understanding the difference is critical. A player with a mild lateral ankle sprain may be back relatively quickly. A player with a significant syndesmotic injury may require several weeks—or potentially surgery—before safely returning to competition.

Lateral vs. High Ankle Sprain: The Basic Difference

The easiest way to understand the difference is to look at where the ligaments are located and how the injury occurs.

Lateral ankle sprain

A lateral ankle sprain affects the ligaments on the outside of the ankle, most commonly:

• Anterior talofibular ligament (ATFL)

• Calcaneofibular ligament (CFL)

• Posterior talofibular ligament (PTFL)

The classic mechanism is an inversion injury, where the foot rolls inward underneath the athlete.

High ankle sprain

A high ankle sprain involves the syndesmosis, the ligamentous complex

connecting the tibia and fibula.

Important structures include:

• Anterior inferior tibiofibular ligament (AITFL)

• Posterior inferior tibiofibular ligament (PITFL)

• Interosseous ligament

• Interosseous membrane

• Transverse tibiofibular ligament

These structures help maintain the normal relationship between the tibia and fibula and provide stability to the ankle mortise. When the syndesmosis is injured, the problem is not simply on the outside of the ankle. It is higher up the leg and closer to the ankle mortise.

How Does a Lateral Ankle Sprain Happen?

The classic lateral ankle sprain occurs when the athlete:

• Plants the foot

• Rolls onto the outside of the foot

• Experiences excessive inversion

• Often has the ankle in some degree of plantarflexion

This commonly occurs during:

• Cutting

• Jumping and landing

• Running

• Stepping on another athlete’s foot

• Contact sports

• Basketball

• Soccer

• Volleyball

• Baseball and softball

The ATFL is usually injured first, followed by the CFL as the force increases.

How Does a High Ankle Sprain Happen?

The mechanism is different.

A syndesmotic injury can occur when the ankle experiences:

External rotation

The foot rotates outward relative to the lower leg.

Forced dorsiflexion

The ankle is pushed aggressively upward while the foot is planted.

Combined external rotation and dorsiflexion

This is one of the classic mechanisms.

Direct contact

A blow to the lower leg or ankle can also disrupt the syndesmosis.

High ankle sprains are particularly common in sports involving contact, cutting, collision and forceful changes of direction.

They are seen frequently in:

• Football

• Hockey

• Basketball

• Soccer

• Wrestling

• Lacrosse

• Skiing

• Other high-demand field and court sports

Although less common, baseball and softball athletes can also sustain syndesmotic injuries, particularly during sliding, awkward landing, contact or aggressive cutting.

The Symptoms Can Be Different

Knowing where the athlete hurts can provide an important clue.

Lateral Ankle Sprain

Pain is typically located:

• Around the outside of the ankle

• Near the ATFL

• Near the CFL

• Around the lateral malleolus

There is commonly:

• Swelling

• Bruising

• Pain with inversion

• Pain with weight bearing

• Tenderness over the lateral ligaments

• Reduced ankle ROM

High Ankle Sprain

Pain may be located:

• Above the ankle joint

• Along the distal tibia and fibula

• Over the front of the ankle

• Along the syndesmosis

• Sometimes extending upward along the interosseous membrane

Athletes may describe a feeling of pain or instability when they:

• Push off

• Run

• Cut

• Pivot

• Rotate the foot outward

• Load the ankle in dorsiflexion

One particularly important finding is tenderness that extends above the ankle along the syndesmosis or interosseous membrane.

This can help distinguish a high ankle sprain from a routine lateral sprain.

Why High Ankle Sprains Can Be More Difficult

A lateral ankle sprain primarily affects the structures that resist excessive

inversion. The syndesmosis has a different job. It helps maintain the relationship between the tibia and fibula and stabilizes the ankle mortise. When these structures are injured, normal loading of the ankle can become painful.

High ankle sprains therefore tend to cause problems with:

• Push-off

• Running

• Cutting

• Jumping

• Acceleration

• Deceleration

• Dorsiflexion

• Rotational movements

Historically, syndesmotic injuries have been recognized as injuries with longer recovery periods than typical lateral ankle sprains. (PubMed)

 

How Is a High Ankle Sprain Diagnosed?

Diagnosis starts with the mechanism of injury and location of symptoms.

A clinician should not simply assume that every ankle sprain is a lateral ligament injury.

Physical Examination

Important components include:

Syndesmotic palpation

Tenderness is assessed over the distal tibiofibular ligaments and interosseous membrane.

Squeeze test

The tibia and fibula are compressed together higher up the lower leg.

Pain near the ankle with this maneuver can increase suspicion for syndesmotic injury.

External rotation stress test

The clinician stabilizes the leg while externally rotating the foot.

Pain around the syndesmosis may indicate injury.

Dorsiflexion testing

Pain with loaded dorsiflexion can be particularly important.

Single-leg testing

As symptoms permit, the athlete can be assessed with:

• Single-leg stance

• Heel raises

• Squatting

• Hopping

• Running

• Cutting

A high ankle sprain can sometimes be surprisingly difficult to diagnose during the first examination.

Current literature continues to emphasize that there is no single perfect clinical test and that diagnosis should incorporate the mechanism, location of tenderness, functional findings and imaging when appropriate. (PubMed)

Imaging for High Ankle Sprains

X-rays are particularly important when there is concern about:

• Fracture

• Widening of the ankle mortise

• Tibia/fibula displacement

• Significant syndesmotic instability

Weight-bearing radiographs may be helpful when tolerated.

In more complicated cases, additional imaging may include:

• MRI

• CT

• Stress radiographs

• Weight-bearing CT in selected cases

MRI can be particularly helpful for evaluating the syndesmotic ligaments and associated soft-tissue injury. Importantly, a normal X-ray does not necessarily mean that the syndesmosis is normal. A syndesmotic ligament injury can exist without obvious widening or fracture.

High Ankle Sprain Grades

Classification systems for syndesmotic injuries are not as universally standardized as the traditional Grade I–III classification used for lateral ankle sprains.

Clinically, however, syndesmotic injuries are often thought of as:

Stable injury

The ligaments are injured, but the ankle mortise remains stable.

These injuries can often be treated conservatively.

Partially unstable injury

There is greater ligament involvement and potentially subtle instability.

These injuries require closer monitoring and sometimes additional imaging or orthopedic consultation.

Unstable syndesmotic injury

The syndesmosis cannot adequately maintain normal tibia-fibula alignment.

These injuries are much more likely to require surgical stabilization.

This distinction is extremely important because the severity and stability of the syndesmosis—not simply the amount of pain—help determine treatment.

How Long Does a High Ankle Sprain Take to Heal?

This is where athletes need to understand the major difference between high and lateral ankle sprains. A typical mild lateral ankle sprain may allow an athlete to return relatively quickly. A syndesmotic injury often takes longer.

Research in athletes has reported wide variation depending on injury severity and treatment. A systematic review found an average return-to-sport time of approximately 46 days, with nonoperative cases averaging about 42 days and operative cases approximately 55 days. (PubMed)

A 2022 meta-analysis of more than 1,100 syndesmotic injuries reported an overall mean return-to-play time of approximately 52 days, with approximately 39 days for nonsurgical injuries and 71 days for surgically treated injuries. (PubMed)

More recent research involving elite athletes found an overall return-to-sport rate of approximately 96%, with an average return around two months, although individual recovery times varied considerably. (PubMed)

The important point:

Do not give a high ankle sprain a two-week return-to-play expectation simply because it is “only an ankle sprain.” The injury needs to be evaluated based on its stability, severity and functional recovery.

Treatment of a High Ankle Sprain

Treatment depends heavily on whether the syndesmosis is stable.

Early Treatment

Initial treatment may include:

• Protection

• Relative rest

• Compression

• Elevation

• Swelling management

• Protected weight bearing

• Appropriate immobilization

Crutches may be necessary if walking is painful.

CAM Boot or Immobilization

A CAM boot can be appropriate for a more significant syndesmotic injury, particularly when the athlete cannot comfortably walk.

The goal is to protect the injured structures while allowing the tissue to heal.

The duration depends upon:

• Severity

• Stability

• Pain

• Weight-bearing tolerance

• Imaging findings

• Physician recommendations

Once the athlete can safely transition out of immobilization, rehabilitation should progressively restore motion, strength and function.

The boot is protection—not rehabilitation.

Medications

NSAIDs such as ibuprofen or naproxen may be used for short-term pain and inflammation management when medically appropriate. Acetaminophen can be another option for pain control.

Medication should be individualized based upon the athlete’s medical history and other medications. The goal is to control symptoms sufficiently to allow appropriate rehabilitation—not to mask pain so the athlete can return too soon.

What About Injections?

Injections are generally not a first-line treatment for an acute syndesmotic ligament injury. The primary objective is to allow the injured ligaments to heal while restoring normal ankle mechanics and function. Injections may occasionally be considered for specific associated conditions or persistent pain after appropriate evaluation, but they should not be viewed as a shortcut for healing an unstable syndesmotic injury. Persistent pain after a supposed “ankle sprain” warrants reassessment rather than simply repeated injections.

 

Physical Therapy for a High Ankle Sprain

Rehabilitation should be progressive and criteria-based.

Phase 1: Protect the Injury

Goals include:

• Control pain and swelling

• Protect the syndesmosis

• Restore safe weight bearing

• Maintain appropriate ROM

• Prevent unnecessary deconditioning

Depending upon severity, this may involve a boot, brace or crutches.

Phase 2: Restore Mobility

As healing permits, rehabilitation progresses toward:

• Ankle dorsiflexion

• Plantarflexion

• Calf mobility

• Foot mobility

• Controlled ankle ROM

Care should be taken with aggressive rotational or dorsiflexion loading early in the rehabilitation process.

Phase 3: Restore Strength

Strengthening may include:

• Calf raises

• Resisted plantarflexion

• Resisted dorsiflexion

• Controlled inversion/eversion

• Foot intrinsic strengthening

• Single-leg strengthening

• Squats

• Split squats

• Step-ups

• Hip strengthening

The athlete must regain the ability to generate force through the injured leg.

Phase 4: Balance and Neuromuscular Control

The athlete progresses toward:

• Single-leg balance

• Dynamic balance

• Reaching activities

• Single-leg squats

• Step-downs

• Perturbation training

• Hopping

The objective is to restore the athlete’s ability to control the ankle while the body is moving quickly.

Phase 5: Running and Plyometrics

Running should be progressed gradually.

A typical sequence may include:

Walking → jogging → running → acceleration → deceleration → lateral movement → cutting → jumping → sport-specific movement

Plyometric training can then progress from:

• Double-leg jumping

• Forward jumping

• Single-leg jumping

• Forward hopping

• Lateral hopping

• Repeated hopping

• Reactive jumping

Return to Play After a High Ankle Sprain

Return to play should be criteria-based rather than calendar-based.

Before returning to unrestricted competition, an athlete should demonstrate:

• Minimal or no swelling

• Pain-free or near pain-free ROM

• Normal walking

• Adequate ankle strength

• Adequate calf endurance

• Good single-leg balance

• Ability to hop without pain

• Ability to accelerate and decelerate

• Ability to cut

• Ability to jump and land

• Ability to tolerate sport-specific movements

• Confidence in the injured ankle

For lateral ankle sprains, research has increasingly emphasized a multidimensional return-to-sport decision involving pain, ankle ROM, strength, balance, athlete-reported function and sport-specific performance rather than time alone. (PubMed)

The same philosophy is particularly important for syndesmotic injuries.

When Does a High Ankle Sprain Need Surgery?

This is one of the biggest differences between a routine lateral ankle sprain and a significant syndesmotic injury.

Stable syndesmotic injuries can often be treated without surgery.

Surgery becomes more likely when there is:

• Clear syndesmotic instability

• Widening of the tibia-fibula relationship

• Diastasis

• Associated fracture

• Failure of conservative treatment

• Persistent instability

• Significant ligament disruption

The goal of surgery is to restore and maintain normal alignment between the tibia and fibula while the injured structures heal.

Modern surgical stabilization may involve:

• Syndesmotic screws

• Suture-button fixation

• Hybrid fixation in selected cases

The specific technique depends upon the injury pattern and surgeon preference.

 

What Are the Outcomes After Surgery?

The good news is that athletes with appropriately diagnosed and treated syndesmotic injuries generally have excellent return-to-sport rates.

A systematic review of athletes reported approximately 94% return to preinjury or equivalent sport levels and approximately 98% return to some level of sport. (PubMed)

A meta-analysis of elite athletes reported a 99% overall return-to-sport rate, although athletes who required surgery generally took longer to return. (PubMed)

More recent research continues to show high return-to-sport rates, with a 2025 meta-analysis reporting approximately 96% return to sport among elite athletes. (PubMed)

However, a successful return to sport does not mean the injury should be rushed.

The more severe the injury, the more important appropriate protection and progressive rehabilitation become.

 

High Ankle vs. Lateral Ankle Sprain: Quick Comparison

	Lateral Ankle Sprain	High Ankle Sprain
Primary structures	ATFL/CFL/PTFL	Syndesmosis
Typical mechanism	Inversion	External rotation/dorsiflexion
Typical pain	Outside of ankle	Above ankle, between tibia/fibula
Swelling	Often lateral	May be less obvious initially
Weight bearing	Often painful	Often painful
Recovery	Often faster	Often slower
Imaging	X-ray when indicated	X-ray + MRI/stress imaging when indicated
Bracing	Common	Depends on stability
Boot	Severe sprains	Common in more significant injuries
Surgery	Uncommon	Needed for unstable injuries
Return to sport	Often weeks	Often several weeks to 2+ months
Main concern	Recurrent lateral instability	Persistent syndesmotic instability

 

Why You Shouldn’t Assume “It’s Just an Ankle Sprain”

One of the biggest mistakes an athlete can make is assuming every ankle injury is the same. A player who rolls their ankle and has tenderness over the ATFL may have a straightforward lateral ankle sprain.

But an athlete who has:

• Pain above the ankle

• Pain with external rotation

• Pain with dorsiflexion

• Tenderness along the syndesmosis

• Difficulty pushing off

• Pain that persists longer than expected may have a high ankle sprain.

That distinction matters because the expected recovery, rehabilitation and potential need for surgery can be very different.

 

The Overhead Athlete: Why the Ankle Still Matters

For baseball and softball players, the ankle may seem far removed from the throwing arm.

It isn’t.

Pitching and throwing require coordinated force production from the ground upward.

The lower extremity contributes to:

Ground reaction force → ankle → knee → hip → pelvis → trunk → shoulder → elbow → hand

An ankle injury can reduce the athlete’s ability to push off, stabilize the lower extremity and efficiently transfer force through the kinetic chain.

This is particularly important for pitchers, who repeatedly perform a high-force, single-leg-dominant movement.

A high ankle sprain can therefore affect more than running.

It can potentially affect:

• Pitching mechanics

• Stride mechanics

• Lead-leg stability

• Force production

• Lower-body power

• Trunk rotation

• Throwing efficiency

This doesn’t mean an ankle sprain automatically causes a shoulder or elbow injury. Rather, it reinforces an important rehabilitation principle:

Don’t rehabilitate only the painful body part. Rebuild the athlete.

The Bottom Line

A lateral ankle sprain and a high ankle sprain are two different injuries.

A lateral ankle sprain typically results from inversion and affects the ligaments on the outside of the ankle.

A high ankle sprain typically involves external rotation and/or dorsiflexion and affects the syndesmotic ligaments connecting the tibia and fibula.

The high ankle sprain is less common but often more demanding to rehabilitate.

The most important differences are:

Different mechanism.

Different anatomy.

Different clinical findings.

Often longer recovery.

Different surgical considerations.

If an athlete has pain above the ankle or symptoms that don’t match a typical lateral ankle sprain, it is important to obtain an appropriate evaluation.

At Athletic Edge and Wellness, our goal is not simply to get athletes out of pain. We evaluate strength, mobility, balance, power, movement quality and sport-specific function so athletes can safely progress from injury back to performance.

Don’t Guess. Get It Evaluated. 📞224-505-3343

If you have sustained an ankle injury, especially one involving persistent pain, instability or pain above the ankle, a sports physical therapy evaluation can help determine what structures may be involved and what needs to be done to safely return to your sport.

Your ankle may feel better before it is ready for competition. Make sure the athlete—not just the pain—is ready to return.