High ankle sprain in hockey players : is it possible wearing skate?

Ankle sprains are not the first injury that comes to mind when you think about injuries in hockey. The lateral ankle sprain, often seen in basketball and soccer is indeed not very common in hockey, mostly because of the skate limiting the range of motion of the ankle. However, high ankle sprains (HAS), also called syndesmotic or tibio-fibular sprain, is regularly seen in hockey. In a 2004 study with players from the Saint-Louis Blues and the Dallas Stars of the National Hockey League, five lateral ankle sprains were recorded versus fourteen HAS (1). The HAS affects the ligament connecting the distal part of the tibia and the fibula, in the anterio-lateral part of the ankle.

Mechanism of injury

HAS happens when the ankle makes a forced external rotation (2). A few mechanisms can explain such movement :
• The athlete pivots towards the inside while the foot stays planted in the ground
• A contact with another player causes an inward movement of the knee while the foot stays planted in the ground
• A fall on the leg while the foot is stuck in an external rotation under the player

In hockey, the skate actually increases the risk for this type of injury due to the way the skate limits movement in the ankle to absorb an impact, along with the high risk of collision that comes with this sport.

Evaluation

The signs and symptoms associated with HAS are :
• Incapacity or difficulty of bearing weight on the injured foot
• Increased pain in ankle movements, especially in dorsiflexion (pulling toes towards the sky)
• Pain when touching the ligament
• Variable swelling depending on the gravity of the related injuries like a fracture or another affected ligament

Many tests exist to evaluate the HAS, but most of them are not completely reliable. The Kleiger test is the most commonly used. It consists of a passive dorsiflexion and external rotation while the examiner stabilises the distal part of the fibula and tibia. Functional testing like walking, jumping, taping the tibio-fibular region while doing active movements of the ankle are also useful to determine if the distal tibio-fibular ligament is affected or not.

Treatment (2)

1. Acute phase
This phase consists of protecting the ankle, minimise pain, inflammation, muscle atrophy and loss of range of motion. Taping, ice, mobility and mild strengthening exercises are used to acheive that goal. Crutches are often used for a two-week period without weight bearing on the injured foot to make sure the ligament heals properly. When the player is able to bear weight on his injured ankle without pain, he can move on to the next phase.

2. Subacute phase
This phase consists of normalizing the mobility, strength and general function of the athlete. Mobility, more advanced strengthening, proprioceptive and balance exercises are included in that phase and must be executed without pain. Swimming and other transfer activities can be useful to maintain cardiovascular function. When the player can jog and jump without pain, he can move on to the next phase.

3. Advanced phase
This phase consists of preparing the return to sport. Slow-to-fast agility, plyometric and sport-specific exercises, executed on many different surfaces should be included in the athlete’s rehabilitation program. The return to sport should be done when the player can execute sport-specific movements with good control and with little or no pain and feeling of instability.

The duration of the rehabilitation period for HAS is longer than for lateral ankle sprains. For HAS, the rehab averages 6 to 8 weeks while the lateral sprain period is from 3 to 4 weeks (1). This then brings the question: how can you prevent ankle sprains? An interesting study done by McGuine TA and al. shows that balance training could have a beneficial effect on the incidence of ankle sprains (3).

Even if the guidelines presented in this article are usually used for the treatment of HAS, they should be adapted to the player in terms of his goals, the presentation of his injury and his general physical condition. A healthcare professional is essential to follow-up on the injury to make sure that the athlete progresses as he should be through the phases of his rehabilitation.

Writen by Ève Poisson, M.Physiotherapy

(1) Wright RW, Barile RJ, Surprenant DA, Matava MJ. Ankle syndesmosis sprains in national hockey league players. Am J Sports Med. 2004 :32(8) :1941-1945.
(2) Williams GN, Allen EJ. Rehabilitation of syndesmotic (high) ankle sprains. Sage Journals. 2010 :2(6) :460-470.
(3) McGuine TA, Greene JJ, Joe J, Thomas G, Leverson G. Balance As a Predictor of Ankle Injuries in High School Basketball Players. Clin Jour Sports Med. 2000 :10(4) :239-244.