Ankle sprains are a very common injury in both youth and elite sports. One may think that hockey players may be protected from this type of injury because they wear a solid boot covering their foot and ankle a.k.a a skate, but this may make them more prone to a different type of ankle sprain: a high ankle sprain (Dubin et al., 2010).
Anatomy
The ankle consists of 3 bones – the tibia, the fibula and the talus. These bones are connected by ligaments. In the common lateral ankle sprain, there is disruption of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL) and the posterior talofibular ligament (PTFL). The high ankle sprain occurs when there is disruption of the interosseus membrane and ligament which connect the tibia to the fibula or the anterior inferior tibiofibular ligament (AITFL).
https://www.flickr.com/photos/nordique/9241569587Mechanism of injury
The mechanism of high ankle sprains often occurs from contact with another players that results in ankle dorsiflexion and external rotation of the foot. Mauntel et al (2017) found that a large portion of high ankle sprains (60.4%) occurred from player contact and that 17.5% occurred from noncontact injuries in NCAA athletes. Interestingly, they also found that 33.3% of ice hockey high ankle sprains occurred from noncontact which seems high considering hockey is a contact sport. However, wearing skates locks in the ankle joint from inversion/eversion, which could make the tib fib joint more susceptible to injury from an awkward fall. They also found that men’s ice hockey had the highest percentage of severe high ankle sprains (>21 days of participation restriction).
Management
An accurate diagnosis is important for early interventions. A good subjective exam can set you up with a differential diagnosis of a high ankle sprain which can then be confirmed by your objective exam. Certain special tests for high ankle sprains can help in your diagnosis (external rotation test, tibia/fibula squeeze test, stabilization test). Or simply applying the tape job mentioned later in the article leading to a reduction of pain with weightbearing or certain painful movements can be an indication of high ankle sprain. (Dubin et al., 2010).
An unstable syndesmosis joint will likely require surgical interventions and should be referred out for imaging if suspected.
For stable high ankle sprains, early nonweightbearing may be appropriate for acute high ankle sprains. When weightbearing through the ankle joint, the tib fib joint will splay to allow room for the talus to move. This splaying may cause pain and the undue stress could delay healing of the ligaments. Restoration of talocrural and subtalar joint range of motion, strengthening of the muscles around the ankle (peronei, tibialis anterior, gastrocnemieus, soleus, etc.), and neuromuscular training for re-education of the proprioceptive receptors will follow in the subacute phase. Return to running, jumping and cutting should occur before returning to skating.
Further challenges may be present when working with hockey players with high ankle sprains, especially high-caliber players. Upjon et al. (2008) found that high-caliber hockey players demonstrate greater degrees of ankle dorsiflexion and are in a constant state of eversion, peaking at 15oof eversion during propulsion. This position of dorsiflexion and external rotation requires the tib fib joint to be able to splay in order to allow for maximal dorsiflexion and the ankle and external rotation of the foot. Therefore, it is critical that the player can tolerate this position before returning to full skating. Taping the distal tib fib joint to stabilize it may allow the player to return earlier with minimal discomfort (video on taping the distal tib fib joint).
High ankle sprains are a common lower body injury in hockey. Management of stable high ankle sprains can be challenging and frustrating because they tend to take longer than lateral ankle sprains. Returning to skating may also be delayed as skating requires adequate and pain-free dorsiflexion and external rotation, which is commonly the mechanism of high ankle sprains, however taping the joint may allow for an earlier return.