High ankle sprains in athletes: A comprehensive imaging focused review

High ankle sprains represent a distinct subset of ankle injuries involving disruption of the distal tibiofibular syndesmosis. Although less common than lateral ankle sprains, these injuries are frequently underdiagnosed on initial clinical and radiographic assessment and carry significant implications for ankle stability and long-term function. In the athletic setting, high ankle sprains are associated with an increased return-to-play time compared to lateral ligament injuries. Accurate diagnosis relies heavily on imaging, with weight-bearing radiographs and computed tomography aiding in assessment of syndesmotic alignment and fractures, whilst MRI allows for direct visualisation of the ligaments and associated injuries. This review provides a comprehensive, imaging-centred overview of the spectrum of high ankle sprain injuries with a focus on lower energy mechanisms, which occur more commonly in sport. We will discuss and review the relevant anatomy, biomechanics, injury patterns, common associated injuries, the phases of healing, postoperative appearances and common complications. KEY POINTS: • MRI is pivotal in diagnosis of high ankle sprains, injury grading, evaluation of associated injuries, assessment of ligament healing and demonstration of postoperative complications. • The sagittal and coronal planes are key in initial MRI assessment of the AITFL. Axial plane assessment is limited due to obliquity of the AITFL and resultant partial sampling. • The AITFL is the first ligament to fail, usually towards the fibular attachment. • The IIOL usually fails toward the tibial attachment. • The PITFL typically fails at the inferior, lateral border of the tibial attachment, with variable propagation superiorly and medially often associated with periosteal stripping and tibial plafond chondral injury.