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Ankle Syndesmosis Injury

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Ankle syndesmosis injury is often known as a high ankle sprain. The syndesmosis joint consists of a fibrous link between the distal tibia and fibula (end of the shin bones) (Hermans et al., 2010). The structures which provide stability for this syndesmotic joint are the interosseous ligament (IOL), the anterior-inferior tibiofibular ligament (AITFL), the posterior-inferior tibiofibular ligament (PITFL) and the transverse tibiofibular ligament (TTFL) (Lin, Gross & Weinhold, 2006).

Signs & Symptoms

  • Inability to hop.
  • Difficultly walking.
  • Pain not necessarily instantly on injury but in the next coming minutes.
  • Can feel unstable.
  • Pain above the ankle bone on the outer aspect and the front – often higher up than most ankle injuries.
  • Sports injury/impact on a fixed foot.
  • Minimal/moderate swelling in the higher ankle.

Causes & Risk Factors

The most common movement which causes this injury is forced outward rotation of the lower limb combined with dorsiflexion of the ankle (flexing up towards your head). This is an injury that can be deceptive as such as the instant symptoms are not as dramatic as an ankle sprain. You are often able to continue your activity for a short while before having to stop, rather than having immediate difficultly weight-bearing like with other ankle injuries.


  • Landing heavily with the foot rotated outwards.
  • Often a fixed foot position.
  • Contact/twisting injury – impact during a sports injury or road traffic accident.
  • Being overweight.
  • Playing contact sport.
  • Inappropriate footwear.

Assessment & Diagnosis

Your Physiotherapist at Pure will take a detailed history prior to carrying out a comprehensive physical assessment to assist with diagnosis and helping to direct optimal treatment & management of your injury. During your examination, these are the signs your Physio will be assessing for:


  • More likely to get an accurate reading once acute pain and inflammation has settled (optimally after 5 days).
  • Palpation – assessing anatomical structures and whether they are tender to touch.
  • Special tests – testing if there is excessive movement or pain is reproduced in specific structures.
  • Reduced and/or painful dorsiflexion and external rotation – knee to wall test is a good objective measure and your Physiotherapist may monitor this over the next coming weeks.


A fast and accurate diagnosis will mean that the most effective treatment and management plan can be implemented straight away, helping to achieve optimal outcomes. Your Physiotherapist will want to know how your condition is effecting you day to day so that your treatment can be tailored to your needs and will mean personalised goals can be established. Regular re-assessment will ascertain if your are making progress towards your goals and will allow adjustments to your treatment to be made.




This is usually performed in weight bearing (as pain allows) from three different views. Although it is not always necessary to have an X-ray, it is useful to see the relationship between the shin bone (Tibia) and the Fibula as this injury essentially partially separates them.


Pakarinen et al. (2011) found that stress radiography done during surgery was good at identifying more severe injuries, but moderate injuries with instability may be quite easily missed. Therefore, Physiotherapists at Pure Physiotherapy look at the whole picture to come to a decision about your diagnosis using various different methods of evaluation.


MRI/CT scan

MRI and CT scans can be useful tools for assessing disruption of the syndesmosis joint, extent of ligament injury, and the position of the Fibula. MRI has been shown to have high accuracy in detecting injury (96 %), compared with X-ray from the front & back (63 %) and bisecting the syndesmosis joint (71 %) (Oae et al., 2003). CT scans are generally stated to be more accurate than X-rays for showing the relationship of the distal tibia and fibula (Gardner et al., 2006).


With the information gathered from assessment – coupled with the results of medical imaging if required, an accurate diagnosis and grade of injury can be provided. Based on symptom severity and the structures involved, syndesmosis injurys are generally classified using a grading scale of I to IV:

  • Grade I – injury to a single ligament, normal X-ray. Recovery typically occurs over a 1-4 week healing time, up to 3 months for return to sport.
  • Grade II – greater ligamentous damage but remains stable, X-ray normal. 6-12 week healing period, with good Physio management, return to full activity in 3-4 months.
  • Grade III – considerable damage to the local structure with instability shown on imaging. 8-16 week healing time. In 18 professional Rugby League players, return to play average was 64 days post injury (Latham et al., 2017).
  • Grade IV – extensive damage to syndesmotic stabilising structures and the medial ankle ligaments, unstable and an associated fracture may be present. 12-20 week recovery, surgery usually required with intensive Physiotherapy and rehabilitation.

(D’Hooghe et al., 2019)

Other Complications

  • Fracture – most commonly the inner ankle bone (medial malleoli) or higher in the shin (fibula) – approximately one in seven syndesmosis injuries have an associated fracture (Dattani 2008).
  • Secondary degeneration of the local cartilage.
  • Nerve or vascular compromise (rarely).


In more severe cases, your Physio will recommended non weight bearing for a period; using crutches and/or an immobilisation boot which will allow healing to take place. To manage the swelling, the Physiotherapist will recommend the PRICE protocol – protection, rest, ice, compression, elevation. You will be given information about your injury and how you can help facilitate healing and achieve optimal outcomes.


  • Taping strategies to support the deficient ligaments role/anatomy and restore stability to aid healing.
  • Strengthening and sports-/activity-specific exercises.
  • The implementation of manual therapy techniques to help restore movement and decrease pain levels.
  • Return to sport/activity rehabilitation.


D’Hooghe, P., Grassi, A., Alkhelaifi, K., Calder, J., Baltes, T. P. A., Zaffagnini, S., & Ekstrand, J. (2019). Return to play after surgery for isolated unstable syndesmotic ankle injuries (West Point grade IIB and III) in 110 male professional football players: a retrospective cohort study. British journal of sports medicine, bjsports-2018.


Dattani, R., Patnaik, S., Kantak, A., Srikanth, B., & Selvan, T. P. (2008). Injuries to the tibiofibular syndesmosis. The Journal of bone and joint surgery. British volume90(4), 405-410.


Gardner, M. J., Demetrakopoulos, D., Briggs, S. M., Helfet, D. L., & Lorich, D. G. (2006). Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot & ankle international27(10), 788-792.


Hermans, J. J., Beumer, A., De Jong, T. A., & Kleinrensink, G. J. (2010). Anatomy of the distal tibiofibular syndesmosis in adults: a pictorial essay with a multimodality approach. Journal of anatomy217(6), 633-645.


Latham, A. J., Goodwin, P. C., Stirling, B., & Budgen, A. (2017). Ankle syndesmosis repair and rehabilitation in professional rugby league players: a case series report. BMJ open sport & exercise medicine3(1), e000175.


Lin, C. F., Gross, M. T., & Weinhold, P. (2006). Ankle syndesmosis injuries: anatomy, biomechanics, mechanism of injury, and clinical guidelines for diagnosis and intervention. Journal of Orthopaedic & Sports Physical Therapy36(6), 372-384.


Oae, K., Takao, M., Naito, K., Uchio, Y., Kono, T., Ishida, J., & Ochi, M. (2003). Injury of the tibiofibular syndesmosis: value of MR imaging for diagnosis. Radiology227(1), 155-161.


Pakarinen, H., Flinkkilä, T., Ohtonen, P., Hyvönen, P., Lakovaara, M., Leppilahti, J., & Ristiniemi, J. (2011). Intraoperative assessment of the stability of the distal tibiofibular joint in supination-external rotation injuries of the ankle: sensitivity, specificity, and reliability of two clinical tests. JBJS93(22), 2057-2061.

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