Ankle Syndesmosis Injuries: The high ankle sprain
Ankle sprains are amongst the most common injuries amongst athletes and the general population1. These injuries take both a physical and mental toll on the person as the pain and loss of function can affect your ability to perform in sport and work and can take you away from the physical and social exercise you love. One type of ankle injury that has received much more press in recent years is the ankle syndesmosis injury, also known as the high ankle sprain. These injuries are often missed and are associated with a slower return to activity and poorer clinical outcomes2. When this injury is not recognised early, it can lead to inappropriate management causing persistent symptoms and long-term complications3.
If you’ve ever watched a footy match at home and heard a commentor say “that could be a syndesmosis” after a player has gone down injured, you wouldn’t be alone in wondering what that term means. We'll be exploring this injury below. As a physiotherapist who has worked extensively in high level rugby - with the Queensland Reds, soccer, and a wide range of other field and court sports, I've had the opportunity to treat all types of ankle injuries, standard lateral ankle sprains, and these often more problematic high ankle sprains. Read on to find out more.
Is your pain preventing you from participating in sports or recreational activities? We'll help you get back on the field, court, track or in the pool!
Book in with one of our experienced Brisbane Sports Physios today!
This blog will cover the following topics on High Ankle Sprains:
- What is the Ankle Syndesmosis
- Causes of an Ankle Syndesmosis Injury
- Signs and Symptoms of an Ankle Syndesmosis Injury
- Diagnosing Ankle Syndesmosis Injuries
- Treatments for Ankle Syndesmosis Injuries
What is the Ankle Syndesmosis?
The ankle syndesmosis is the joint above the ankle where the two bones of the shin, the tibia and fibula, connect. These bones come together to form the ankle mortise (the upper surface of the ankle joint). This is a fibrous joint that provides stability to the ankle that is crucial for the ankle joint to function.
The joint is stabilised by ligaments connecting the two bones at the front (anterior tibiofibular ligament), centre (interosseus membrane) and back (posterior tibiofibular ligament) of the joint, as well as the muscles and fascia (fibrous connective tissue) surrounding the lower ankle. Due to this bony rigidity and stability, it allows very little movement between these two bones creating a stiff yet flexible frame for healthy ankle function.
Find our physio clinic in Salisbury, Brisbane
Our Brisbane Physiotherapy Clinic, services areas including: Salisbury, Brisbane, Tarragindi, Mount Gravatt, Holland Park, Rocklea, Yeronga, Annerley, Camp Hill, Carindale, Coorparoo, Salisbury, Sunnybank, Greenslopes, Seven Hills, Acacia Ridge, Indooroopilly, Woolloongabba, etc.
Because of our expertise in hip conditions, hypermobility, sports injuries, and dance injuries and performance, we also have people visiting us from all over Queensland, Australia and even international visitors. We also have a telehealth service for remote patients.
Injured your ankle playing sport?
Need help with diagnosing your injury, and getting on-top of your pain?
Book in with one of our Sports Physios, and let us help you achieve the best outcomes from your rehab.
Causes of a Syndesmosis Injury
Ankle Syndesmosis injuries more frequently occur in change of direction and contact/collision sports. It is caused when the ankle is twisted outwards relative to the shin at high force, usually when a foot is stuck in the ground during a twisting movement or is caught by the body of another player. The foot then acts like a lever between these two bones, pushing the fibula out and away from the tibia. This can partially or completed tear one or several of the stabilising ligaments of the syndesmosis.
Signs and Symptoms of an Ankle Syndesmosis Injury
It is common to feel pain immediately at the front and/or side of the ankle joint and lower shin. This is often accompanied by a ‘pop’ and/or sensation of instability in the ankle. The ankle will swell and bruise, normally at the front and outside of the lowest part of the shin, though you may have pain and swelling over other parts of the ankle as it is common to stress and injure the surrounding ligaments and bones as well.
Immediately after the injury, it is normally painful to put weight through the ankle, especially as you step forward on that foot, so crutches may be required to walk.
Not sure if your Ankle Injury is a Syndesmosis Injury?
Book today, and let one of our Sports Physiotherapists assess your ankle and provide you with the appropriate course of action to help you get back to performing your best! You can read more about foot and ankle injuries below!
Diagnosing Ankle Syndesmosis Injuries
In a clinical examination by one our skilled skilled physiotherapists at PhysioTec, we will conduct several tests to determine if an ankle injury involves the syndesmosis. It is important to differentiate this from a common lateral ankle sprain and to rule out other concurrent injuries that may occur, such as:
- Lateral Ankle Sprain (most common)
- Osteochondral defect of talus (21%)4.
- Peroneal tendon injuries
- Deltoid Ligament injury
- Fractures
- Fibula
- 5th metatarsal base
- Anterior process of calcaneus
- Lateral/Posterior process of talus
If an ankle syndesmosis injury is suspected, MRI is the gold standard for assessment to determine the extent of the injury5. Your treating physio or doctor may refer you for an x-ray or CT if there are signs of concurrent bony injury. A syndesmosis injury may be shown by disruption of the ligaments and soft tissue on MRI, or diastasis (widening) of the tibia and fibula on x-ray or CT.
Treatments for Ankle Syndesmosis Injuries
Ankle syndesmosis injuries can be treated conservatively under the guidance of a Specialist and your physiotherapist, or surgically with a TightropeTM or screw repair. Whether a syndesmosis injury requires non-surgical or surgical management should be decided by the person with guidance from a surgeon and physiotherapist, based on severity of the injury after MRI and/or CT, and the sport/activities to which they would like to return.
Non-surgical Management
Non-surgical management may involve spending time with the ankle in a protective boot and/or non-weight bearing to allow the damaged structures to heal.
Rehabilitation with a physiotherapist is aimed at restoring ankle range of motion, normal walking, running and jumping mechanics, strength and power in and around the affected ankle and coordination in preparation for sport or activity-specific tasks.
Once these goals are achieved, the person may begin a safe graduated return to sport/activity under the guidance of their physiotherapist.
Surgical Management
If physical examination and MRI and/or CT study demonstrates an extensive injury leading to an unstable joint, surgical repair may be preferred, especially for those returning to high impact activities such as running. In isolated syndesmosis injuries, the Tightrope method is most used. This stabilises the joint to allow the damaged structures to heal and is associated with a very high rate of return to activity6.
Following this operation, the ankle will normally be put in a cast or boot to allow the ankle to heal, followed by a period of rehabilitation with your therapist focused on safely restoring your ankle range of motion, strength and power until the person is ready to safely return to activity.
Struggling with a recent ankle injury? Visit us at PhysioTec. Our skilled Sports Physio Team can evaluate your injury and develop a personalised plan to enhance your recovery, helping you get back to doing the activities to love!
↓ MAKE A BOOKING TODAY ↓
Author
This blog was written by Andrew Vetter, one of our sports physiotherapists. Andrew has a special interest in treating hip and groin pain, shoulder injuries, and lower limb recoveries. Andrew aims to provide high quality care to his patients, help them perform better, recover from injuries, and get back to doing the things they love. Andrew has gained extensive experience as the rehabilitation physiotherapist for various rugby teams over the years, including the Queensland Reds!
You can read more about Andrew here.
References:
- Van Dijk, C. N., & Vuurberg, G. (2016). There is no such thing as a simple ankle sprain: clinical commentary on the 2016 International Ankle Consortium position statement. British Journal of Sports Medicine, 51(6), 485–486. doi:10.1136/bjsports-2016-096733
- Heifner JJ, Kilgore JE, Nichols JA, Reb CW. Syndesmosis Injury Contributes a Large Negative Effect on Clinical Outcomes: A Systematic Review. Foot & Ankle Specialist. 2024;17(3):284-294.
- Nussbaum, E. D., Hosea, T. M., Sieler, S. D., Incremona, B. R., & Kessler, D. E. (2001). Prospective Evaluation of Syndesmotic Ankle Sprains without Diastasis. The American Journal of Sports Medicine, 29(1), 31–35. doi:10.1177/03635465010290011001
- Dahmen J, Jaddi S, Hagemeijer NC, et al. Incidence of (Osteo)Chondral Lesions of the Ankle in Isolated Syndesmotic Injuries: A Systematic Review and Meta-Analysis. CARTILAGE. 2022;13(2).
- Krähenbühl, N., Weinberg, M.W., Davidson, N.P. et al. Imaging in syndesmotic injury: a systematic literature review. Skeletal Radiol 47, 631–648 (2018). https://doi.org/10.1007/s00256-017-2823-2
- Vancolen SY, Nadeem I, Horner NS, Johal H, Alolabi B, Khan M. Return to Sport After Ankle Syndesmotic Injury: A Systematic Review. Sports Health. 2019;11(2):116-122. doi:10.1177/1941738118816282