Ankle Syndesmosis Injuries: Causes, Symptoms, and Treatment Options
▫️Written by John Keller
✅ Reviewed by Dr. Jenny Hynes on JULY 28, 2023
Welcome to an in-depth exploration of high ankle sprains and ankle syndesmosis injuries — a common yet often overlooked concern with significant implications on daily life. An advanced understanding of these injuries is not only pivotal for athletes and fitness enthusiasts, but also for anyone striving for a healthy, active lifestyle. Recent studies affirm the critical role of timely diagnosis in initiating a proper treatment regimen, and the need for precise management and thorough rehabilitation for optimal recovery (Hopkinson et al., 1990)
These injuries, associated with the disruption of the syndesmosis - a robust fibrous connection comprising the anterior and posterior tibiofibular ligaments and the interosseous membrane, which links the distal ends of the tibia and fibula. Damage to this region can precipitate substantial deficits in biomechanical stability and functionality, particularly when not appropriately managed (Hopkinson et al., 1990). The current literature highlights the fact that insufficient or incorrect treatment can exacerbate long-term ankle instability and persistent pain (Porter et al., 2014), thereby emphasizing the importance of knowledge in this area and its associated pathologies.
Drawing from the latest research, this blog will explore the intricate details of high ankle sprains and ankle syndesmosis injuries, equipping you with a comprehensive understanding of these conditions and their management. By delving into this topic, we can build a path towards healthier ankle joints, ultimately contributing to an enhanced quality of life. We invite you to accompany us as we dissect the multifaceted nature of these commonly encountered, yet anatomically intricate injuries.
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What Is a Syndesmosis Injury?
A high ankle sprain, medically known as a syndesmosis injury, is a specific type of sprain that occurs in the ligaments connecting the distal ends of the tibia and fibula — the two bones of the lower leg. This collection of ligaments, known as the syndesmosis, ensures the stability of the ankle joint, facilitating pivotal movement and weight-bearing capabilities (Hopkinson et al., 1990)
The syndesmosis is an intricate network comprising three primary ligaments: the anterior and posterior inferior tibiofibular ligaments and the interosseous tibiofibular ligament. An additional ligament, the transverse tibiofibular ligament, may also be present. These ligaments function cohesively to maintain the appropriate spacing and alignment of the tibia and fibula, thereby ensuring optimal biomechanical function of the ankle joint (Hopkinson et al., 1990).
High ankle sprains occur when an excessive external rotational or forced dorsiflexion force is applied to the foot, resulting in the disruption of one or more of these ligaments. This force commonly arises from incidents such as sports-related injuries — particularly in football, rugby, and soccer where the foot is often planted and then twisted — trauma, and falls. The damage can range from a minor sprain to a complete ligament tear, potentially associated with an ankle fracture (Hopkinson et al., 1990).
Importantly, an accurate diagnosis of a high ankle sprain syndesmosis is vital for determining the best course of action for treatment, as inadequate or delayed management can result in long-term complications, such as chronic instability or post-traumatic arthritis (Sman et al., 2013).
Signs and Symptoms
Syndesmosis sprains present with a constellation of clinical symptoms that differentiate it from other ankle injuries. Primary indications include localized pain just above the ankle, especially upon external rotation or forced dorsiflexion of the foot. This discomfort is usually more severe and localized higher on the ankle compared to traditional ankle sprains (Nussbaum et al., 2001).
Patients may also report swelling, bruising, and tenderness over the anterior and posterior aspects of the syndesmotic region. Some may experience instability of the ankle joint, causing difficulty in walking or bearing weight. In severe cases, widening of the ankle joint may be observed due to disruption of the syndesmosis, creating an increased space between the tibia and fibula (Nussbaum et al., 2001).
Given these symptoms, seeking immediate medical attention is critical to prevent exacerbation of the injury or potential long-term complications. Thorough clinical examination is paramount, often supplemented with diagnostic tools such as physical assessments, X-rays, and stress tests (Hopkinson et al., 1990). The squeeze and external rotation tests are common physical assessments used to evaluate high ankle sprains.
Imaging modalities like X-rays, computed tomography (CT), and magnetic resonance imaging (MRI) can provide further diagnostic clarity, aiding in differentiating between a simple sprain and a more complex syndesmosis injury. These detailed evaluations allow healthcare professionals to implement an appropriate and effective treatment regimen, optimizing recovery outcomes (Sman et al., 2013).
Grading and Severity of High Ankle Sprain Syndesmosis
The severity of a high ankle sprain syndesmosis injury is typically categorized using a three-grade system, based on the extent of ligament damage and associated instability (van Dijk et al., 2016).
Grade I injuries represent a mild sprain, where the syndesmotic ligaments are stretched but not torn. Symptoms include localized pain and swelling, but the stability of the ankle is preserved. Conservative management is typically sufficient for recovery, with an expected healing time of about 6 weeks (van Dijk et al., 2016).
Grade II sprains involve partial tearing of one or more of the syndesmotic ligaments, leading to moderate pain, swelling, bruising, and some loss of function. Conservative management including rest, immobilisation in a CAM boot, and rehabilitation exercises is usually effective, though the recovery timeline extends to approximately 6-12 weeks (van Dijk et al., 2016).
Grade III injuries, the most severe, involve a complete tear of the syndesmotic ligaments, often associated with a fracture. This leads to significant pain, swelling, instability, and a pronounced inability to bear weight on the affected leg. Treatment may necessitate surgical intervention to restore the normal alignment and stability of the ankle joint, followed by an extensive rehabilitation program. The recovery period can range from 3-6 months or longer, depending on the complexity of the injury and the individual's overall health status (van Dijk et al., 2016).
These gradations underscore the complexity and variability of high ankle sprain syndesmosis injuries, highlighting the necessity for an individualized and stage-appropriate approach to management and recovery.
Treatment Options
The management of high ankle sprain syndesmosis encompasses a broad spectrum of treatment modalities, primarily bifurcated into conservative (non-surgical) and surgical approaches. The selection of treatment is contingent upon a multitude of factors including the grade of injury, patient's age, activity level, overall health status, and personal preferences (Rammelt et al., 2015).
Conservative treatment typically forms the first line of management for Grade I and II injuries. In the management of Grade I and II high ankle sprain syndesmosis, the conventional PRICE (Protection, Rest, Ice, Compression, Elevation) approach has been increasingly updated to the POLICE principle (Protection, Optimal Loading, Ice, Compression, Elevation). While both principles emphasize protection, rest or optimal loading, ice, compression, and elevation, the POLICE approach underscores the importance of optimal loading, allowing for a controlled and progressive return to weight-bearing activities as part of the rehabilitation process (Bleakley, Glasgow, & MacAuley, 2012). Pain management through medication, immobilization using braces or splints, and progressive physiotherapy also form integral parts of the treatment paradigm for syndesmotic injuries (Magan et al., 2014).
Physiotherapy plays an instrumental role in the management of these injuries, with Keilor Road Physiotherapy offering expert-led, personalized rehabilitation programs. These encompass exercises to restore range of motion, strength, proprioception, and balance, along with techniques to enhance ankle stabilization and carefully calibrated weight-bearing protocols to ensure optimal recovery (Porter et al., 2014).
For Grade III injuries, and in instances where conservative management proves inadequate, surgical intervention may be warranted. The surgical aim is to re-establish the anatomic alignment and stability of the ankle joint, often through the use of temporary or permanent fixation devices. Post-operative rehabilitation under the guidance of a certified physiotherapist is integral to the recovery process (Porter et al., 2014).
In essence, the treatment of high ankle sprain syndesmosis should be individualized, adopting a holistic, patient-centric approach that promotes optimal healing and return to activity.
Rehabilitation and Recovery
Rehabilitation and recovery following a high ankle sprains are dynamic processes, involving different stages tailored to the individual's condition and progress. It generally begins with protected weight-bearing, gradually introducing exercises to improve range of motion (Bleakley, O'Connor, Tully, & Rocke, 2007).
As the healing process advances and pain subsides, the focus shifts to proprioception training - relearning the body's awareness of joint positioning and movement. This is paramount in preventing re-injury and restoring balance (Hiller, Kilbreath, & Refshauge, 2011).
Next, strengthening exercises are integrated, targeting the muscles surrounding the ankle, thus promoting stability and resilience against future injuries. Lastly, the rehabilitation process culminates with sport-specific activities, progressively enabling a safe return to pre-injury levels of activity (van Rijn et al., 2007).
Keilor Road Physiotherapy provide expert guidance through each stage of this process. Adherence to the rehabilitation plan, consistent attendance at physiotherapy sessions, and dedication to home exercise programs are critical for a successful recovery. Patients are advised to remain patient, understand that recovery takes time, and avoid rushing through the rehabilitation stages, thereby reducing the risk of complications or re-injury (Eils & Rosenbaum, 2001).
Throughout this journey, effective management of pain and swelling is paramount. This may involve pain relief medications, ice applications, compression, and elevation of the injured limb. Patients should be cognizant of potential complications such as persistent pain, instability, or limited mobility, warranting immediate medical attention (Bleakley, O'Connor, Tully, Rocke, 2007).
Preventing High Ankle Sprain Syndesmosis
Prevention is an indispensable component of managing high ankle sprain syndesmosis, with a series of actionable strategies playing an important role. This starts with integrating proper warm-up and cool-down routines into any physical activity or sport, preparing the body for the exertion and facilitating recovery post-activity (Fradkin, Zazryn, & Smoliga, 2010).
Wearing appropriate footwear that offers good support and fits well is a practical measure to protect the ankle. Equally, the use of protective equipment such as ankle braces or tape can provide additional stability, particularly for individuals with a previous ankle injury or those engaging in high-risk activities (Janssen, Steele, Munro, & Brown, 2012).
Creating and maintaining a safe environment for physical activity is also important. This includes checking the surface for uneven ground, holes, or obstacles, particularly in outdoor sports.
Moreover, incorporating sport-specific training and ensuring a gradual progression of physical activities can minimize undue stress on the ankle. Neuromuscular retraining, including balance and agility exercises, as part of a well-rounded fitness program, can enhance proprioception and help reduce the risk of high ankle sprain syndesmosis (Verhagen et al., 2004). Keilor Road Physiotherapy offer specialised neuromuscular training programs that are individualized according to one's needs and capabilities.
Regular ankle strengthening and mobility exercises are vital to maintain joint stability and resilience. By fostering strong and flexible ankle muscles, we can significantly lessen the likelihood of future injuries (Eils & Rosenbaum, 2001).
Conclusion
High ankle sprains represent a significant injury, impacting the connection between the tibia and fibula, posing a substantial challenge to individuals' mobility and well-being. Commonly caused by sports injuries, falls, and traumatic incidents, it manifests through symptoms like pain, swelling, instability, and difficulty in walking or bearing weight. Immediate medical attention is crucial.
Understanding the severity of the injury using a grading system enables appropriate treatment decisions, whether through conservative management or surgical intervention. Early diagnosis, informed treatment choices, and dedicated rehabilitation are vital for optimal recovery.
It is estimated that ankle syndesmosis injuries account for around 10-18% of all ankle injuries (Prakash, 2020). Keilor Road Physiotherapy, with its specialised care, provides expert physiotherapy and personalized home exercise programs to guide patients throughout their recovery. Engaging in neuromuscular training plays a pivotal role in preventing such injuries by enhancing joint stability and improving muscular coordination. With proper treatment, rehabilitation, and preventive measures, individuals can confidently navigate their journey to recovery, regain their mobility, and resume their usual activities. Seeking professional care from a Keilor Road Physiotherapist ensures a safe and efficient return to optimal health and mobility, empowering individuals to overcome the challenge of syndesmosis injuries.
References
Here are the references organized in alphabetical order:
Beumer, A., Valstar, E. R., Garling, E. H., Niesing, R., Ranstam, J., Löfvenberg, R., & Swierstra, B. A. (2003). Effects of ligament sectioning on the kinematics of the distal tibiofibular syndesmosis: a radiostereometric study of 10 cadaveric specimens based on presumed trauma mechanisms with suggestions for treatment. Acta Orthopaedica, 74(4), 448-456.
Bleakley, C. M., Glasgow, P., & MacAuley, D. C. (2012). PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine, 46(4), 220-221.
Eils, E., & Rosenbaum, D. (2001). A multi-station proprioceptive exercise program in patients with ankle instability. Medicine and science in sports and exercise, 33(12), 1991-1998.
Fradkin, A. J., Zazryn, T. R., & Smoliga, J. M. (2010). Effects of warming-up on physical performance: a systematic review with meta-analysis. Journal of Strength and Conditioning Research, 24(1), 140-148.
Hiller, C. E., Kilbreath, S. L., & Refshauge, K. M. (2011). Chronic ankle instability: evolution of the model. Journal of athletic training, 46(2), 133-141.
Hopkinson, W. J., St Pierre, P., Ryan, J. B., & Wheeler, J. H. (1990). Syndesmosis sprains of the ankle. Foot & Ankle, 10(6), 325-330.
Janssen, K. W., van Mechelen, W., & Verhagen, E. A. (2014). Bracing superior to neuromuscular training for the prevention of self-reported recurrent ankle sprains: a three-arm randomised controlled trial. British journal of sports medicine, 48(16), 1235-1239.
Magan, A., Golano, P., Maffulli, N., & Khanduja, V. (2014). Evaluation and management of injuries of the tibiofibular syndesmosis. British Medical Bulletin, 111(1), 101-115.
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.
Porter, D. A., Jaggers, R. R., Barnes, A. F., & Rund, A. M. (2014). Optimal management of ankle syndesmosis injuries. Open Access Journal of Sports Medicine, 5, 173.
Prakash AA. Epidemiology of High Ankle Sprains: A Systematic Review. Foot & Ankle Specialist. 2020;13(5):420-430.
Rammelt, S., Obruba, P., Swords, M., & Shazar, N. (2015). Syndesmotic injuries. EFORT Open Reviews, 1(6), 239-249.
Sman, A. D., Hiller, C. E., & Refshauge, K. M. (2013). Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review. British Journal of Sports Medicine, 47(10), 620-628.
van Dijk, P. A., Lubberts, B., Verheul, C., DiGiovanni, C. W., & Kerkhoffs, G. M. (2016). Classification and diagnosis of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines. Knee Surgery, Sports Traumatology, Arthroscopy, 24(8), 2470-2476.
van Rijn, R. M., van Os, A. G., Bernsen, R. M., Luijsterburg, P. A., Koes, B. W., & Bierma-Zeinstra, S. M. (2007). What is the clinical course of acute ankle sprains? A systematic literature review. The American journal of medicine, 120(4), 324-331.
Article by
John Keller
Clinical Director | Sports & Musculoskeletal Physiotherapist
John graduated as a Physiotherapist from the Auckland University of Technology with the John Morris memorial prize for outstanding clinical practise in 2003. John has since completed Post Graduate Diplomas in both Sports Medicine and Musculoskeletal Physiotherapy with distinction, also collecting the Searle Shield for excellence in Musculoskeletal Physiotherapy.
Reviewed by
Dr. Jenny Hynes FACP
Clinical Director | Specialist Musculoskeletal Physiotherapist
Jenny sat extensive examinations to be inducted as a fellow into the Australian College of Physiotherapy in 2009 and gain the title of Specialist Musculoskeletal Physiotherapist, one of only a few physiotherapists in the state to have done so.