High Ankle Sprain/Syndesmosis Injury

This injury is sustained to the tissue (ligaments) that connect the tibia and the fibula. These are the bones that make up the lower leg (the inner bone being the tibia or shin and the outer being the fibula). In the high ankle sprain, there are several structures potentially damaged. These include ligaments that connect the tibia to the fibula known as the tibfib ligaments, as well as a tissue called the interosseous membrane.

The severity of this injury often depends on how many of these structures are damaged. The recovery time frame varies from 8 weeks to 6 months and this is why the high ankle sprain is so dreaded. Syndesmotic ankle sprains account for 11% to 17% of all ankle sprains in athletic populations. Most of these injuries occur in collision sports such as football, rugby, hockey and rugby league.

How do you get a high ankle sprain?

  • The common mechanism of injury is during sport when there is a forceful twist of the ankle outward. The outward twisting motion of the ankle will cause the two bones to pull away from one another and tear the ligaments that connect them.
  • Another way to injure these ligaments is through excessive dorsiflexion – which refers to a movement where the toes are forced toward the shin beyond their normal range. This often occurs when the foot is planted and/or trapped and the athlete is forced or fall forward.


Common Symptoms

  • Pain, swelling and bruising is usually seen above the ankle joint
  • Swelling is usually only very minimal
  • There is a history of a similar mechanism of injury as mentioned above
  • Aggravative movements include excessive dorsiflexion and outward rotation of the foot


How are high ankle sprains treated?

When identified early a stable high ankle sprain is treated through stabilisation, usually using bracing for a period of 6 weeks.

Post-immobilisation, the real tough part of the recovery begins. At this point, the joints in the ankle and foot are very stiff. Physiotherapy is vital to restore full range of motion, strength, balance and re-educate on appropriate movement patterns to avoid re-injury.

If the injury has not been detected early, then it is usually treated similar to a regular ankle sprain. Due to this, the process can be lengthy and tedious, but with appropriate rehabilitation can return to full function. There is increased caution with a high ankle sprain as ongoing instability is one of the primary factors that can lead to re-injury.

In summary, it is important to get your ankle injury assessed, as a missed high ankle sprain can have long-term consequences. A thorough rehab programme in place from our physios can get you back on the playing field as soon as possible.

What can physiotherapy do for you?


Phase 1: Protection

Goal – Avoid further damage, reduce effects of inflammation, maintain range and strength as able


Phase 2: Mobility

Goal – Restore range of motion and allow ligamentous tissue to heal in most optimal way (6 weeks for scar tissue to mature)

  • Massage muscles around ankle joint and assist scar tissue to be laid in ideal manner
  • Joint mobilisation techniques
  • Range of motion exercises in weight bearing and non-weight bearing
  • Muscle lengthening exercises


Phase 3: Strengthening

Goal – Re-establish muscle strength to the muscle surrounding the leg, ankle and foot

  • Progressing exercises from non-weight bearing, partial weight bearing, full weight bearing
  • With gradual improvement, begin to increase resistance


Phase 4: Neuromuscular control, proprioception and balance

Goal – Regain static balance, before progressing to more dynamic stability

  • Static balance progression – feet together, tandem stance, single leg – change surfaces – firm stable, uneven, wobble boards, bosu balls
    • Challenge various sensory systems – eyes open vs eyes closed, dual tasking
  • Dynamic balance exercises – need to begin incorporating movements that are needed in the particular sport/activity


Phase 5: Return to sport specific activities

Goal – Incorporate back into team specific drills and training, before return to sport

  • Depending on the sport/activity gradual progression back into full training is key
  • Agility drills, plyometric exercises, sport specific skills
  • Before return to sport there is certain criteria that must be metrunning
    • Full pain free range of motion
    • Full strength
    • Complete neuromuscular control
    • Pain free mobility – running, walking
    • Specific tests – Able to hop down a 30cm box and land on injured leg without any loss of balance, pain or instability.


Surgical Management

In more severe cases, injury may need to be addressed surgically. With use of metal work, the injury site is reduced and fixated to increase the stability at the joint.

What is the surgical procedure?

Under anaesthetic the syndesmosis is positioned back into its desired position and fixed with a screw which runs through the tibia and fibula. Surgery is normally a day surgery and patients can be discharged from hospital the day of surgery.

Following surgery

After the surgery, the ankle is typically immobilised for a period of 2 weeks. After the initial period of immobilisation, the ankle is typically under a strict non-weight bearing status for 6-8 weeks in a boot. Once boney union has occurred and the appropriate healing has occurred, weight bearing is cleared. Swelling can persist after this procedure for a considerable time, along with stiffness at the ankle joint.

Physiotherapy is important to regain full function at the ankle. A similar rehabilitation regiment is followed as per above. Any post-surgical specific modifications are made depending on the severity of injury, surgical complication or surgeon’s recommendations. As the tibia and fibula should have some movement in normal function the syndesmotic screw may be removed at a later date once practical.

If you are experiencing pain after an ankle injury, the qualified Physiotherapists at Pivotal Motion are here to help. Book an appointment online or call us today on 07 3352 5116

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