Ankle & Achilles Injuries
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Syndesmosis (High Ankle) Sprain

What is Syndersmosis (High Ankle Sprain)?

Syndesmosis, or high ankle sprain, is a common injury for athletes. This injury affects the ligaments above the ankle joint. In Syndesmosis, one or more ligaments that connect the bottom ends of the tibia and fibula bones (the lower leg bones) is/are sprained. It is more severe than a typical ankle sprain. Ergo, even a minor high ankle sprain takes twice the time to heal than an ordinary ankle sprain.

The involved ankle-part in Syndesmosis is a joint of the same name; it is the connection point of the joint where the thick connective ligaments hold the rough edges of two bones. The connecting bones of the lower leg are the tibia and fibula. The majority of the joints in the human body are synovial joints, and syndesmosis joints are also situated in the lower spine. In this syndesmosis joint, the involved bones are triangular-shaped sacrum that fit between the pelvis bones.

Three main ligaments hold the ankle syndesmosis together:

  • Anterior Inferior Tibiofibular Ligament (AITFL)
  • Posterior Inferior Tibiofibular Ligament (PITFL)
  • Transverse ligament

Apart from these three main ligaments, there is the interosseous ligament. Situated between the tibia and fibula, it is a long sheet of connective tissue. The interosseous ligament connects the entire stretch of the tibia and fibula, from the knee to the ankle.


Although doctors don’t fully understand how high ankle sprains occur; it appears that it often happens due to the foot being thrust upward and outward forcefully. As such, footballers often suffer from syndesmosis injuries, as do snow skiers.

High ankle sprains are often mistaken for ordinary ankle sprains. The diagnosis sometimes isn’t made until later, when treatments for the ankle sprain don’t work.

While stretched ligaments in the ankle typically cause minor ankle sprains, syndesmosis injuries occur when the connective tissue tears at any one (or more) ankle connections. Pain can be used as an indicator as to how severe the sprain is.

Many times, syndesmosis injuries incapacitate athletes who are getting back into their sports routines and normal life resumption, as these type of ankle sprains are the worst.

High ankle sprains leave the ankle joint unstable and weak, unable to mobilise the body in an ambulatory fashion. Any movement in the afflicted ankle will engender pain.

Examinations on the ankle are carried out to determine syndesmosis injuries:

  • The doctor moves the ankle in all directions, holding the lower leg. A squeeze test, whereby the doctor squeezes the ankle, is also carried out. When the patient feels pain, it indicates a high ankle sprain.
  • Tenderness is determined in the affected area – usually, tenderness manifests over the anterior ankle ligaments.
  • Stress X-rays are performed to establish the severity of a syndesmosis injury; i.e. whether the tibia and fibula splay away from each other


High ankle sprain treatment is two pronged, non-surgical and surgical.

Non-surgical treatment is done for mild syndesmosis sprain. Painkillers and anti-inflammatory medicines are given orally. The affected ankle should be rested; crutches will have to be used for a few weeks, as well as an ankle brace. Ice compression will attenuate swelling and promote faster healing and pain relief. Exercises to strengthen the ankle muscles, as well as walking, is commenced so that the patient can return to normal life.

Surgery is only done when nonsurgical treatment does not work. If there is diastasis, then surgery is considered an option.

Screw fixation is done to reduce the spatial between the tibia and fibula. Screws will be fixed through the two bones to be held together, letting the ligaments heal.

The next surgical procedure is open incision. It is performed when the tibia and fibula cannot be fused – an incision is made on the front edge of the ankle, allowing the surgeon to clear any scar tissue that may hinder the bones from being attached to each other.

X-rays are taken for both surgical procedures to see if the screws are where they should be and whether the tibia and fibula in the affected ankle mirror the other ankle.

Rehabilitation & Recovery

Rehabilitation for nonsurgical treatment is physiotherapy so that the affected ankle regains its normal functions. The physiotherapy regime is essential to restore strength and coordination in the ankle. Since a high ankle sprain carries more severity than an ordinary ankle sprain, getting back to routine activity is a gradual process, and healing takes twice as long.

As for surgery recovery, the surgical ankle is placed in a brace, and the ankle should be given complete rest for 2 – 4 weeks. Gradually, weight is put on the foot, supported by a stirrup brace. Therapy is given, up to 2 – 3 months, and full recovery may take up to 6 months.

The first goal is to reign in pain and swelling – ice and electrical stimulation treatments are done as a part of the therapy. Therapy also includes massage, light and circumspect ankle twisting to improve motion without exerting the ankle.

After four weeks, the ankle can be moved gently (motion done on a stationary bicycle). Exercises that increase strength in the ankle muscles can be done after six weeks, under the supervision of the therapist. Subsequently, progression to high impact movements may begin at a minimum of 12 weeks post-surgery.

The objective of rehabilitation therapy is to control pain, restore strength, control the affected ankle and achieve the widest possible range of motion as was prior to an injury. The therapy and exercises are to be continued via a home program, where the therapist will continue to keep tabs on improvement and recovery.

Adnan Munye

A certified personal trainer, Adnan specialises in weight loss, muscle building, body conditioning, core strengthening and injury rehabilitation. Adnan comes from a sporting background, where he has played football, badminton, rugby, and swimming all at various levels.

Adnan has always been passionate about health and fitness. He comes from a sporting background playing football, badminton, rugby, and swimming at various levels from a young age.