Syndesmosis Injuries Explained

In recent years there has been a lot of publicity around syndesmosis injuries. We have seen rules in sport to try and minimise the risk of these injuries. These injuries have long recovery times and, in many cases, require surgery. This can be an injury that is sustained in local weekend sport right through to the elite level.

The syndesmosis is the joint where the two bones in the lower leg, tibia and fibular, meet. This is above what is commonly known as the ankle joint therefore the term high ankle sprain is regularly used. The joint is made up of three ligaments, one at the front, one in between the two bones and one at the back. These are known at the Anterior Inferior Talo-Fibular ligament (AITFL), Interosseus ligament (IOL) and Posterior Inferior Talo-Fibular Ligament (PITFL). The function of these is to keep the tibia and fibular in the correct position.

In the case of syndesmosis injury, any number of these ligaments may be injured. These injuries are graded in terms of the structures injured and the stability of the ankle. A grade 1 injury represents a AITFL sprain, with a grade 2A being a complete tear of the AITFL and partial tear to the IOL and PITFL. A 2A injury is classified as stable and does not need surgery. However, a grade 2B has the same pathology with the joint being assessed as unstable. This is seen through weightbearing X-rays, and a Tightrope surgery will be performed. Finally, grade 3 injuries are a complete tear of all three ligaments and frank widening of the joint. This also requires a Tightrope surgery.

The Tightrope is a technique of surgery where a hole is drilled through the tibia and fibular with a rope like object being fed through. This is then tightened to pull the bones back into alignment. This fixation is not removed. Here is a link to an animation of the surgery if this is of interest.

As this is almost exclusively a sporting injury, the rehabilitation generally follows a return to performance framework. The phases of this are: protected loading, return to activity, return to skills followed by a return to performance. The goals of the 1st phase of the process are based around wound healing, building range of motion, and keeping the capacity of other structures around the ankle.

Phase 2 goals are, in the first instance, restoring the range of the ankle. This runs parallel with building high level strength, coordination, neuromuscular control, and an introduction to cardiovascular fitness. Phase 3 is then a return to skills where the focus expands from the injured ankle to the whole body where reconditioning and strength is needed. This incorporates skills of the chosen sport with speed, agility and conditioning. This phase does not allow the athlete to return to full team training. This phase is still completed in a majorly controlled environment.

Finally, phase 4 or return to performance. This phase is aimed at getting the injured athlete back to their previous level of competition. To do this, replication of chaotic agility demands of games and training, max sprint and distance running, high quality and high demand skills work and 2 weeks of integrated training. Pending the athlete has passed all steps, They then will be cleared for return-to-play.

If you have experienced a syndesmosis injury, please reach out to get the care and rehabilitation needed for this injury.