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Syndesmosis Injury: Causes, Symptoms & Treatment

A syndesmosis injury is damage to the ligament complex connecting the tibia and fibula above the ankle joint. It commonly results from twisting or rotating the foot.

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A syndesmosis injury is damage to the ligament complex connecting the tibia and fibula above the ankle joint. It commonly results from twisting or rotating the foot.

What is a Syndesmosis Injury?

A syndesmosis injury refers to damage of the syndesmosis – the strong ligamentous connection between the lower ends of the tibia (shinbone) and the fibula (calf bone). This ligamentous structure stabilizes the so-called “ankle mortise” and is essential for the stability and function of the upper ankle joint. Syndesmosis injuries are also known as high ankle sprains and are generally more serious than typical lateral ankle sprains.

Causes

Syndesmosis injuries most commonly result from a forced external rotation of the foot, often combined with dorsiflexion. Typical causes include:

Sports accidents (particularly soccer, basketball, and skiing)
Falls with a twisted foot
High-energy trauma (e.g., motor vehicle accidents)
Ankle fractures with simultaneous ligament damage

Syndesmosis injuries frequently occur alongside ankle fractures, such as Weber B or Weber C fractures.

Symptoms

Symptoms of a syndesmosis injury can resemble a standard ankle sprain but tend to be more intense and persistent. Common complaints include:

Pain at the front and inner aspect of the upper ankle joint
Swelling and bruising around the ankle
Tenderness on pressure over the syndesmosis
Pain during walking, stair climbing, or foot rotation
Feeling of instability in the ankle

Unlike a typical lateral ligament tear, pain from a syndesmosis injury is usually located slightly higher and more anterior on the ankle.

Diagnosis

Diagnosis is established through a combination of physical examination and imaging:

Squeeze test: Compression of the tibia and fibula at mid-calf – positive if pain is felt at the ankle
External rotation stress test: Pain provoked by external rotation of the foot
X-ray: Exclusion of fractures and assessment of joint space
MRI (magnetic resonance imaging): Detailed visualization of injured ligaments and severity grading
Ultrasound: Supplementary soft tissue assessment

Syndesmosis injuries are classified into three grades: mild sprain (Grade I), partial tear (Grade II), and complete rupture with instability (Grade III).

Treatment

Conservative Treatment

Mild to moderate injuries (Grade I and II) are typically managed conservatively:

RICE protocol: Rest, Ice, Compression, Elevation during the acute phase
Immobilization with a brace or functional taping
Partial weight-bearing with crutches if needed
Physiotherapy to restore strength and stability
Anti-inflammatory medications (e.g., ibuprofen) for pain relief

Surgical Treatment

Severe injuries (Grade III) or significant joint instability may require surgery:

Placement of a syndesmotic screw to temporarily fix the tibia and fibula
Ligament repair or reconstruction
Osteosynthesis in cases of accompanying fractures

Surgery is followed by a period of immobilization and a structured rehabilitation program.

Recovery and Prognosis

Syndesmosis injuries generally take longer to heal than typical ankle sprains. Mild injuries may resolve within 4–8 weeks, while severe ruptures requiring surgery can demand 3–6 months of rehabilitation before full sporting activity is resumed. Early and consistent treatment is essential to prevent chronic ankle instability and the development of ankle joint arthritis.

References

Rammelt S, Grass R, Zwipp H: “Injuries to the ankle syndesmosis.” Orthopäde, 2011; 40(8): 689–698.
Dattani R, Patnaik S, Kantak A et al.: “Injuries to the tibiofibular syndesmosis.” Journal of Bone and Joint Surgery (British), 2008; 90(4): 405–410.
Sman AD, Hiller CE, Refshauge KM: “Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review.” British Journal of Sports Medicine, 2013; 47(10): 620–628.

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