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.
Things worth knowing about "Syndesmosis injury"
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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