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Syndesmotic Ligament – Function, Injury and Treatment

The syndesmotic ligament connects the tibia and fibula just above the ankle joint. Injuries to this structure are among the most common ankle injuries in sports.

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Things worth knowing about "Syndesmotic Ligament"

The syndesmotic ligament connects the tibia and fibula just above the ankle joint. Injuries to this structure are among the most common ankle injuries in sports.

What Is the Syndesmotic Ligament?

The syndesmotic ligament is a strong fibrous complex that connects the lower ends of the tibia (shinbone) and fibula (calf bone) just above the ankle joint. This connection is called the syndesmosis – a tightly bound, minimally mobile joint that is essential for ankle stability. The ligament complex includes primarily the anterior and posterior tibiofibular ligaments and the interosseous tibiofibular ligament.

Function

The primary role of the syndesmotic ligament is to hold together the ankle mortise – the socket formed by the tibia and fibula that grips the talus (ankle bone) like a clamp. This structure ensures stable and even force transmission during walking, running, and jumping. Without an intact syndesmotic ligament, the ankle mortise would widen, severely disrupting joint mechanics.

Causes of Syndesmotic Injury

Syndesmotic ligament injuries typically occur as a result of:

Forceful outward rotation (external rotation) of the foot, common in skiing and contact sports
Severe twisting of the ankle, either inward (inversion) or outward (eversion)
Falls from height with impact on the foot
Direct trauma to the ankle

These injuries are often called high ankle sprains because the pain is located above the ankle joint – distinguishing them from the more common lateral ankle sprain.

Symptoms

Typical signs of a syndesmotic injury include:

Pain above the ankle, between the tibia and fibula
Swelling and tenderness over the front of the ankle joint
Increased pain with external rotation of the foot
A feeling of instability when bearing weight
Difficulty or pain when walking

Diagnosis

Diagnosis of a syndesmotic injury involves both clinical examination and imaging studies:

Physical examination: Specific tests such as the squeeze test (compression of the tibia and fibula) or the external rotation stress test indicate syndesmotic involvement.
X-ray: Used to rule out fractures and assess the gap between the tibia and fibula.
MRI (Magnetic Resonance Imaging): The gold standard for accurately evaluating the extent of ligament damage and associated injuries.
Ultrasound: Can be used as a supplementary tool for assessing ligament structures.

Treatment

Conservative Treatment

Mild to moderate syndesmotic injuries are generally managed without surgery:

Immobilization of the ankle with a brace or cast for several weeks
Ice application and elevation to reduce swelling
Pain management with anti-inflammatory medications (e.g., ibuprofen)
Physical therapy to restore strength, coordination, and range of motion

Surgical Treatment

Complete ligament rupture or instability of the ankle mortise often requires surgical intervention. The syndesmosis is stabilized using specialized implants such as positioning screws or flexible suture-button systems (e.g., TightRope), restoring the correct alignment of the tibia and fibula. Surgery is followed by a structured rehabilitation program lasting several weeks to months.

Recovery and Prognosis

Syndesmotic injuries generally take longer to heal than classic lateral ankle sprains. Full recovery can take anywhere from six weeks to several months depending on the severity of the injury. If left untreated or improperly managed, these injuries can lead to chronic ankle instability and early-onset joint degeneration (osteoarthritis).

References

Hagemeijer NC, Chang SH, Abdelaziz ME et al. - Range of Syndesmotic Instability in Systematic Destabilization of the Ankle. Journal of Bone and Joint Surgery, 2019.
Schepers T - Acute distal tibiofibular syndesmosis injury: a systematic review of suture-button versus syndesmotic screw repair. International Orthopaedics, 2012.
Williams GN, Jones MH, Amendola A - Syndesmotic Ankle Sprains in Athletes. American Journal of Sports Medicine, 2007.

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