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Writer's pictureBrodey Castle

Blog # 3 – Understanding Syndesmosis Injuries

Syndesmosis injuries, often referred to as a high ankle sprain, are becoming increasingly recognised in the sporting environment, yet they remain perplexing for both athletes and casual fitness enthusiasts that are unaware of what they entail. By understanding how syndesmosis injuries present, it can help you recognise symptoms, seek treatment and prevent further issues.


What Is a Syndesmosis Injury?

The syndesmosis refers to the fibrous joint that connects the two bones of the shin, which in this case are the tibia (large shin bone) and fibula (smaller bone that sits on the outside). Unlike typical ankle sprains that affect the ligaments on the outer side of the ankle and sit below the ankle joint, syndesmosis injuries involve the distal tibiofibular joint and occurs with damage to the syndesmosis ligaments. This joint is crucial for maintaining stability in the ankle and ensuring proper foot function. A syndesmosis injury, which is often referred to as a "high ankle sprain," occurs when the ligaments that hold these bones together are stretched or torn.

“Syndesmosis injuries, often referred to as a high ankle sprain, are becoming increasingly recognised in the sporting environment.”


Common Causes

Syndesmosis injuries typically occur during activities that involve:

  • Sudden directional changes: Sports like rugby league, basketball, and soccer can lead to twisting motions that stress the ankle.

  • High-impact collisions: Contact sports often result in falls or awkward landings that can injure the ligament. In contact sports this is often referred to as a hip drop tackle.

  • Overexertion: Repeated high-impact activities that force the knee over your toes can lead to microtears in the syndesmosis ligament.

 

Symptoms to Look Out For

Identifying a syndesmosis injury can be tricky and they are often misdiagnosed in the early stages. Common symptoms include:

  • Pain above the ankle: Unlike standard ankle sprains, which usually cause pain on the outer side, syndesmosis injuries manifest as pain and tenderness above the ankle joint.

  • Swelling and bruising: Expect to see swelling above the ankle joint, and bruising can extend both above and below the ankle joint.

  • Difficulty bearing weight: Walking or putting weight on the affected leg can be painful in the first few days post injury.

  • Instability: A feeling of looseness in the ankle, especially during movement, running or change of direction.


Diagnosis

If you suspect a syndesmosis injury, it’s crucial to be assessed early to ensure it can be managed effectively. Our sports physiotherapists may use the following methods to confirm a diagnosis:

  • Physical examination: A thorough hands on assessment, checking for tenderness, bruising and swelling. Assessing functional tasks such as walking, range of motion and strength.

  • Imaging tests: you may be referred for secondary imaging, X-rays can be useful to rule out fractures, while MRIs provide a detailed view of soft tissue injuries, including the syndesmosis ligament.

 

Treatment Options

Treatment for syndesmosis injuries will vary based on the severity of damage and functional impairments. As per most ligamentous injuries, these are graded 1-3 and it is important to determine the extent of damage to ensure you are moved in the right direction.

 

Grade 1

  • Minor stretching of the ligaments with no major damage.

  • A structurally stable injury with a return to play timeline of around 4 weeks.

Grade 2

  • Depending on severity, can be classed as stable (not requiring surgery) or unstable (requiring fixation), this is based on clinical symptoms, along with MRI findings determining the extent of ligamentous damage.

  • A stable grade 2 injury will have a return to play timeframe of 8 weeks.

  • An unstable injury will require surgical intervention and 3-4 months of rehabilitation.

Grade 3

  • Demonstrate significant instability, functional impairments and damage on MRI.

  • These will be managed surgically and require 3-4 months of rehabilitation.

 

Surgical Intervention

In grade 2 and grade 3 injuries where there is significant disruption to the ligaments and the joint is unstable, surgery is required to restore ankle stability.  Surgical options might include:

  • Screw fixation: A small screw may be inserted to stabilise the bones and allow the ligament to heal properly.

  • Tightrope Fixation: The TightRope system anchors the ends of the tibia and fibula together with a braided polyethylene cord, to restore the original position of the bones and to allow for proper healing.

 

Rehabilitation

Once the acute phase has passed, a structured rehab plan is essential for recovery and an effective return to sport. Here at Rehab Advantage, a Syndesmosis rehab will follow the following phases.  

Phase 1 - Acute Repair:

This phase will differ dependent on whether you have undergone surgery or if your injury is managed conservatively. During this phase you will be placed in a CAM boot and may require crutches depending on the severity of your injury and pain. This is done to ensure we can begin to facilitate repair of the damaged ligaments to develop good anatomical healing and scar formation.


Our main goals for this phase are:

  1. Reduction of pain and swelling

  2. Re-activation of the foot and calf muscles - with the added tool of electrical stimulation

  3. Maintenance of hamstring, quadricep and hip strength

  4. Development of single leg stance and lateral hip rotation control

  5. Maintain energy expenditure – through off-legs conditioning

 

Phase 2 - Reload:

The reload phase focuses on the restoration of your gait (walking) mechanics while progressing into full body strength loading with the goal of returning to running. Your rehab program will begin to switch from bilateral (double leg) to unilateral (single leg) orientated exercises to challenge ankle stability and capacity.


Our main goals for this phase are:

  1. Normalise gait pattern

  2. Increase ankle range of motion

  3. Foot and ankle strength progressions

  4. Balance and proprioceptive exercises

  5. Introduction of plyometric loading and run drilling

 

Phase 3 - Rebuild:

The main addition to this phase is the introduction of your rehab running which is done on field and supervised by one of our physiotherapists. The severity of your injury will determine the length of this phase, but you will progress through the different stages of:

  1. Linear running

  2. Speed and planned change of direction

  3. Reactive change of direction and sports specific conditioning


Our rehab goals for this phase are:

  • Building running loads

  • Consolidating strength and power

  • Normalising plyometric profiling

  • Progression of sports specific skills in a controlled environment

 

Phase 4 and 5 - Return to Training and Sport

Our final two phases are aimed at a staged return to training, building from controlled to chaos, before a return to competition and full functional participation. Our goal during these phases is to ensure you return to your sport at a level greater than pre-injury and are ready to return to performing.


Our rehab goals for this phase are:

  • Progressing team training loads from controlled to chaos

  • Maintaining strength, power and plyometric loading

  • Education on ongoing resilience exercises to help prevent reinjury


Summary


Syndesmosis injuries can be painful and frustrating but understanding them can empower you to take the right steps for prevention and treatment. If you suspect you have a high ankle sprain, it is important to be assessed by a healthcare practitioner to guide you in the right direction and safely get you back to sport. With proper care and rehabilitation, individuals can recover fully and return to their sport with no ongoing complications.


BC


PS - To see how this comes together, Check out the Rehab Journey Video of one of our recent Post-op Ankle Syndesmosis Surgery rehabs Johnny.



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