Clinical Sports Medicine Update

Syndesmotic Ankle Sprains in Athletes

Glenn N. Williams,*†‡ PT, PhD, ATC, Morgan H. Jones,§ MD, and Annunziato Amendola,*†‡ll MD
From the *Graduate Program in Physical Therapy and Rehabilitation Science, University of Iowa
†
Hospitals and Clinic, Iowa City, Iowa, University of Iowa Sports Medicine Center,
‡
University of Iowa Hospitals and Clinic, Iowa City, Iowa, Department of Orthopaedics and
Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, and
§
Department of Orthopaedics, Cleveland Clinic Foundation, Cleveland, Ohio

Ankle sprains are among the most common athletic injuries and represent a significant source of persistent pain and disability.
Despite the high incidence of ankle sprains in athletes, syndesmosis injuries have historically been underdiagnosed, and assess-
ment in terms of severity and optimal treatment has not been determined. More recently, a heightened awareness in sports med-
icine has resulted in more frequent diagnoses of syndesmosis injuries. However, there is a low level of evidence and a paucity
of literature on this topic compared with lateral ankle sprains. As a result, no clear guidelines are available to help the clinician
assess the severity of injury, choose an imaging modality to visualize the injury, make a decision in terms of operative versus
nonoperative treatment, or decide when the athlete may return to play. Increased knowledge and understanding of these injuries
by clinicians and researchers are essential to improve the prevention, diagnosis, and treatment of this significant condition. This
review will discuss the anatomy, mechanism of injury, diagnosis, and treatment of syndesmosis sprains of the ankle while iden-
tifying controversies in management and topics for future research.
Keywords: syndesmosis; anterior inferior tibiofibular ligament; sports injury; rehabilitation

Despite the fact that ankle sprains are the most common ligaments. The fibula sits in a groove created by the anterior
injury sustained by athletes, these injuries continue to be a and posterior tibial processes, which provides bony stability to
challenge for the sports medicine professional. The manage- the syndesmosis.14 The ligaments of the distal tibiofibular
ment of tibiofibular syndesmosis sprains (high ankle sprains) syndesmosis include the anterior inferior tibiofibular liga-
is especially problematic. A study from the United States ment, the posterior inferior tibiofibular ligament, the inferior
Military Academy found that syndesmosis involvement was transverse ligament, and the interosseous ligament.14,49 The
the most predictive factor of chronic ankle dysfunction 6 deep portion of the deltoid ligament also contributes to the
months after an ankle injury.22 Although our ability to diag- stability of the syndesmosis and must be evaluated after
nose this injury has improved, determining the extent and these injuries, either acutely or in the chronic situation.36,49
severity of injury, predicting when an athlete is ready to The anterior inferior tibiofibular ligament attaches to the
return to sports participation, and identifying those who anterolateral distal tibia and runs distal and lateral in an
would be best treated by operative stabilization remain enig- oblique direction to attach to the anteromedial distal fibula.
matic. This review will discuss the anatomy, mechanisms of The tibial attachment is wider than the fibular attachment,
injury, and the diagnosis and treatment of distal tibiofibular giving the ligament a trapezoidal shape. The anterior inferior
syndesmosis sprains. We will also identify controversies in tibiofibular ligament has a width of approximately 18 mm
management and discuss topics for future research. The focus and a thickness of 2 to 4 mm. The posterior inferior tibiofibu-
of this article is the management of syndesmosis sprains lar ligament attaches to the posterolateral distal tibia and
without associated fractures or frank diastasis of the ankle runs horizontally to the posteromedial distal fibula. This liga-
mortise, as this is the most common syndesmosis injury expe- ment has a width of approximately 18 mm and a thickness of
rienced when treating the athletic population. approximately 6 mm.2 Both of these ligaments, as well as the
relationship between the tibia and fibula, can be visualized
arthroscopically (Figure 1).
ANATOMY AND BIOMECHANICS The distal tibiofibular syndesmosis is a very stable joint;
however, movement of the fibula occurs to accommodate
The stability of the syndesmosis is provided by the architec-
the talus during gait. Radiostereometric evaluation of nor-
ture of the distal tibia and fibula and by the syndesmotic
mal ankles by Beumer et al4 showed that with an external
ll
Address correspondence to Annunziato Amendola, MD, Department of rotation moment of 7.5 N⋅m applied to the foot, the fibula
Orthopaedics & Rehabilitation, University of Iowa Hospitals & Clinics, 200 externally rotated between 2° and 5°, translated medially
Hawkins Drive, Iowa City, IA 52242 (e-mail: [email protected]). between 0 and 2.5 mm, and translated posteriorly between
No potential conflict of interest declared. 1 and 3.1 mm. This movement occurs chiefly during the
The American Journal of Sports Medicine, Vol. 35, No. 7 stance phase of gait. In a second study evaluating the
DOI: 10.1177/0363546507302545 mechanical and material properties of the syndesmotic
© 2007 American Orthopaedic Society for Sports Medicine ligaments, Beumer et al8 demonstrated that there is no

1197
1198 Williams et al The American Journal of Sports Medicine

Figure 1. A, an arthroscopic picture of a normal anterior inferior tibiofibular ligament (arrow). B, arthroscopic view of the normal
tibiofibular relationship. C, normal anterior inferior tibiofibular ligament (arrow). D, a probe is touching the end of a torn anterior
inferior tibiofibular ligament. T, tibia; F, fibula; Ta, talus.

significant difference in strength or stiffness between the are more likely to have their foot in this externally rotated
anterior inferior tibiofibular ligament, the posterior infe- position when planted, although this has not been demon-
rior tibiofibular ligament, and the deep portion of the del- strated scientifically. This mechanism of injury is supported
toid ligament. Xenos et al49 used cadaveric specimens to by many biomechanical studies that demonstrate increased
evaluate the effect of sequential syndesmotic ligament sec- external rotation of the talus and fibula relative to the tibia as
tioning on the ankle’s resistance to an external rotation syndesmotic structures are sequentially sectioned.14 By far,
force. The distal tibiofibular diastasis was 2.3 mm after the most common mechanism of injury reported involves an
sectioning of the anterior inferior tibiofibular ligament, 5.5 external rotation fracture mechanism. In this mechanism, the
mm with the additional sectioning of the distal 8 cm of the foot is planted fixed on the ground with internal rotation of
interosseous ligament, and 7.3 mm after sectioning the the leg and body with respect to the foot, resulting in relative
posterior inferior tibiofibular ligament as well. In the same external rotation of the talus within the mortise and creating
study, sectioning of all 3 ligaments allowed a mean of 4.7° an external rotation force on the fibula with respect to the
of pathologic external rotation at the ankle joint. tibia. As a result, the fibula separates from the tibia, causing
disruption of the distal inferior anterior syndesmotic liga-
ment. In addition, the talus externally rotates with respect to
MECHANISM OF INJURY the tibia, possibly injuring the medial deltoid. The severity of
the force and how long it is applied will determine how prox-
The mechanism of injury for syndesmosis sprains has classi- imal the syndesmotic and interosseous injury extends.
cally been ascribed to the ankle being subjected to an exter- Sometimes the proximal extent of the injury on the fibula
nal rotation moment with the foot in a dorsiflexed, pronated results in fracture. This mechanism has been shown to reli-
position.49 Athletes with a planovalgus (flat) foot alignment ably produce syndesmotic and deltoid injury in vivo and in
Vol. 35, No. 7, 2007 Syndesmotic Ankle Sprains in Athletes 1199

the laboratory, but a paucity of studies are available that test variety of injury mechanisms as described above. They may
the maximal inversion, plantarflexion injury that also occurs complain of pain anteriorly between the distal tibia and
commonly in sport. One possible explanation for why some of fibula, as well as posteromedially at the level of the ankle
these more subtle injuries are diagnosed late is that on initial joint. Patients will also complain of pain when bearing
evaluation, it was not clear that the injury mechanism or the weight or pushing off the ground. Physical examination
syndesmosis sprain were associated with a lateral ankle should begin with an evaluation of swelling and palpation for
sprain.32 A survey of National Football League athletic train- areas of tenderness. Anterior tenderness between the tibia
ers conducted by Doughtie17 suggests that current opinion and fibula should be evaluated, and the distance that this
continues to favor this mechanism of injury; 70% of respon- tenderness extends proximal to the ankle joint should be
dents thought that most syndesmotic sprains involved an measured. This distance, termed “tenderness length,” has
external rotation component. However, in a retrospective been reported to correlate well with degree of injury and time
review of 15 cases by Hopkinson et al,26 3 patients reported a to return to sports participation.34
hyperdorsiflexion mechanism, 3 reported an inversion mech- Special tests for the evaluation of syndesmosis injuries
anism, one reported a plantarflexion mechanism, and only 1 include the squeeze test, the external rotation stress test,
reported an abduction/external rotation mechanism. The the fibula translation test, the Cotton test, and the crossed-
results of these studies suggest that an injury that causes sig- leg test.7,29 The squeeze test is performed by compressing
nificant rotation of the talus within the mortise, such as a the proximal tibia and fibula. Pain at the level of the ankle
severe inversion sprain, may injure the syndesmotic liga- joint indicates a positive test result. The external rotation
ments. In one biomechanical study with hyper plantar flexion, stress test is performed by placing the ankle in a dorsi-
deltoid injury occurred, suggesting that injury to the deltoid flexion position and applying an external rotation force
would aggravate any amount of injury to the syndesmosis.16 In (Figure 2). Pain with this maneuver indicates a positive
addition, a radiologic study inferred that syndesmotic injury test result.1 In the fibula translation (drawer) test, the
can occur with inversion sprains.32 Further investigations are examiner attempts to translate the fibula from anterior to
warranted to increase understanding of the mechanism of posterior. In the normal ankle, there is a firm end point
injury so that preventive strategies can be developed. and little movement. Increased translation relative to the
contralateral side and pain indicate a positive test result.
The Cotton test is performed by translating the talus
INCIDENCE within the mortise from medial to lateral. Increased trans-
lation or pain may suggest syndesmosis involvement, as
Syndesmosis injuries are more common than lateral ankle
well as a deltoid (medial) ligament injury. Kiter and
sprains in collision sports and those that involve rigid immo-
Bozkurt29 recently reported a new test for syndesmosis
bilization of the ankle in a boot, such as skiing and hockey.
injury that mimics the squeeze test and is called the
Fritschy21 noted a shift from lateral ankle sprains to syn-
crossed-leg test. This test result is performed by having
desmosis injuries in skiers in the late 1970s as ski boots
the sitting patient rest the midtibia of the affected leg on
became more rigid. He reported 10 injuries in World Cup
the knee of the unaffected leg. The patient then applies a
skiers that all occurred during the slalom event, when the
gentle downward force on the medial side of the knee, and
skier straddled a gate, caught the inner ski on a stake, and
the test result is positive if the patient experiences pain in
experienced a violent external rotation force on the ankle and
the region of the syndesmosis. They report using this test
foot. Flik et al19 prospectively collected injury data for 12
to diagnose 9 patients with syndesmosis injuries.
National Collegiate Athletic Association Division I hockey
Amendola has described the “stabilization test,” which can
teams over 1 season. There were 114 injuries reported in 23
be useful to confirm diagnosis during the subacute or
096 athlete exposures. Five of the 14 ankle injuries reported
chronic phase of injury once acute swelling and pain have
were syndesmosis sprains. Wright et al48 retrospectively
subsided (unpublished data, 2001). This test is performed by
reviewed medical records for 2 National Hockey League
tightly applying several layers of 1.5-in athletic tape just
teams over 7 to 10 years. They reported that 74% of the ankle
above the ankle joint to stabilize the distal syndesmosis (Figure
sprains (14 of 19) were syndesmosis injuries. Other collision
3). The patient is then asked to stand, walk, and perform a toe
sports in which syndesmosis sprains are common include
raise and jump. The test result is positive if these maneuvers
football, rugby, wrestling, and lacrosse. In the series reported
are less painful after taping. In general, the diagnosis of a
by Hopkinson et al,26 75% (6 of 8) of injuries occurred during
syndesmosis sprain is fairly straightforward; however, there
football. In the series of Nussbaum et al,34 72% (43 of 60) of
is no specific test or imaging study that clearly defines the
the injuries occurred during football or lacrosse, while 75%
severity or extent of injury. Consequently, it remains difficult
(12 of 16) of the syndesmosis injuries reported by Gerber et
to prescribe highly specific treatment strategies for the spec-
al22 occurred during football, lacrosse, or rugby. In the general
trum of syndesmosis injuries seen in athletes. Only 1 test,
athlete population, the incidence of syndesmosis sprains is
the external rotation test, has been correlated with the pres-
much lower; reported values are between 10% and 20% of all
ence of a syndesmosis sprain and is associated with a longer
ankle sprains.13,22
return to preinjury activities.1
Beumer et al7 performed a biomechanical evaluation of 4
HISTORY AND PHYSICAL EXAMINATION special tests to determine the degree of distal tibiofibular
displacement induced by each test in intact cadaveric
A careful history and physical examination are essential for ankles and after sectioning of the anterior inferior
the diagnosis of syndesmosis injuries. Patients may report a tibiofibular ligament, the posterior inferior tibiofibular
1200 Williams et al The American Journal of Sports Medicine

Figure 2. A, the manual external rotation test. B, radiographic view of a right ankle demonstrating diastasis. C, external rotation
test using a standardized Telos machine. D, radiographic view of the left ankle during the external rotation test.

ligament, and the deltoid ligament. The average increase not able to accurately predict the degree of mechanical
in displacement after sectioning of all ligaments was only instability associated with a syndesmosis injury.
about 1 mm. Another biomechanical evaluation of the
squeeze test demonstrated that the distance between the
tibial and fibular attachment sites of the anterior tibiofibu- IMAGING
lar ligament only increased by approximately 0.2 mm after
sectioning of syndesmotic ligaments.41 These findings sug- Imaging of syndesmosis injuries of the ankle should begin
gest that current clinical tests for syndesmosis injuries are with plain radiographs to rule out fracture and to look for
Vol. 35, No. 7, 2007 Syndesmotic Ankle Sprains in Athletes 1201

Figure 3. The stabilization test is performed by applying

tape, allowing the patient to run/jump, and determining if the
tape stability improves symptoms.

Figure 5. A, magnetic resonance image demonstrating a syn-

desmosis injury with tibial bone edema at the posterior
attachment of the posterior inferior tibiofibular ligament with
an intact ligament. B, the same magnetic resonance image
showing a torn anterior inferior tibiofibular ligament.

Some authors have advocated using stress radiographs

to identify injuries to the syndesmosis. Beumer et al5 used
radiostereometric techniques to evaluate changes in trans-
lation and rotation when a 7.5-N⋅m external rotation
moment was applied after sequential sectioning of the syn-
desmotic ligaments in cadaveric ankles. When the anterior
tibiofibular, posterior tibiofibular, and deltoid ligaments
were sectioned, the mean medial-lateral translation was
only 1.0 mm (range, 0.1-2.1 mm), and the mean anterior-
posterior translation was only 1.9 mm (range, 6.2 mm
posterior to 3.5 mm anterior). These data suggest that
external rotation stress views cannot be used to reliably
predict syndesmosis injury; however, if widening of the
mortise is seen on radiographs, it indicates a more severe
Figure 4. Diastasis of the ankle demonstrated with radiography. injury and potentially complete disruption of the syn-
desmosis, which requires operative stabilization.
Magnetic resonance imaging (MRI) can be used to diag-
the presence of diastasis of the syndesmosis (Figure 4). nose syndesmosis injury. A cadaveric study demonstrated
Common views include weightbearing anteroposterior, mor- that high-resolution MRI can effectively image the struc-
tise, and lateral. Diastasis is identified by an increased tures of the syndesmosis,33 and a clinical study demon-
tibiofibular clear space on an anteroposterior radiograph to a strated high interobserver agreement (κ = 0.9) in the
value of 6 mm or greater.25 Avulsion fractures from the ante- evaluation of these structures (Figure 5).45 A subsequent
rior or posterior tibia can occur in up to 50% of syndesmosis study correlating MRI evaluation of the syndesmosis with
injuries and aid in identifying disrupted structures20; how- arthroscopy in 52 patients showed a sensitivity of 100% and
ever, the use of radiographs to assess integrity of the syn- a specificity of 93% for diagnosis of anterior inferior tibiofibu-
desmosis is difficult because of the inability to consistently lar ligament tear and sensitivity and specificity of 100% for
position the patient, even under ideal conditions.6 diagnosis of posterior inferior tibiofibular ligament tear.38
1202 Williams et al The American Journal of Sports Medicine

Researchers have yet to demonstrate the relationship average of 55 days for return to full activity, compared with 28
between MRI findings and clinical outcomes or the need days for grade III lateral ankle sprains. Nine of the patients
for operative intervention. had interosseous calcification on follow-up radiographs.
Boytim et al10 reported on 98 ankle injuries on a profes-
sional football team over a 6-year period; 18 of these were
CLASSIFICATION syndesmosis sprains. Players with syndesmosis injuries
missed or were limited for a mean of 6.3 practices, com-
Gerber et al22 described the West Point Ankle Grading
pared with 1.1 practices for players with lateral ankle
System that classifies syndesmotic injuries into 3 cate-
sprains. Radiographs were taken a minimum of 1 month
gories (grade I, II, or III) based on evidence of syndesmosis
after injury in 8 players; interosseous calcification was
instability. Grade I indicates no instability, grade II indi-
present in 6 ankles.
cates some evidence of instability, and grade III suggests
Fritschy21 reported 10 syndesmosis injuries in World
definite instability. The criteria these authors used to dif-
Cup skiers over an 11-year period. Three patients under-
ferentiate the grades of instability include ability to bear
went surgical repair of the anterior inferior tibiofibular lig-
weight, extent of edema, localization of tenderness,
ament and fixation of the syndesmosis with a screw or
response to manual stress testing, and evidence of widen-
Kirschner wire, followed by 3 to 6 weeks immobilization in
ing on radiographs. Edwards and DeLee18 proposed a clas-
a nonweightbearing cast. The other 7 patients were
sification scheme for syndesmosis injury without ankle
treated with walking casts for 2 to 6 weeks. All patients
fracture and divided patients into those with latent dias-
resumed training after 4 to 8 weeks and were able to
tasis and those with frank diastasis. This classification
resume their preinjury level of activity. One patient who
system has limited applicability to most tibiofibular syn-
was treated with a cast complained of persistent ankle
desmosis sprains in athletes because disruptions with
pain; the remaining patients were asymptomatic after a
acute or latent diastasis, which require reduction and sta-
follow-up of between 18 months and 12 years.
bilization, are relatively uncommon in this population.
Brown et al12 evaluated 94 ankle magnetic resonance
images in patients with a history of severe ankle sprains and
identified syndesmosis injuries in 59 ankles (63%). Associated
NATURAL HISTORY AND ASSOCIATED INJURIES injuries included anterior talofibular ligament injury in 49 of
59 ankles (83%), bone bruises in 18 of 23 patients (78%) with
Based on the studies available in the literature, one must
acute injury and 4 of 36 patients (11%) with chronic injury,
conclude that there is a spectrum of syndesmosis injury
talar dome osteochondral lesions in 11 of 23 patients (48%)
severity that leads to variability in the time lost from
with acute injury and 14 of 36 patients (39%) with chronic
injury. The high prevalence of associated injuries leads to
injury, and osteoarthritis in 1 of 23 patients (4%) with acute
further variability because the resulting pain and chronic
injury and 7 of 36 patients (19%) with chronic injury.
dysfunction often prevent a timely return to sport.
The results of these studies indicate that syndesmosis
Guise24 identified 20 ankle injuries that resulted in time
sprains are unpredictable in the time it will take an athlete
lost from practice or competition on a professional football
to return to sports participation and the rate of reinjury and
team over a 5-year period. Sixteen of these injuries (80%)
ankle dysfunction; these injuries also have a high rate of
were syndesmosis injuries diagnosed by the presence of
associated injuries. Further research is necessary to more
tenderness over the distal tibiofibular syndesmosis and a
completely define the extent and severity of these complex
positive dorsiflexion-external rotation test result. The
injuries. Additional studies are needed to define when sur-
average time lost was 2.5 weeks (range, 0.5-7), 11.7 prac-
gery should be considered and when associated findings such
tices (range, 5-30), and 1.4 games (range, 0-6). In compari-
as osteochondral injuries should be addressed.
son, the 4 patients with severe lateral ankle sprains
missed an average of 1.25 weeks (range, 0.5-3), 3.5 prac-
tices (range, 2-5), and 0.3 games (range, 0-1). TREATMENT
Taylor et al40 reported 44 consecutive syndesmotic
sprains in collegiate football players with an average 47 Rehabilitation
months of follow-up. Players required an average of 31 days
to return to full activity, but all players still reported per- There are no published randomized controlled trials in
sistent stiffness and pain while pushing off. At final follow- indexed journals that have investigated the efficacy or
up, 18 patients reported no symptoms, 20 patients reported effectiveness of rehabilitation programs for tibiofibular
mild symptoms, and 6 patients reported moderate symp- syndesmosis injuries. Consequently, the optimal rehabili-
toms. Three patients sustained another syndesmosis tation program for patients with these injuries is currently
sprain, 15 patients sustained subsequent lateral ankle unknown. Common questions related to rehabilitation that
sprains, and 1 patient sustained a bimalleolar ankle frac- the sports medicine team must address include the follow-
ture. Of 22 patients who had follow-up radiographs, 11 had ing: Is there a need for complete immobilization? If so, for
interosseous calcification. how long? How much stress can be safely placed on the joint
In their review of 1344 ankle sprains that occurred in West during the subacute phase of rehabilitation? Should
Point cadets over a 41-month period, Hopkinson et al26 iden- patients’ symptoms alone guide functional progression, or
tified 10 syndesmosis sprains. These injuries required an should the medical team stipulate certain limitations
Vol. 35, No. 7, 2007 Syndesmotic Ankle Sprains in Athletes 1203

based on science related to healing and their repeat clini- should progress in a safe but timely fashion to mitigate
cal assessments? Finally, when can the athlete return to potential neuromuscular and biomechanical deficiencies
sport safely and effectively? that can result from prolonged disuse and dysfunction.
We found only 3 articles in which rehabilitation pro- Pain and edema are minimized through the protection
grams for syndesmosis sprains have been described in suf- provided by immobilization and limited weightbearing,
ficient detail to allow discussion.11,22,34 The programs as well as elevation, compression, appropriate use of ther-
presented in these papers are relatively similar. Each has apeutic modalities, and the judicial use of anti-inflamma-
included a 3-phase or 4-phase program. The first phase is tory medications. Combined compression, elevation, and
an acute phase, in which the primary goals are protection cryotherapy are particularly beneficial in minimizing
of the injured joint and minimization of the inflammatory postinjury edema. In addition to cryotherapy, other helpful
response, including pain control. The second phase is a therapeutic modalities include electric stimulation, com-
subacute phase, in which the goals are to restore mobility, pression pumps, antiedema massage, and joint mobiliza-
strength, and function in basic tasks such as ambulating tion. In addition, athletes often find alternative therapies
with a normal gait pattern. The remaining phase(s) such as acupuncture and acupressure helpful. When the
include advanced training, directed at preparing the ath- medical team feels that it is safe for range of motion exer-
lete for return to sports participation by increasing cises to begin (those with minor injuries may be ready
strength, neuromuscular control, and function in sport- immediately, whereas others may take 1 to 2 weeks),
specific tasks such as cutting, pivoting, and jumping. Two mobility exercises are begun within the comfortable range
of the groups11,34 provide temporal guidelines for progres- of motion. Light use of a cycle ergometer is often a good
sion from phase I to phase II, whereas Gerber et al22 choice for mobilizing the ankle in this stage. Patients are
describe a functional, criterion-based approach to progres- progressed to the subacute phase of treatment when pain
sion. Gerber et al22 and Nussbaum et al34 both state that to and edema are controlled and the patient can walk with a
be progressed to phase III, patients must demonstrate the minimally antalgic gait on the various surfaces they will
ability to ambulate and hop repetitively without pain or experience in their daily activities.
dysfunction. Each of the groups describe the use of func- The subacute phase is directed at obtaining normal
tional testing as criteria for return to sports participation; mobility; increasing strength; improving neuromuscular
testing includes 1 or more of the following tasks: forward control; and promoting function in basic tasks such as piv-
hopping, vertical hopping, lateral hopping, sprinting, cut- oting of the foot when walking, quickly moving over and
ting, figure-8 drills, or backward pedaling. around small obstacles, light jogging, and hopping. Mobility
Authors’ Preferred Approach. The 3-phase approach is facilitated with the use of assistive devices such as towels
described above is consistent with our preferred approach. or cords, or activities such as squatting, gastrocnemius-soleus
The most critical factors to success are careful and contin- stretching, and riding a cycle ergometer. Joint mobilization is
ual assessment of the patient; tailoring the program to the especially helpful and effective in this stage. Strengthening
individual patient’s unique circumstances, needs, and begins with basic resistance exercises using bands, cords,
goals; and frequent, unambiguous communication with the or ankle weights and progresses to closed-chain functional
patient and other members of the sports medicine team. In tasks such as heel raises/dips and calf presses with weight
the first phase (acute, protection phase), our key consider- machines. Strengthening begins with lower-intensity,
ations are immobilization, weightbearing status, and con- higher-repetition sets and progresses to the use of high-
trol of the inflammatory process. The question of whether intensity, low-repetition sets directed at inducing muscle
complete immobilization is required is not a trivial issue. overload and, thereby, hypertrophy. Strength, endurance,
Safety and joint protection are the critical concerns. For and muscle control are facilitated through balancing on
this reason, complete immobilization by splinting, casting, unstable surfaces such as air-filled cushions, domes, or
or a boot-type immobilizer is reasonable if the patient has trampolines. Aquatic therapy is also beneficial in this
significant pain, poor muscle activation, or the early stage. Patients are progressed to the advanced training
assessment suggests that the extent of the injury is severe. phase when they are able to jog and hop repetitively with-
If pain is not especially severe, there is evidence of good out difficulty.
muscle activation, and the early assessment suggests that The advanced training phase is directed at ensuring
the joint is fairly stable; then use of an ankle brace, stirrup, that the patient is ready to return to sports participation
or taping is a reasonable alternative. at discharge. In this phase, more aggressive strengthening,
Patients who sustain syndesmosis sprains rarely are additional neuromuscular training, and sport-specific
able to ambulate without the use of an assistive device. functional/agility training exercises are employed. In addi-
The use of crutches or other assistive devices is advised tion to more intense training in the activities described
until the patient’s gait is essentially normal, including above, functional activities such as jumping rope, bound-
ascending/descending stairs and ambulating on the vari- ing, carioca, and shuffling forward, backward, and laterally
ous types of surfaces he or she will experience during are begun. Plyometric training is employed late in the
activities of daily living. The level of weightbearing (non- phase and directed at improving power. As the patient pro-
weightbearing, partial, as tolerated, or full) depends on the gresses, activities become quicker and more intense. Sport-
patient’s symptoms, early assessment of injury severity, specific drills such as dribbling a soccer ball, running
and the patient’s functional presentation. Weightbearing reception patterns in football, or shooting a basketball are
1204 Williams et al The American Journal of Sports Medicine

Figure 6. A, arthroscopic views of a widened syndesmosis (arrow). B, deltoid ligament injury with widening between the talus
and medial malleolus (arrow). T, tibia; F, fibula; Ta, talus; MM, medial malleolus.

performed in a progressive fashion. Determining when an 35 months after injury in 8 patients. All patients reported
athlete is able to safely and effectively return to sports par- excellent results and return to full activities.
ticipation is challenging. This decision is based on a con- Tasto reported treatment of 10 patients with missed ini-
fluence of information indicating that the patient is ready, tial diagnosis or failure of traditional appropriate treat-
including patient report and outcomes ratings, results of ment (unpublished data, 2001). Arthroscopic evaluation of
functional testing including activities like those described the syndesmosis was performed to establish diagnosis and
earlier (lateral hopping, quick acceleration/deceleration, treat associated injury in the ankle. Instability was noted
cutting at high rates of speed, jumping, and other sport- not only in the coronal plane but also in the sagittal plane
specific skills), and the patient’s physical examination. and with rotation. On diagnosis of instability, the distal
syndesmosis was stabilized with percutaneous screw fixa-
Surgical Treatment of Acute Injuries tion after arthroscopic curettage and debridement. Eight of
10 patients had good results with return to full activities.
Current indications for surgical treatment of acute syn- Beumer et al3 reported on 9 patients who underwent late
desmosis injuries include frank diastasis of the syndesmosis reconstruction of the syndesmosis an average of 27 months
or diastasis on stress radiographs. Arthroscopic evidence of after injury (range, 4-102 months). All patients had arthro-
syndesmotic instability is another indication for operative scopically confirmed instability of the syndesmosis. Through
treatment (Figure 6). Surgical treatment should include an anterolateral incision, a 0.7 cm × 0.7-cm bone block at the
reduction and transsyndesmotic fixation with 1 or 2 metallic tibial attachment of the anterior inferior tibiofibular liga-
screws (Figure 7). The patient should be placed in a non- ment was mobilized medially and proximally and fixed
weightbearing cast for 6 weeks postoperatively and then into a bony trough with a screw. In addition, a syndesmotic
begin progressive weightbearing and range of motion exer- screw was placed across 4 cortices. Patients were placed in a
cises. These can begin with the screws in place. We prefer nonweightbearing cast for 6 weeks before screw removal,
removal of screws at 8 to 10 weeks, but this should not slow followed by full weightbearing. At a mean follow-up of 45
down the rehabilitation process. Rehabilitation can progress months (range, 38-62 months), all patients felt improved,
to functional activities when the patient demonstrates the and none complained of instability.
ability to perform activities of daily living, ambulate on Wolf and Amendola47 reported on the treatment of 14
uneven/soft surfaces, and ascend/descend stairs without diffi- patients with syndesmosis injury treated from 1991 to
culty. Patients may return to sports participation when they 1999. All patients were athletically active individuals
demonstrate the ability to perform aggressive sport-specific without fracture or tibiofibular diastasis. The diagnosis
tasks like running, jumping, kicking, and cutting/pivoting at was made using clinical examination and radiographs as
competition/practice speed without noteworthy symptoms well as additional imaging modalities in select cases.
during or after participation. The expected time frame to Arthroscopy was performed at an average of 9.5 months
return is around 12 to 14 weeks. after injury (range, 2-20 months). Arthroscopic debride-
ment of soft tissue anterior and distal to the anterior infe-
Surgical Treatment of Chronic Injuries rior tibiofibular ligament was performed to allow adequate
visualization of the syndesmosis, and percutaneous
Mosier-LaClair et al reported on late stabilization under transsyndesmotic fixation was performed with arthro-
formal arthrotomy of the ankle joint and open debridement scopic demonstration of syndesmosis instability. Three
of the syndesmosis (unpublished data, 2000). Open reduc- patients required additional lateral ligament reconstruc-
tion with syndesmosis fixation and repair of the anterior tion using a Brostrom technique. Postoperative manage-
distal tibiofibular ligament were performed an average of ment included 2 weeks in a bulky dressing followed by
Vol. 35, No. 7, 2007 Syndesmotic Ankle Sprains in Athletes 1205

active and passive range of motion exercises. Non-

weightbearing continued for a total of 8 weeks, and the
syndesmosis screw was removed at 8 to 10 weeks under
local anesthesia in the outpatient clinic. After screw
removal, aggressive range of motion, strengthening, and
functional rehabilitation exercises were begun with a goal
of return to sporting activities. At a minimum of 6 months
after surgery, all 14 patients were evaluated by history,
physical examination, and radiographs. Results were rated
using the scale developed by Edwards and DeLee.18 Two of
14 patients (14%) had an excellent result, 10 of 14 (71%)
had a good result, and 2 of 14 (14%) had a fair result.

Controversies in Surgical Treatment

From our point of view, the main area of controversy lies in

the decision to perform early surgery versus nonoperative
rehabilitation in those injuries without obvious syn-
desmotic or mortise widening (normal radiograph parame-
ters). The purpose of this surgery is to prevent the late
pain and chronic syndesmotic injury as reported in the
chronic injury section. Because the severity of the injury is
difficult to assess, deciding on surgical intervention
remains difficult. Different methods of treatment have
been described. On the basis of the literature, reconstruc-
tion of the syndesmotic ligaments does not appear to be
necessary to gain stability, but stabilizing the tibial fibular
relationship with fixation in a reduced position will facili-
tate stable healing. Ligamentoplasty has been described23
to restore ligamentous anatomy.
Surgeons have traditionally advocated fixation of the
syndesmosis with the foot in maximal dorsiflexion to avoid
overtightening of the mortise and limited ankle motion
postoperatively.35 Tornetta et al43 evaluated the effect of
foot position on ankle range of motion during syndesmosis
fixation in cadaveric specimens. Fluoroscopy was used to
measure range of motion in 19 specimens before and after
compression fixation of the syndesmosis with varying
degrees of ankle flexion, and there was no significant dif-
ference in postfixation motion between the specimens, sug-
gesting that foot position during syndesmosis fixation will
not influence postoperative range of motion. Another
topic of controversy concerns the optimal mode of syn-
desmosis fixation. Traditionally, various authors have
advocated fixation across 3 or 4 cortices with 1 or 2 metal-
lic screws followed by screw removal before resumption of
weightbearing. Our preference would be to use 2 screws
and 4 cortices; in the case of screw breakage, the medial
end can be removed from the medial side. Recent studies
have evaluated the use of bioabsorbable fixation or flexible
fixation to obviate the need for hardware removal.
Bioabsorbable screws provide stability comparable with
that of metallic screws in cadaveric specimens,15 as well as
Figure 7. A, anteroposterior and mortise views demonstrate equivalent clinical results without the need for subsequent
a complete disruption of the syndesmosis. B, arthroscopic screw removal.28,37,42 Complications of bioabsorbable screw
examination revealed widening of the syndesmosis as pic- fixation may include formation of a sterile abscess or cyst,
tured in Figure 6 and a chondral flap (arrow). C, radiographic particularly with a rapidly degrading polymer such as
view demonstrates reduction and stabilization with 2 screws. polyglycolic acid; more slowly degrading polymers such as
T, tibia; Ta, talus. polylevolactic acid are less likely to have this effect.9,27,28,36
1206 Williams et al The American Journal of Sports Medicine

Foot alignment is also a consideration. In the planoval-

gus foot, there is an inherent external rotation moment on
the ankle and the distal fibula. Therefore it is likely pru-
dent in this type of foot alignment to be more cautious,
leaving the fixation in place longer and returning to sport
when the syndesmosis is completely stabilized.

Complications

Several authors have reported calcification of the syn-

desmosis as a complication after both conservative and
operative treatment of isolated syndesmosis injury,
although this condition is not always symptomatic.30,31
During a 24-month period, McMaster and Scranton30 iden-
tified 7 patients with persistent pain after a soft tissue Figure 8. Lateral (A) and anteroposterior (B) radiographs
injury to the ankle who had radiographic evidence of distal demonstrating calcification at 6 weeks after sprain. The lat-
tibiofibular synostosis. This finding was identified from 3 eral view shows calcification in the area of the posterior infe-
to 11 months after injury. All patients underwent operative rior tibiofibular ligament.
excision of the synostosis. The first 2 patients had recur-
rence of the synostosis, but after the procedure was modi- evaluate the risk factors for this injury, including sport,
fied by applying bone wax to the bone edges, the position, experience, performance level, sex, strength,
subsequent 5 patients had no recurrence of pain or synos- endurance/fatigue, sensorimotor control, and psychosocial
tosis at a maximum of 28 months of follow-up. Miller et al31 influences. Studies that examine the specificity, sensitivity,
reported calcification of the syndesmosis in 25% (1 of 4) of and clinical relevance of our physical examination methods
their syndesmosis injury cases treated with single-screw are also required to define the precision of our methods and
transsyndesmotic fixation (Figure 8); the patient had a find better tests. The role that imaging plays in diagnosing
score of “good” on the scale of Edwards and DeLee.18 The the extent and severity of injury, as well as predicting the
other 3 patients rated excellent (4 of 4) on the scale, and patient’s prognosis, should be another topic of research.
the complication was attributed to screw placement too Randomized controlled trials are needed that evaluate the
close to the ankle joint. Veltri et al44 reported symptomatic efficacy and effectiveness of rehabilitation and surgical
interosseous ossification in 2 professional football players approaches to treating syndesmosis injuries. Finally, longitu-
after syndesmosis sprain. Both players initially underwent dinal cohort studies that evaluate the long-term effects of
nonsurgical treatment and returned to play at 5 and 6 these injuries are needed to assess the prevalence of
weeks after injury. After regaining their preinjury levels of osteoarthritis and chronic dysfunction.
activity, they developed subsequent pain in the region of
the syndesmosis at 8 months and 1 year postinjury.
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