Ankle Syndesmosis Injury

Syndesmosis injuries are also commonly referred to as high ankle sprains. The ligaments affected are above the ankle joint.

Syndesmosis injuries are less common than a traditional ankle sprain, however the recovery period is often longer and the symptoms are more disabling. Therefore it is important to distinguish whether you have sustained a high ankle sprain, as this will affect the management and rehabilitation of your ankle.


What exactly is the syndesmosis?

Your lower leg consists of two bones- the tibia and fibula. Just above the ankle joint these two bones are held together by the distal tibiofibular ligament. Between the two bones is a fibrous connective tissue that helps to hold them together, and this is the syndesmosis.

The syndesmosis provides stability and support during weight bearing, rotational movements, and high loads through the ankle joint.


How can the syndesmosis be injured?

Ankle syndesmosis injuries often occur when the foot is planted on the ground and the leg twists inwards, or if the foot itself is forcefully twisted outwards. This results in an over-stretching and possible tearing of the syndesmosis and distal tibiofibular ligament. These injuries are more common in the sporting population.

There are specific tests that can be performed to diagnose a syndesmosis injury, and scans such as x-rays or MRI can help confirm the diagnosis and determine the extent of the injury.


Symptoms of syndesmosis injuries


  • Pain across the front of the ankle joint
  • Pain aggravated with external rotation of the foot (twisting outwards)
  • Pain and difficulty with weight-bearing
  • Swelling or bruising across the front and/or side of the ankle
  • Pain does not settle with rest


What are the recovery timeframes for syndesmosis injuries?

The length of recovery depends on how severe the injury is.

Grade 1 injuries involve overstretching of the ligament without any tears. The recovery is approximately 6 weeks.

Grade 2 injuries involve partial tearing of the ligament and can be classified as stable or unstable. If it is unstable, surgery may be required. Recovery is typically between 6-12 weeks.

Grade 3 injuries refer to a complete rupture of the ligament. Surgery is required and recovery can take between 3-6 months.

Surgery of syndesmosis injuries involves inserting pins to hold the tibia and fibula together to prevent widening of the bones during weight-bearing activities. The specifics of the surgery will be determined by your specialist depending on your injury.


How to treat syndesmosis injuries

Treatment of your syndesmosis injury will depend on the severity of it. The first stage is all about protecting the ankle to allow for adequate healing, swelling management and pain relief. You will need to rest it and may need to wear a CAM boot for a short period of time. Then you will need to restore your ankle range of motion, strength, proprioception and balance in preparation for return to functional activities and sport. You may need to tape it when you first return to sport to give it some extra support and stability.

Physiotherapy is very effective in treating ankle syndesmosis injuries. Treatment usually includes manual therapy such as soft tissue massage and joint mobilisation to help restore range of motion and reduce muscle tightness. Ultrasound, heat packs and TENS can also be used for pain relief. Your Physiotherapist will advise you on appropriate load management strategies to help optimise healing. You will prescribed individually tailored exercises to restore flexibility, strength, proprioception and balance. You will be guided through a graded return to sport.

If you need to have surgery, physiotherapy will be important post-operatively to help with swelling and pain management, and to help restore mobility and strength. Your Physiotherapist will liaise closely with your specialist throughout your recovery.

If you are suffering from an ankle syndesmosis injury and would like some more advice or have any questions, give us a call on +61 02 9875 3760 or email We would be more than happy to help!


If you need physical therapy to relieve
your pain, and would like some more
information, feel free to contact us!

Give us a call on (02) 9875 3760 or email We would
be more than happy to help you.