What Is a Syndesmosis Injury?

A Physiotherapist’s Guide to Treatment and Recovery

Syndesmosis injuries, often called high ankle sprains, affect the strong ligaments that hold the tibia and fibula together above your ankle joint. These ligaments are vital for ankle stability, especially during twisting and cutting movements. When they fail, the result is a painful and often slow-to-settle ankle injury that needs specific syndesmosis injury treatment, not just simple sprain care.

These injuries are common in running and change-of-direction sports such as football, netball, rugby and soccer. Because symptoms can mimic a standard ankle sprain, syndesmosis injuries are sometimes missed or under-treated, which can delay your return to sport and increase your risk of long-term ankle problems.

Ankle Syndesmosis Anatomy

The ankle syndesmosis is a group of ligaments that connects the lower tibia and fibula. Together they:

• Keep the ankle mortise stable around the talus.
• Allow small but important movements during walking, running and landing.
• Protect the ankle from rotational and high loading forces.

A syndesmosis injury occurs when these ligaments are overstretched or torn, usually by a twisting force with the foot planted, or from a contact injury that forces the ankle outwards. Because the ligaments sit higher than the usual lateral ankle ligaments, pain often sits above the ankle joint line rather than only around the bony ankle knobs.

Common Causes of Syndesmosis Injuries

Syndesmosis injuries usually occur with one or more of the following mechanisms:

• Twisting the leg while the foot is fixed on the ground.
• Forced outward rotation of the foot, such as during a tackle.
• High-impact landings from a jump, especially on uneven ground.
• Contact injuries that drive the ankle into an awkward position.
• Previous ankle injuries that left residual weakness or poor control.

These mechanisms are common in collision and field sports, so athletes often benefit from early sports physiotherapy review after any significant high ankle injury.

Symptoms of a Syndesmosis Injury

Syndesmosis injuries usually feel different from a simple ankle sprain. Typical symptoms include:

• Pain above the ankle joint: often between the tibia and fibula rather than only around the ankle bones.
• Swelling that tracks up the leg: rather than staying just around the ankle.
• Difficulty weight bearing: walking and stairs may be painful or impossible.
• Feeling of instability: the ankle can feel loose or “weak”, especially with twisting.
• Reduced push-off: running, hopping or changing direction feels limited or unsafe.

If you notice these features after an ankle injury, it is wise to seek early ankle physiotherapy so that a syndesmosis injury is not missed.

How Is a Syndesmosis Injury Diagnosed?

Accurate diagnosis combines a skilled clinical assessment with appropriate imaging.

• Clinical assessment: Your physiotherapist or doctor will examine your ankle, test specific syndesmosis stress tests, check your walking pattern and assess strength and balance.
• X-rays: Used to exclude fractures and to assess the space between the tibia and fibula.
• MRI: Provides detailed images of the syndesmosis ligaments and surrounding structures and is often the best test to grade injury severity.
• CT scans: Sometimes used when there is concern about joint alignment or associated fractures.

Your physiotherapist may also complete a broader sports injury assessment to identify any related injuries higher up the leg.

Is It More Than a Simple Ankle Sprain?

It is important to distinguish a syndesmosis injury from a more common ankle sprain. Compared with a standard sprain, syndesmosis injuries typically show:

• Pain higher above the ankle joint.
• More difficulty weight bearing.
• Greater feeling of instability or looseness.
• Longer recovery times if left untreated.

Because the syndesmosis is crucial for ankle stability, incorrect management can lead to long-term problems. Early diagnosis and targeted ankle strengthening exercises are key parts of successful syndesmosis injury treatment.

Syndesmosis Injury Treatment

Immediate Care and Protection

In the early phase your priorities are pain control and joint protection.

• Relative rest: Reduce painful loading and avoid hopping, running and twisting.
• Ice, compression, elevation: To help control swelling and discomfort.
• Immobilisation: A moon boot or supportive brace often protects the ligaments while they start to heal.
• Mobility aids: Crutches may be needed if weight bearing is very painful or unsafe.

Your physiotherapist will guide how long you should use a CAM walker moon boot or brace and when it is safe to begin weaning off the support.

Early Physiotherapy Goals

Once pain and swelling begin to settle, physiotherapy focuses on:

• Restoring gentle ankle range of motion.
• Activating the calf and lower leg muscles.
• Maintaining strength in the hips and core.
• Preventing stiffness in nearby joints.

Treatment may include hands-on joint mobilisation, massage, taping, gentle exercises and advice about safe levels of activity at work, home and sport.

Strength, Control and Balance

As healing progresses, your program will shift towards:

• Strength training: resistance exercises for calf, peroneals, tibialis muscles and hip control.
• Balance and proprioception training: single leg balance, wobble board and dynamic stability exercises to restore ankle control.
• Foot and ankle biomechanics: assessment of foot posture and gait, with foot and ankle biomechanics advice and orthotic or footwear recommendations if needed.

This stage reduces the risk of chronic ankle instability and helps you move confidently without fear of re-injury.

Running and Return-to-Sport Progression

Before returning to sport, you will usually complete a structured graded loading program:

• Walking tolerance and pain-free daily activity.
• Graduated jogging on level surfaces.
• Change-of-direction drills, side steps and cutting.
• Jumping, landing and sport-specific drills.
• Full training, then competition.

Your physiotherapist may use objective return to sport testing to check that your strength, balance and agility are ready for match demands.

Do I Need Surgery?

Not all syndesmosis injuries need surgery. The decision depends on:

• How much the tibia and fibula have separated.
• Whether there is an associated fracture or dislocation.
• Your sport, work and activity goals.

Unstable injuries are usually referred for orthopaedic opinion. Surgery aims to realign and stabilise the bones with screws or flexible fixation so the ligaments can heal in the correct position. After surgery, a staged rehabilitation program with your physiotherapist is an important part of recovery.

Recovery Time Frames

Recovery times vary with injury grade, associated injuries and workload demands. As a general guide:

• Mild (Grade I): Short boot or brace phase, then progressive rehab. Many people return to sport within 3–6 weeks.
• Moderate (Grade II): Longer period of protection, often 4–6 weeks in a boot followed by 6–12 weeks of structured rehabilitation.
• Severe or surgical cases (Grade III): Protection and non-weight bearing for several weeks, then months of progressive rehab. Return to sport can take 3–6 months or longer.

These time frames are broad guides only. Your physiotherapist will tailor your plan based on your progress, goals and medical advice.

Prevention and Long-Term Ankle Health

Good ankle care can reduce your risk of future syndesmosis problems:

• Maintain calf and hip strength with regular conditioning.
• Include balance and proprioception training in your weekly routine.
• Address any lingering weakness or stiffness after previous ankle injuries.
• Use appropriate footwear and bracing or taping for high-risk sports.

If you continue to feel unstable, stiff or sore months after an injury, a review with a physiotherapist can help you identify and manage the remaining issues.

People Also Ask: Syndesmosis Injuries

How do you treat a syndesmosis injury?

Treatment focuses on protecting the ligaments, gradually restoring movement, then rebuilding strength, balance and sport-specific function. Severe or unstable injuries may also require surgical stabilisation before rehabilitation.

How long does recovery take?

Minor injuries may settle in a few weeks with appropriate care. More severe or surgically treated injuries can take several months before safe return to full sport or heavy work.

Can you walk with a syndesmosis injury?

Some people can walk with a mild injury, but many struggle to bear weight due to pain and instability. Your physiotherapist or doctor will advise on safe weight bearing and whether a boot or crutches are needed.

What happens if a syndesmosis injury is not treated properly?

Poorly managed injuries may lead to chronic pain, ankle instability, early joint wear and reduced confidence with sport. Early, targeted management may help lower these risks.

What to Do Next

If you suspect a syndesmosis injury, do not ignore it or try to train through the pain. Early assessment by a physiotherapist or doctor may help you recover more efficiently and with fewer ongoing issues, but individual results vary.

PhysioWorks physiotherapists can:

• Provide a clear diagnosis and explain your injury.
• Guide imaging and orthopaedic referral when needed.
• Plan a structured rehabilitation program from protection through to sport.
• Help you decide when it is safe to return to work, running and competition.

You can book online or phone your nearest clinic to arrange an appointment.

Related Articles

1. High Ankle Sprain
2. Sprained Ankle
3. Ankle Fractures
4. Common Ankle Injuries
5. Ankle Tendinopathies
6. Ankle Arthritis

References

1. Liu J, Valentine D, Ebraheim NA. Management of syndesmosis injury: a narrative review. Orthop Res Rev. 2022.
2. Regauer M, Mackay G, Nelson O, et al. Evidence-based surgical treatment algorithm for unstable syndesmotic injuries. J Clin Med. 2022;11(2):331.
3. Salameh M, Hantouly AT, Rayyan A, et al. Return to play after isolated syndesmotic ligamentous injury in athletes: a systematic review and meta-analysis. Orthop J Sports Med. 2022;10(5):23259671221096482.
4. Vancolen SY, Nadeem I, Horner NS, et al. Return to sport after ankle syndesmotic injury: a systematic review. Sports Health. 2019;11(2):116-122.