Syndesmotic Injury (High Ankle Sprain)

What is the ankle syndesmosis?

The two bones of the leg (tibia and fibula) are connected just above the ankle by strong ligaments. This complex is called the ankle syndesmosis. It allows a small amount of movement between the leg bones during activities.

What is an ankle syndesmotic injury (high ankle sprain)?

Inwards twisting the leg on a planted foot can tear these ligaments making the syndesmosis unstable. Occasionally the fibula can break high up the leg near the knee (Maisonneuve Fracture).

This pattern of injury is different to the usual ankle sprain where the ankle rolls over the foot and tears the "low" ankle ligaments instead. 

Therefore, the term "high ankle sprain" is used for syndesmotic injuries.

Symptoms of syndesmotic injury

Pain is often felt just above the ankle and can spread up the leg. There can also be pain in the inner ankle. Swelling and bruising are often less than expected. A common feeling is instability when trying to pivot on one foot.

Chronic or missed syndesmosis injury can cause long-term ankle pain, weakness during change of direction activities, and even ankle arthritis. 

Diagnosis of Ankle Fractures

This injury is often not recognised immediately unless severe or the treating doctor/physiotherapist thinks about it. Fortunately, early treatment is similar to that given for a regular ankle sprain.

Specific examination techniques help make the diagnosis, but investigations are always required to confirm and determine severity. 

Weight-bearing X-rays comparing both ankles are useful, with MRI, weight-bearing CT and even ankle arthroscopy sometimes required to determine whether the syndesmosis is stable or unstable.

Treatment of ankle syndesmotic injury

  • Clearly stable syndesmotic injuries require reduced weight-bearing with crutches and either a brace or "moonboot" until comfortable. 
  • Obviously unstable syndesmotic injures need surgery within two weeks.
  • Injuries that may be unstable can wait four weeks to assess progress and allow further investigations.Occasionally, people need to know immediately if there is instability (elite athletes, etc) and will undergo ankle arthroscopy +/- syndesmotic stabilisation within two weeks of injury.
  • Unstable injuries treated within eight weeks require ankle arthroscopy and syndesmotic stabilisation using one or two Arthrex TightRopes ("keyhole surgery"). This is followed by progressive weight-bearing and a month in a "moonboot" with physiotherapy-assisted rehabilitation.
  • Unstable injuries treated after eight weeks still undergo ankle arthroscopy but usually require open syndesmotic reconstruction (Arthrex Internal Brace).
Return to running and sport is at least two months following injury or surgery. Full recovery can take six months.

Surgery has small but real risks. TightRope buttons only need removing in 5% of cases. Please see the TREATMENTS menu for further information on ankle arthroscopy.

Treatment Process

Preparation for Surgery

  • Provide a complete list of your medications so you can be advises which to stopped prior to surgery,
  • Treat any tooth, gum, bladder or bowel problems before surgery to reduce the risk of infection
  • Stop anti-inflammatory medications (NSAIDs) at least seven days before the procedure.
  • Stop or cut down smoking to reduce your surgery risks and improve your recovery
  • Consider losing weight (if overweight) before surgery

Day of Surgery

  • Report any infections to me prior to surgery as the procedure cannot be performed until all infections have cleared up.
  • Do not consume alcohol - 24 hours prior to treatment,
  • Do not eat or drink anything, including water, for 6 hours before surgery
  • Avoid vigorous physical activity or exercise 24 hours prior to surgery,

During Surgery

  • Administration of general anesthesia or sedation and local anesthesia
  • The entire procedure can take 60 minutes to two hours.
  • Fractured bone is accessed by making an incision over the ankle area and then specially designed plates are screwed onto the bone, to realign and stabilize the fractured parts
  • The incision is then sutured closed and the operated ankle is immobilized with a splint or cast
  • Procedure is performed and sent to recovery room, for observation
  • Pain medications are prescribed to help with pain during the recovery phase. 

After Surgery

  • Do not consume large amounts of alcohol after surgery,
  • Avoid vigorous physical activity or exercise until advised,
  • Follow the Post Surgery Treatment Plan proscribed by the surgeon and post op care specialists.
  • Any questions or complications should be communicated directly to the surgeon

Common Questions

If you have a specific question about your treatment, we recommend contacting the clinic
  • Hospital Discharge?

    The patient is then discharged from the hospital in a day or two after the procedure. 


    Patients are advised on the steps to keep the wound dry and clean and on scar management.


    The patient is advised to maintain a strict elevation of the joint for ten days. 

    • arrange help to assist with chores, and
    • avoid putting any weight on the joint, with the help of crutches and walkers. 
  • Recovery After Ankle Surgery?

    After ankle surgery, you will be instructed to avoid putting weight on the ankle by using crutches while walking for at least six weeks.

  • Wound Management?

    At the time of discharge patients are advised on:

    • The necessary steps to keep the wound dry,
    • Wound care and Cleaning, and 
    • On scar management. precautions.
  • What if I Am Pregnant?

    It is not recommend surgery while pregnant, as the risks are uncertain due to the lack of information available about the effect on the fetus. 


    For more information please call us on and request to speak with one of our medically-trained registered doctor or nurse.

  • Post Surgery Treatment Program

    Long term outcomes depend on the severity of the initial injury. 


    Physical therapy of the ankle joint will be recommended by the doctor. After 2-3 months of therapy, the patient may be able to perform their normal daily activities.


    Some patients won’t get back to their pre-injury function or sport, even with well-performed surgery. 


    Ten Days After Surgery

    X-rays are repeated ten days after the procedure to determine the situation. 


    Physiotherapy

    For the best possible outcome, postoperative physical therapy plays an important role in proper recovery following your procedure. 


    This postoperative management includes regular scheduled visits with a physical therapist 


    Extended Recovery Period

    The patient is advised to limit their activities for six to eight weeks after the surgery.


    Certain activities such as driving are also restricted for up to six weeks post-surgery. 

  • Possible Risks or Side Effects?

    The procedure carries all the risks associated with surgery, such as 

    • infection, 
    • bleeding and 
    • a severe allergic reaction to anesthesia. 

    Redness and bruising at the site of injection may be seen which should resolve over time. 


    You may experience post operative pain for prolonged period or other serious side effects contact your surgeon, as well as:

    • damage to the structures around the operative zone such as nerves, blood vessels, tendons, muscles,
    • chronic pain due to nerve entrapment
    • delayed healing
    • wound infection or breakdown.

    Rarely, surgery may result in incomplete healing of the fracture, which requires another surgery to repair.

  • Possible Complications of Surgery?

    Complications that can occur with ankle fractures include improper casting or improper alignment of the bones which can cause deformities and eventually arthritis. In some cases, pressure exerted on the nerves can cause nerve damage, resulting in severe pain.

  • Do You Offer Discounts?

    Due to strict regulations set by the Australian Medical Board it is against the law to offer surgical inducements. 


    Discounted treatments should raise alarm bells when you are choosing which specialist to trust your treatment to. 


    The surgeon's skill is more important than price. Effective surgery will maximise your health outcome.