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High Ankle Sprain/ Syndesmosis Injury

What is a Syndesmosis Injury?

A high ankle sprain is an injury to the ligaments situated just above the ankle joint. These high ankle ligaments connect the tibia (shin bone, inner bone of leg) to the fibula (outer bone of the leg). The injury involves the syndesmosis between the tibia and fibula just above the ankle joint.

A syndesmosis is a fibrous joint where the two leg bones are connected together by ligaments or connective tissue and usually have very little mobility.

High ankle sprains are much less common but are more disabling than a traditional lower ankle sprain. It must be diagnosed in an early stage and appropriate treatment initiated, which differs from a lower ankle sprain.


High ankle sprains most commonly occur when the foot is planted on the ground and then an excessive outwards twisting of the foot occurs. High ankle ligaments can also sprain when the ankle is loaded severely and pushed into excessive dorsiflexion. This often occurs in football tackles.

High Ankle Sprain1

Symptoms of High Ankle Sprains

High ankle sprains occur following a traumatic ankle injury. Pain is felt above the ankle that increases with outward rotation of the foot. Pain while walking and often significant bruising and swelling across the higher ankle rather than around the ankle.

The severity of symptoms will depend on the grade of ankle sprain, mild, moderate, or severe. Patients with a high ankle sprain without fracture may be able to bear weight but will have pain over the junction between the tibia and fibula just above the level of the ankle. This is higher than the more traditional sprains.


Clinically assessment of ankle ligament integrity can help diagnose the problem. An X-ray, CT scan, or MRI may be needed to confirm the diagnosis.

Treatment of High Ankle Sprains

It is important to have stability between the tibia and fibula at this level because there is a tremendous amount of force that passes through this area when walking and running. A small amount of rotation of the fibula with respect to the tibia is permitted by these ligaments.

Once syndesmosis is ruptured or overstretched, the bones of the lower leg move apart with every step causing pain and loss of passive ankle stability.

Physiotherapy Treatment Aims at:

  • Pain, Inflammation, and swelling control
  • Achieve Full Range of ankle movement
  • Strengthening the Ankle and Foot Muscles
  • Restore Joint Proprioception & Balance
  • Restore Normal Function, Speed & Agility training
  • Sport-Specific Skills training

Pain Inflammation and Swelling Control

The initial treatment can be abbreviated as PRICE – Protection, Rest, Ice, Compression, and Elevation.

  • Rest: In the early phase, walking is quite difficult with a sprained ankle. The primary aim is to provide some active rest from pain-provoking postures and movements. In most cases, the non-weight bear is preferred. An ankle walking boot, a supportive ankle brace, or crutches are used for this purpose.
  • Ice is applied to reduce pain and swelling. Apply for 10-15 min every 3 to 4 hours during the initial phase.
  • Compression: A compression bandage, compression stocking, or kinesiology supportive taping can help to both support the injured soft tissue and reduce excessive swelling.
  • Elevation: Elevating the injured ankle to reduce excessive swelling around the ankle.

Physiotherapists can use a range of helpful modalities, pain-relieving techniques, strapping and dry needling to reduce the pain.

Anti-inflammatory medication may help reduce your pain and swelling.

Achieve Full Range of ankle movement

If the joint is protected appropriately with adequate immobilization in a proper position the torn ligaments will successfully reattach and heal at a normal functional length. Scar maturation may take 6-8 weeks. At times scar formed during healing may get entrapped in the lateral gutter between the talus and fibular lateral malleolus causing “Anterolateral impingement”.

During this time, it is important to lengthen and orientate the healing scar tissue via massage and exercises designed to address a joint range of motion, muscle length, and normal neural tissue motion.

Physiotherapists should not overstretch the ligaments and soft tissue, or it may develop a passively unstable ankle.

Strong Restoration of Muscle Strength

The muscles around the ankle and foot need to be strengthened in cases of a syndesmosis injury. It is important to provide normal dynamic ankle control and function.

The strength and power should be gradually progressed from non-weight bear to partial and then full weight bear and resistance loaded exercises.

Normalize Foot Biomechanics

In order to prevent a recurrence, the arch of the foot and its control should be assessed properly. In some instances, a foot orthotic (shoe insert) may be required.

Restore High Speed, Power, Proprioception, and Agility

Most sprained ankle injuries occur during high-speed activities, which place enormous forces on the ankle and adjacent structures. Balance and proprioception are taught to prevent a re-injury.

Sport-specific training of speed, agility, proprioception, and power should be customized to achieve an optimal level of fitness prior to resuming sports.


High ankle sprains are different from the common ankle sprain and will take a longer time to get better. High ankle sprains must be diagnosed in an early stage and appropriate treatment should be initiated, which does differ from a lower ankle sprain.

A high ankle sprain can be a stable or unstable injury, which needs to be determined first. If the injury is stable, then the high ankle sprain can be treated in a cast or walking boot, usually for a period of six weeks.

  • Grade 1 – Mild

In mild cases, full ligament healing can occur in approximately 6 weeks, but it will usually take longer to return to functional sport again. Often gets better with rest, but, one must go through the rehabilitation protocol to avoid reoccurrence.

  • Grade 2 – Moderate

In moderate cases, the ligament shows excessive stretchability with a significant injury to the syndesmosis. Such injuries may take a recovery period of 6 to 12 weeks. With the increasing severity of the injury, the rehabilitation process becomes more complex and extensive.

  • Grade 3 – Severe

Grade 3 ligament injuries imply a completely ruptured ligament. More severe high ankle sprain injuries can also include fractures of the bones or high ankle sprains, which will require additional rehabilitation time compared to a simple ankle sprain. If the injury is unstable, then a “syndesmotic screw” can be placed between the tibia and fibula to hold the bones in proper position while the syndesmotic ligament heals. The rehabilitation of a Grade 3 ankle sprain normally takes 3 to 6 months but is quite variable depending on the specific injury.

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