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High Ankle Sprainsand 

Syndesmosis Injury 

Mark M. Casillas, M.D.

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Disclosures

• No relevant disclosures

Learning Objectives:

1. Understand that the syndesmotic ligaments are strong 

2. Never ever use the term “high ankle sprain”

3. Briefly describe treatment options

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This presentation is the intellectual property of the author. Contactthem for permission to reprint and/or distribute.

Lateral Ankle Ligaments

• ATFL (3)

• CFL (4)

• PTFL (5)

Alexander I J, The Foot: Examination and Diagnosis

Medial Ankle Ligaments

• Deltoid 

– Superficial (3)

– Deep (1,2,4)

Alexander I J, The Foot: Examination and Diagnosis

Syndesmosis Ligaments

• AITFL (2)

• PITFL (1)

• IOL

Alexander I J, The Foot: Examination and Diagnosis

This presentation is the intellectual property of the author. Contactthem for permission to reprint and/or distribute.

Syndesmosis Ligaments

• AITFL (2)

• PITFL (1)

• IOL

Alexander I J, The Foot: Examination and Diagnosis

Syndesmosis Injury

• The syndesmosis 

– Stabilizes distal tibia and fibula

– Keeps talus under the tibia

• The tibio‐talar surface 

– Must be perfectly matched

– 1 mm lateral shift increases joint surface pressure by 42%

Syndesmosis Injury

• A failed syndesmosis 

– Leads to lateral translation

– � tibio‐talar pressure

– Promotes ankle arthritis

– Results in a loss of function

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Classification

• AMA and O’Donoghue 

– Stretch

– Partial tear

– Complete rupture 

• Never use the term “high ankle sprain”

– Potential confusion with high grade sprain

– Not an anatomic term

History

• Mechanism

– External rotation

• Ability to continue play

• Current complaints

– Pain over the syndesmosis

– Pain over the proximal fibula, mid‐leg, ankle

Physical Examination

• Systematic approach

• Inspection 

• Palpation 

• Provocative maneuvers 

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Provocative Maneuvers 

• Resisted motor function 

• Squeeze test

• Stress tests 

– varus

– valgus

– external rotation

Resisted Motor Function 

Squeeze Test 

• Syndesmosis injury

• Compress mid‐leg 

• Pain at syndesmosis 

• Must first rule‐out

– fracture

– contusion

– compartment syndrome

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External Rotation Stress Test

• Syndesmosis injury

• Knee forward facing

• Examiner applies ER

• Pain at syndesmosis

Syndesmosis Imaging

• X‐ray

– Standing

– ER stress test

– Comparison view

– Alignment

– Associated injuries Non-WB ER Stress

Imaging

• X‐ray

– Standing

– ER stress test

– Comparison view

– Alignment

– Associated injuries

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Syndesmosis Imaging

CT

– Axial 

– Comparision

– Alignment

– Associated injuries

Syndesmosis Imaging

MR

– AITFL injury

– Alignment

– Associated injuries

Syndesmosis Treatment

• Grade I and II

• Grade III

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Grade I and Grade II Sprains

• Immediate: RICE method 

• Subacute: Splint, cast or cast boot

• Rehabilitation: PT, non‐rigid functional ankle brace 

• Return to sport: Tape, brace

Grade III Sprains

• Surgical repair with delayed weight bearing

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Grade III Injury with Fracture

Screw Removal

• WB after screw removal

• Spontaneous improved reduction after screw removal (Song et al, FAI 2014)

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Screw Retention

• Physiologic motion

• Osteolysis

• Screw failure

• Pain

• Prominent hardware

Complications

• Instability

• Persistent pain

• Ossification

Learning Objectives:

1. Understand that the syndesmotic ligaments are strong 

2. Never ever use the term “high ankle sprain”

3. Briefly describe treatment options

This presentation is the intellectual property of the author. Contactthem for permission to reprint and/or distribute.

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Mark M. Casillas, M.D. – Orthopaedic Surgery, Foot & Ankle

Jeremy L. Dickerson, M.D. – Family Practice, Sports Medicine

Stacé S. Rust, M.D. – Orthopaedic Surgery, Hand, Wrist, Elbow & Shoulder

Ryane M. Galindo – MPAS, PA-C

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