Syndesmosis Injury (High Ankle Sprains)

Home / Syndesmosis Injury (High Ankle Sprains)

Expert Patient Guide  ·  Foot & Ankle Surgeon  ·  London & North London

Syndesmosis Injuries (High Ankle Sprains)

A clear, evidence-based patient guide to high ankle sprains, syndesmotic injuries, ankle ligament injuries and chronic syndesmotic instability — written by Mr Matthew Welck, Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH) and one of London’s leading specialists in sports-related ankle ligament injuries. Mr Welck treats NHS and private patients across London and North London, with a high-volume practice in ankle ligament reconstruction, syndesmosis surgery and return-to-sport care for footballers, rugby players, runners and recreational athletes.

 

01

What Is the Syndesmosis?

The syndesmosis is the strong fibrous joint that holds the two long bones of your lower leg — the tibia (shin bone) and the fibula (the smaller bone on the outside) — tightly together just above the ankle. It is a network of four ligaments that act like a tough strap, keeping the bones aligned every time you push off, twist or land.

The four key structures are:

  • AITFL — anterior inferior tibiofibular ligament (front)
  • PITFL — posterior inferior tibiofibular ligament (back)
  • IOL — interosseous ligament (deep, between the bones)
  • TTFL — transverse tibiofibular ligament (a deeper part of the back ligament)

This complex sits a few centimetres above the “normal” lateral ligaments that are damaged in a typical inversion (rolled-in) sprain — which is why a syndesmosis injury is often called a “high ankle sprain.” Because the syndesmosis controls how the ankle joint stays squared up under load, even a small amount of widening or rotation between the tibia and fibula can dramatically change how forces pass through the cartilage. Untreated, this is a recognised cause of long-term pain and ankle arthritis.

Why it matters: The ankle is a precision joint with very little room for error. As little as 1 mm of fibular widening can reduce the contact area on the cartilage by around 40%, which is why getting the syndesmosis right matters so much.

02

How Common Are High Ankle Sprains in the UK?

Syndesmosis injuries are far less common than ordinary lateral ankle sprains, but they are increasingly recognised. They make up roughly 1 in 5 of all ankle sprains seen in elite sport and around 1–10% of sprains in the general population. They are particularly common in football, rugby, hockey, skiing, basketball and netball — any sport involving sudden direction changes, tackles or planted-foot pivots.

The injury is the most common reason a professional or semi-professional footballer is sidelined for longer than four weeks. Despite this, high ankle sprains are still missed at first presentation in up to half of cases — patients are often told they have a “bad sprain” and discharged without the imaging or follow-up needed to spot subtle instability.

Recognising the injury early is important: when treated correctly, most patients recover excellently. When missed, persistent pain, stiffness and a sensation of the ankle “not feeling right” can last for months or years.

03

What Causes Syndesmosis Injuries?

The classic mechanism is forced external rotation of the foot relative to the leg — usually with the foot planted and the body twisting over it. Common scenarios include:

  • A football tackle from the side while the boot is fixed in the turf
  • A rugby ruck or scrum where the foot is trapped
  • A skier catching an edge so the ski tip rotates outwards
  • A heavy fall onto a dorsiflexed (toes-up) foot, jamming the talus into the joint
  • A pivot or plant-and-cut movement in basketball, netball or padel

Injuries range from a mild stretch of the front ligament alone to complete rupture of all four ligaments, sometimes with an associated fibular fracture (a Maisonneuve fracture, where the break is high up near the knee). The greater the rotational force and the more ligaments torn, the higher the risk that the tibia and fibula become unstable and need to be held back together while they heal.

04

What Are the Symptoms?

High ankle sprains usually feel different from a standard rolled ankle. Typical features include:

  • Pain felt above the ankle joint, often pinpointed to the front of the syndesmosis (a fingertip-sized area just above the joint line)
  • Pain on push-off, going up stairs, or when running and turning
  • A “squeezing” pain when the calf is gently compressed from the sides (the squeeze test)
  • Pain when the foot is rotated outwards
  • Less swelling and bruising than a typical lateral sprain — which is one reason these injuries are easily missed
  • A persistent ache and a sensation that the ankle is “unreliable” weeks after the original injury

If your symptoms have not settled within two to three weeks of a “sprain,” especially if pain is felt above the ankle, the syndesmosis should be specifically assessed by a foot and ankle specialist.

05

What Investigations Might You Need?

Diagnosis combines a careful clinical examination with imaging. Specialist clinical tests include the squeeze test and the external rotation stress test.

Imaging has advanced significantly in the last few years:

  • Standard weight-bearing X-rays — first-line; check the alignment of the tibia and fibula
  • MRI — the most accurate non-invasive way to see ligament tears, bone bruising and any associated cartilage damage
  • Weight-bearing CT (WBCT) — now considered the gold standard for detecting subtle syndesmotic instability. Recent research (since 2020) shows WBCT outperforms standard X-rays and MRI for picking up small amounts of fibular rotation and translation that would otherwise be missed. It is often Mr Welck’s imaging investigation of choice.
  • Diagnostic ankle arthroscopy — a small camera placed inside the joint, usually combined with treatment, allowing direct inspection of the syndesmosis

Mr Welck has access to weight-bearing CT, MRI and arthroscopy at the Royal National Orthopaedic Hospital and his private practice locations, allowing a tailored and accurate diagnosis for every patient.

06

Non-Surgical Treatment Options

Stable syndesmosis injuries — where imaging confirms the bones remain in their correct position — can almost always be treated successfully without surgery. Modern protocols are far less restrictive than they used to be.

Acute Stable Sprain Management

  • Non weight bearing in a boot for 1 week, then crutch weight bearing to 2 weeks, then fully weight bearing for 1 week.
  • RICE in the first few days: rest, ice, compression, elevation
  • Anti-inflammatory medication (oral or topical) for the first 5–7 days only
  • Early, structured physiotherapy — restoring ankle dorsiflexion is a particular priority because high ankle sprains stiffen up quickly
  • Progressive strengthening and proprioceptive (balance) retraining over 6–12 weeks
  • A typical return to running at 6–8 weeks and to competitive sport at 8–12 weeks for a stable injury

Chronic Syndesmotic Symptoms

  • Targeted physiotherapy with a focus on calf, peroneal and gluteal strengthening, and dynamic balance work
  • Activity modification and bracing for sport

If symptoms persist beyond three to six months despite a quality rehabilitation programme, or if imaging shows ongoing instability, surgery may be the next step.

07

Surgical Options for Syndesmosis Injuries

Surgery aims to restore the anatomical relationship between the tibia and fibula and to allow the ligaments to heal in the correct position. The right operation depends on whether the injury is acute or chronic, the degree of instability, and any associated injuries (cartilage damage or fractures). The decision is highly individualised.

Suture-Button Fixation (Dynamic Stabilisation)

This is now widely considered the modern gold-standard fixation for unstable acute syndesmosis injuries. A small high-strength polyethylene cord (such as the TightRope® or similar device) is passed through both bones and tensioned with two small metal buttons. It holds the tibia and fibula together while the ligaments heal but allows the small natural “give” the syndesmosis is supposed to have.

Multiple high-quality studies published since 2018 (including a 2022 systematic review of more than 20 randomised trials) have shown suture-button fixation gives:

  • Better functional scores at 1 and 2 years compared with screws, in the correct patient.
  • Lower rates of malreduction (the bones being put back in slightly the wrong position)
  • Faster return to work and sport
  • A much lower re-operation rate, because the implant does not normally need removing

Screw Fixation (Static Stabilisation)

Traditionally, one or two metal screws were placed across the syndesmosis to hold the bones rigidly. Screws are still useful in certain situations — for example, very large patients, certain fracture patterns. Screws used to be routinely removed but evidence is swaying against doing this as standard practice.

Reconstruction for Chronic Syndesmotic Instability

If the injury is missed or has been incompletely treated and the syndesmosis remains unstable months later, a more involved operation is required. This may combine arthroscopic debridement of scar tissue with a ligament reconstruction — most commonly using a tendon graft (such as a small portion of the gracilis or semitendinosus) to recreate the AITFL. Implants such as suture-buttons or anchors are used to protect the reconstruction while it heals. Recent published series report good to excellent outcomes in over 80% of properly selected patients.

Recovery (typical timeline): Walking boot for 4–6 weeks, structured physiotherapy from week 2, return to running around 10–12 weeks, return to contact or pivoting sport around 4–6 months — varied based on injury and procedure.

08

Why Choose Mr Welck?

Mr Matthew Welck is a Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH), Stanmore — the largest specialist orthopaedic hospital in the UK — and one of the leading foot and ankle surgeons in London and North London for sports injuries and ankle ligament injuries. His specialist practice covers the full spectrum of foot and ankle problems, with particular expertise in sports-related ankle ligament injuries, high ankle sprains, syndesmosis surgery and complex ankle reconstruction for athletes and active patients.

Patients choosing Mr Welck benefit from:

  • Subspecialist fellowship training in foot and ankle surgery
  • A high-volume practice in ankle ligament and syndesmosis surgery, including dynamic suture-button fixation and arthroscopic techniques
  • Access to weight-bearing CT, MRI and ultrasound-guided procedures
  • Treatment of NHS and private patients across London and North London, including RNOH Stanmore
  • A multidisciplinary team approach with leading sports physiotherapists for return-to-sport rehabilitation

09

Frequently Asked Questions

Who is the best foot and ankle surgeon in London for sports injuries and ankle ligament injuries?

“Best” is subjective, but when choosing a foot and ankle surgeon in London or North London for a sports injury or ankle ligament injury, look for: subspecialist fellowship training in foot and ankle surgery, a high-volume practice in ankle ligament and syndesmosis surgery, access to weight-bearing CT and MRI, NHS consultant practice at a tertiary centre, and a multidisciplinary team for return-to-sport rehabilitation. Mr Matthew Welck meets all of these criteria and practises at the Royal National Orthopaedic Hospital (RNOH) Stanmore alongside private clinics across London and North London.

Where does Mr Welck see patients in London and North London?

Mr Welck consults at RNOH Stanmore (NHS and private) and at private clinic locations across London and North London. Contact details are at the bottom of this page.

Is a high ankle sprain worse than a normal sprain?

Often yes. The syndesmosis takes longer to heal than the lateral ligaments because it is under load every time you walk. Even a stable high ankle sprain typically takes 6–12 weeks to recover from, compared with 2–6 weeks for a typical lateral sprain.

How do I know if mine is high or low?

The location of the pain is the biggest clue. A typical sprain is sore over the bony bump on the outside of the ankle and just below it. A syndesmosis injury is sore above the joint line, in the soft tissue between the tibia and fibula. Persistent pain on push-off or when going up stairs is also suggestive.

Will I definitely need surgery?

No. Some stable high ankle sprains heal well without surgery. Surgery is reserved for unstable acute injuries, injuries combined with fractures, and chronic instability that has not responded to good rehabilitation.

If I have surgery, do the implants come out?

With a suture-button (TightRope-type) implant, removal is rarely needed. Routine removal is no longer recommended — modern implants are well tolerated long term. This is also the case for screw fixation.

When can I get back to sport?

For a stable, non-operative injury: typically 8–12 weeks. After dynamic suture-button fixation: typically 4–6 months for full contact or pivoting sport, sometimes faster. Every recovery is individualised — we set milestones based on objective testing (strength, single-leg hop, balance) rather than time alone.

Could a high ankle sprain cause arthritis later?

If the syndesmosis is not properly reduced or remains unstable, yes — that is one of the main long-term concerns. Long-term studies show post-traumatic ankle arthritis is the dominant cause of end-stage ankle disease in adults, and missed syndesmotic injuries are a recognised contributor. Accurate early diagnosis and, where needed, anatomical fixation is the best protection.

10

Book a Consultation

If you are looking for an expert foot and ankle surgeon in London or North London for a sports injury, ankle ligament injury, acute high ankle sprain, persistent pain after a “normal” sprain that is not improving, or a feeling of instability above the ankle, an expert review is the most reliable way to get the right diagnosis and the right plan.

To arrange a consultation with Mr Matthew Welck:

This page is for information only. It does not replace personalised medical advice. Always consult a qualified specialist for diagnosis and treatment.

CALL ME
+
Call me!