Syndemosis Injury HUB 


Syndemosis - About

A syndesmosis joint is a fibrous joint where two bones are connected by strong ligaments or membrane. The Ankle Syndemosis is also referred to as the distal tibiofibular syndesmosis, between the fibula and tibia, and it is formed by the following ligaments:

  1. the anterior inferior tibiofibular ligament (AITFL),
  2. the posterior inferior tibiofibular ligament (PITFL), and
  3. the interosseous tibiofibular ligament (ITFL).
  4. A fourth ligament, the inferior transverse tibiofibular ligament, is congruent with the PITFL, but sometimes considered a separate ligament
Injury to this area is often referred to as a high ankle srpain, but is typically a bit more than just a sprain. "High Ankle Sprain" & Syndesmosis Injuries are traumatic injuries that affect the distal tibiofibular ligaments and most commonly occur due to sudden external rotation of the ankle. Diagnosis is suspected clinically with tenderness over the syndesmosis which worsens with squeezing of the tibia and fibula together at the midcalf. Plain stress radiographs of the ankle are required to diagnosis complete syndesmosis injuries with tibiofibular diastasis. Treatment is nonoperative for syndesmotic sprains without diastasis or ankle instability. Operative management is indicated for patients with diastasis of the tibiofibular joint or injuries with associated fractures.


It is reported that the ankle syndesmosis injury can occur in up to 11% of all ankle sprains without fractures and.and occurs in 13% of all ankle fractures. The high ankle sprain results in more dysfunction espcially if left untreated. The instability could result from widening of the ankle mortice following stretching of the ligaments.

Syndemosis - Diagnositic tests

Special Testing 1. Dorsiflexion External Rotation Stress Test (Kleiger's Test) Determines rotation damage to the deltoid ligament or the distal tibiofibular syndesmosis. Performed by having the knee flexed by 90 degrees with the ankle in neutral position and appyling an external rotational force to the affected foot and ankle. (+) test: Pain in the anterolateral ankle. An indicator of deltoid ligament damage would be if there is a displacement of the talus away from the medial malleolus. 2. Squeeze Test Squeezing of the shin from the sides - checks for any separation of the tibia and fibula Identifies a fibular fracture or syndesmosis sprain. Performed by squeezing the tibia and fibula together above the injury. (+) test: Pain will be reproduced along the fibular shaft if it’s a fibular fracture and the distal tibiofibular jt for syndesmosis sprain. 3. Cotton Test Assess for syndesmosis instability with diastasis. Performed: steadying the distal leg with one hand while grasping the plantar heel with the opposite hand and moving the heel directly from side to side (+) test: Any lateral translation would indicate syndesmotic instability 4. Fibular Traslation Test Attmpting to A-P mobilise the distal head of the Fibula



GOLD STANDARD ANKLE SYNDESMOSIS REHAB PROTOCOLS The Lower Extremity Group offers to you the Gold Standard in Lower extremity injury rehabilitation. We utilise a World Class rehabilitation program for Ankle Syndesmosis injuries, and this is deilvered to you online in the comfort of your own home. All you have to do is follow our easy to use evidence based plan to treat and manage your Ankle Syndesmosis injury. This online program contains 4 complete weeks of revolutionary rehabilitation guides to help you manage and treat your Ankle Syndesmosis injury issues every single day. We deliver our evidence-based daily Ankle Syndesmosis injury management program via our amazing app, which is very easy for you to follow and includes 28 days of;

  • Progressive neuromuscular exercises that will strengthen the muscles around the foot and ankle and help reduce the pain associated with Ankle Syndesmosis injury.
  • 5 progressive levels of evidence based rehabilitation that do not require expensive equpiment
  • Passive and dynamic mobility exercises to increase range of motion and tissue extensibility of mucles and fascia
  • ​Myofascial massage exercises
  • Using the app will enable you to understand when to apply the various exercises to help manage Ankle Syndesmosis injury
  • Plus more
We offer online consultations as a part of the rehabiliation precess to help you rehabilitate and manage your Ankle Syndesmosis injury. ​Our experienced therapists have taken these aforementioned technical modalities and simplified them into easy to watch videos for you to follow and complete. These are delivered daily to your smart device within our Ankle Syndesmosis injury management program. Book in today - Online or in clinic


Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review Sman et al 2013

find article here Br J Sports Med. 2013 Jul;47(10):620-8. doi: 10.1136/bjsports-2012-091702. Epub 2012 Dec 6. Abstract Objectives: To determine the value of clinical tests for accurate diagnosis of ankle syndesmosis injury. Design: Systematic review. Data sources: An electronic database search was conducted (to 6 August 2012) of databases such as: MEDLINE, CINAHL, EMBASE, PubMed and Cochrane Databases. References from identified articles were examined and seven authors of eligible studies were contacted for additional information. Study selection: Studies of any design, without language restriction, were included; however, systematic reviews were excluded. Eligible studies included participants with a suspected ankle syndesmosis injury but without fracture. Reliability studies compared one or more clinical tests and studies of test accuracy compared the clinical test with a reference standard. Results: The database search resulted in 114 full text articles which were assessed for eligibility. Three studies were included in the review and raw data of these studies were retrieved after contacting the authors. Eight clinical diagnostic tests were investigated; palpation of the tibiofibular ligaments, external rotation stress test, squeeze, Cotton, fibula translation, dorsiflexion range of motion (ROM) and anterior drawer tests. Two studies investigated diagnostic accuracy and both investigated the squeeze test by with conflicting results. Likelihood ratios (LR) ranging from LR+1.50 to LR-1.50 were found for other tests. High intra-rater reliability was found for the squeeze, Cotton, dorsiflexion ROM and external rotation tests (83-100% close agreement). Inter-rater reliability was good for the external rotation test (ICC2,1>0.70). Fair-to-poor reliability was found for other tests. Conclusions: This is the first systematic review to investigate the reliability and accuracy of clinical tests for the diagnosis of ankle syndesmosis injury. Few studies were identified and our findings show that clinicians cannot rely on a single test to identify ankle syndesmosis injury with certainty. Additional diagnostic tests, such as MRI, should be considered before making a final diagnosis of syndesmosis injury

Diagnostic imaging of ankle syndesmosis injuries: A general review John J Kellett  et al 2018

Find article here J Med Imaging Radiat Oncol. 2018 Apr;62(2):159-168.doi: 10.1111/1754-9485.12708. Epub 2018 Feb 5. Abstract Literature on the various techniques for imaging injuries to the ankle syndesmosis to determine the most appropriate imaging modality for diagnosing syndesmosis ligament disruption and instability was reviewed using the following data sources: Pubmed, Google scholar, SportsDiscus, E-journals and PLOSone. Search terms used were: syndesmosis paired with injury, imaging, radiology, X-ray, stress X-ray, arthrography, ultrasound, nuclear medicine scan, CT scan, MRI and arthroscopy. Articles were selected by reading abstracts and the full article if indicated. Further articles were derived from the references of the primary articles. Plain x-rays of the ankle will detect approximately half on AP view to two-thirds on mortise view of syndesmosis injuries. Syndesmosis injuries frequently occur in association with tibial or fibular fractures. Intra-operative stress radiography failed to detect approximately half of instabilities confirmed at arthroscopy. The current benchmark imaging techniques to diagnose syndesmosis injury and diastasis are arthroscopy and high-power (3T) MRI. Ultrasound is a promising, developing, cost-effective imaging technique which is yet to reach its full diagnostic potential. CT and nuclear medicine scans have limited roles. MRI (3T) scanning in the plane of the syndesmotic ligaments is the investigation of choice to detect ankle syndesmosis injuries. In the presence of associated injuries requiring surgery, arthroscopic viewing with stress examination is the diagnostic benchmark when available.

High Ankle Sprains and Syndesmotic Injuries in Athletes Hunt et al 2015

J Am Acad Orthop Surg. 2015 Nov;23(11):661-73. doi: 10.5435/JAAOS-D-13-00135. Abstract Treatment of athletes with ligamentous injuries of the tibiofibular syndesmosis can be problematic. The paucity of historic data on this topic has resulted in a lack of clear guidelines to aid in imaging and diagnosing the injury, assessing injury severity, and making management decisions. In recent years, research on this topic has included an abundance of epidemiologic, clinical, and basic science investigations of syndesmotic injuries that are purely ligamentous or associated with ankle fracture. Several classification systems can be used to classify ligamentous injury to the syndesmosis. These systems integrate clinical and radiographic findings but do not address the location of the injury or its severity. Injury to the syndesmosis can be purely ligamentous; however, many unstable syndesmotic injuries are associated with fractures. Nonsurgical management can be used for stable ligamentous injuries without frank diastasis, but surgical management, including screw or suture-button fixation, is indicated for fractures with unstable syndesmotic injuries.

Syndesmosis Stabilisation: Screws Versus Flexible Fixation Solan et al. 2017 Foot Ankle Clin. 2017 Mar;22(1):35-63. doi: 10.1016/j.fcl.2016.09.004. Abstract Orthopedic surgery is not short of situations where there is controversy regarding optimum management. Treating ankle syndesmosis injuries is an example where practice varies widely and there are many questions that remain unsatisfactorily answered. When addressing the type of syndesmosis stabilization that is required it is essential to ascertain the extent of instability. Only then can a logical approach to restoring the ankle mortise be achieved. Fixation of fibula shaft fractures and posterior malleolus fractures can restore sufficient stability to render syndesmosis stabilization unnecessary. The indications and techniques for stabilizing the distal tibiofibular joint are reviewed with clinical examples.