Medically Reviewed | Dr. Tom Biernacki, DPM | Board-Certified Podiatric Surgeon | Balance Foot & Ankle, Michigan
Quick Answer:
Quick Answer: A syndesmosis injury (high ankle sprain) involves the ligaments connecting the tibia and fibula above the ankle joint. These injuries are frequently misdiagnosed as routine ankle sprains but require different treatment and have longer recovery timelines. Dr. Biernacki at Balance Foot & Ankle provides expert syndesmosis evaluation and treatment in Michigan, including suture-button fixation when needed.
Not all ankle sprains are created equal. While the common low ankle sprain involves the lateral ligaments (ATFL, CFL), a syndesmosis injury—often called a high ankle sprain—involves the ligaments that bind the tibia and fibula together above the ankle joint. Syndesmosis injuries are frequently misdiagnosed as standard sprains, leading to inadequate treatment, prolonged recovery, and chronic instability. At Balance Foot & Ankle, Dr. Tom Biernacki provides expert syndesmosis evaluation and management for Michigan patients from initial diagnosis through return to activity.
The Ankle Syndesmosis: Anatomy
The distal tibiofibular syndesmosis is a fibrous joint complex maintaining the mortise—the socket that houses the talus. It consists of four primary structures: the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), the interosseous ligament (IOL), and the interosseous membrane. The syndesmosis allows slight spreading of the fibula during normal ankle dorsiflexion. When syndesmosis ligaments are disrupted, the mortise can widen—a catastrophic event for ankle joint mechanics that must be identified and addressed.
How Syndesmosis Injuries Occur
Syndesmosis injuries typically result from external rotation and dorsiflexion mechanisms—the foot planted and externally rotated while the body rotates over it. Football tackles, soccer slide tackles, skiing, and wrestling are common mechanisms. Ankle fractures (particularly Weber B and C fibula fractures) frequently accompany syndesmotic disruption and must be assessed together. The “cleat” mechanism—cleated shoe fixed to turf while the body rotates—is the classic sports injury scenario.
Diagnosis: Why High Ankle Sprains Are Missed
Syndesmosis injuries present with tenderness above and anterior to the lateral malleolus, pain with external rotation stress testing (Kleiger test), and a positive squeeze test (pain with fibula and tibia compression proximal to the ankle). The Cotton test assesses fibular translation under fluoroscopy or with stress X-rays. The injury is frequently missed because patients present with lateral ankle pain—similar to a common sprain—but the mechanism, anatomic tenderness location, and provocative tests reveal the syndesmosis as the primary structure. MRI provides definitive visualization of ligament disruption status and degree.
Classification and Treatment
Stable syndesmosis injuries (ligament sprain without diastasis) are treated non-operatively: protected weight-bearing in a boot for 4–6 weeks, followed by progressive rehabilitation. Recovery is typically longer than a standard ankle sprain—4–8 weeks to return to sport compared to 1–3 weeks for a grade I low ankle sprain. Unstable syndesmosis injuries with fibular diastasis (mortise widening) require surgical stabilization. Suture-button fixation (TightRope or equivalent) is the modern surgical standard—flexible fixation allowing physiologic fibular motion while maintaining reduction, with superior outcomes to rigid screw fixation that required removal. Hardware removal is generally not needed with suture-button devices.
Return to Sport
Stable syndesmosis sprains treated non-operatively require 6–10 weeks before return to competitive sport—substantially longer than lateral ligament sprains. Operatively treated injuries require 3–4 months post-surgery. Premature return to sport risks chronic syndesmotic instability, accelerated ankle arthritis, and recurrent injury. Dr. Biernacki uses objective functional testing—single-leg balance, hop tests, sport-specific agility—rather than time alone to clear athletes for return.
Dr. Tom's Product Recommendations
Ossur Formfit Walker Boot for Ankle Immobilization
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Semi-rigid walking boot for immobilization during stable syndesmosis sprain recovery. Restricts dorsiflexion and external rotation stress on healing syndesmotic ligaments.
Dr. Tom says: “My high ankle sprain needed more than an ankle brace. The boot Dr. Biernacki prescribed restricted the rotation that kept re-injuring me.”
Stable syndesmosis sprains, protected weight-bearing during acute recovery phase
Unstable syndesmosis with diastasis—requires surgical stabilization, not boot alone
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ASO Ankle Stabilizing Orthosis Brace
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Functional ankle brace for return-to-sport phase after syndesmosis injury recovery. Provides external rotation resistance during athletic activity.
Dr. Tom says: “My athletic trainer recommended this brace for return to soccer after my high ankle sprain. The external rotation support made me feel secure.”
Return-to-sport phase after stable syndesmosis injury, sports with rotation demands
Acute syndesmosis injury or post-operative period (requires boot/cast)
Disclosure: We earn a commission at no extra cost to you.
✅ Pros / Benefits
- Accurate early diagnosis prevents the chronic syndesmotic instability that results from missed or undertreated injuries
- Suture-button fixation eliminates the second surgery previously required for screw removal
- Objective return-to-sport testing prevents premature athletic clearance that risks re-injury
❌ Cons / Risks
- Recovery is substantially longer than lateral ankle sprains—athletes must resist pressure to return too quickly
- Unstable injuries require surgery—patients hoping for non-operative management of diastasis have poor outcomes without fixation
- Chronic missed syndesmosis injuries may develop ankle arthritis requiring long-term management
Dr. Tom Biernacki’s Recommendation
High ankle sprains are one of the most important diagnoses in sports podiatry to get right—and one of the most commonly missed. I’ve seen athletes treated for ‘bad ankle sprains’ for months before someone finally examines the syndesmosis carefully and finds the real problem. The external rotation stress test, squeeze test, and precise tenderness mapping take 60 seconds—but they completely change the diagnosis and treatment plan. When an athlete presents with an ankle injury and the mechanism was external rotation or there’s tenderness proximal to the fibula tip, my syndesmosis alarm goes off immediately.
— Dr. Tom Biernacki, DPM | Board-Certified Podiatric Surgeon | Balance Foot & Ankle
Frequently Asked Questions
How do I know if I have a high ankle sprain vs. a regular ankle sprain?
High ankle sprains involve tenderness anterior and proximal to the lateral malleolus (above and in front of the outside ankle bone), pain with external rotation of the foot, and a positive squeeze test (pain when tibia and fibula are compressed together higher up the leg). Regular ankle sprains have tenderness directly over the lateral malleolus ligaments and pain with inversion. A physician examination and weight-bearing X-rays are needed to confirm.
How long does a high ankle sprain take to heal?
Stable syndesmosis sprains (no diastasis) typically require 6–10 weeks before return to competitive sport with appropriate rehabilitation. This is significantly longer than the 1–4 weeks of typical lateral ankle sprains. Surgical cases require 3–4 months post-fixation. Rushing return increases chronic instability risk substantially.
Do I need surgery for a high ankle sprain?
Surgery is required for syndesmosis injuries with documented diastasis (widening of the tibiofibular joint) on stress X-rays or Cotton test. Stable injuries without diastasis are treated non-operatively with protected weight-bearing. Dr. Biernacki performs stress radiograph evaluation to definitively classify stability before recommending surgical versus conservative management.
What is suture-button fixation for syndesmosis repair?
Suture-button fixation (TightRope or equivalent) uses flexible endobuttons connected by high-strength suture passed through drill holes in the tibia and fibula. Unlike screws, suture-buttons allow physiologic fibular motion during ankle function while maintaining syndesmotic reduction. They do not require removal surgery, and outcomes are equivalent or superior to screw fixation with fewer complications.
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Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.
- Diagnosis and Treatment of Plantar Fasciitis (PubMed / AAFP)
- Heel Pain (APMA)
- Hallux Valgus (Bunions): Evaluation and Management (PubMed)
- Bunions (Mayo Clinic)
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