Medically reviewed by Dr. Tom Biernacki, DPM
Board-certified podiatric surgeon | Balance Foot & Ankle, Howell & Bloomfield Hills, MI
Last reviewed: May 2026
Balance Foot & Ankle offers same-day appointments for urgent foot and ankle conditions across Southeast Michigan — but the most important factor in outcomes isn’t getting seen quickly. Our podiatrists explain what to do in the first 24-48 hours before your appointment that most patients skip entirely. Call (810) 206-1402 — expert podiatric care across Michigan.
| West Point Grade | Ligaments Involved | Diastasis on X-ray | Treatment |
|---|---|---|---|
| Grade I (Sprain) | AITFL partial; PITFL intact; IOM intact | None (<5mm tibiofibular clear space) | NWB boot 3–6 weeks → PT; no surgery |
| Grade II (Partial disruption) | AITFL complete; PITFL partial; IOM intact | Borderline (5–6mm); stress views diagnostic | Boot NWB 6 weeks; surgery if stress X-ray shows instability |
| Grade III (Complete disruption) | AITFL + PITFL + IOM all disrupted | Clear (>6mm tibiofibular clear space; >5mm medial clear space) | Surgical fixation: suture-button (TightRope) or syndesmotic screw |
| Fixation Method | Advantage | Disadvantage | Hardware Removal | Return to Sport |
|---|---|---|---|---|
| Syndesmotic Screw (traditional) | Rigid fixation; cost-effective; well-studied | Limits physiologic fibular motion; must be removed before full activity | Required at 8–12 weeks | 4–6 months |
| Suture-Button (TightRope) | Dynamic fixation; allows physiologic motion; no mandatory removal | Higher cost; risk of fibular malreduction if technique imperfect | Usually not required | 3–5 months |
| Arthroscopic-assisted reduction | Direct visualization ensures anatomic reduction | Adds OR time; requires arthroscopy skill | N/A (technique only) | 3–5 months |
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Medically Reviewed | Dr. Tom Biernacki, DPM | Board-Certified Podiatric Surgeon | Balance Foot & Ankle, Michigan
What Is a Syndesmosis Injury?
The ankle syndesmosis is the fibrous joint that connects the distal tibia and fibula just above the ankle joint. It is stabilized by four ligaments: the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), the interosseous ligament (IOL), and the interosseous membrane. Together, these structures maintain the precise anatomical relationship between the tibia and fibula that allows the ankle mortise to function as a stable, congruent joint.
A syndesmotic injury — commonly called a “high ankle sprain” because the pain is above the ankle joint rather than below it — occurs when these ligaments are stretched, partially torn, or completely disrupted. Unlike typical lateral ankle sprains (which involve the ATFL and CFL below the joint), syndesmosis injuries are more serious, take significantly longer to heal, and can result in chronic ankle instability and early arthritis if diagnosed late or treated inadequately.
At Balance Foot & Ankle, Dr. Tom Biernacki provides expert assessment of syndesmosis injuries using stress radiographs and MRI, grades injury severity accurately, and provides definitive treatment — including surgical fixation for unstable injuries — that restores ankle stability and prevents chronic complications.
Mechanism of Syndesmosis Injury
Syndesmotic injuries typically result from:
- External rotation of the foot with a planted foot: The classic mechanism — the foot is fixed to the ground and the body rotates externally, creating rotational stress at the ankle that tears the syndesmotic ligaments.
- Hyperdorsiflexion: Extreme upward ankle movement widens the mortise, stressing the syndesmosis.
- High-energy trauma: Severe ankle fractures (Maisonneuve fracture with spiral fibula fracture, bimalleolar fractures) commonly involve syndesmotic disruption.
Sports with high syndesmosis injury rates include football, soccer, basketball, skiing, wrestling, and any contact or cutting sport. The injury can occur without fracture — sometimes with minimal swelling that belies the severity of ligamentous disruption.
High Ankle Sprain vs. Lateral Ankle Sprain
Distinguishing syndesmosis injuries from lateral ankle sprains is critical because management differs substantially:
| Feature | Lateral Ankle Sprain | High Ankle Sprain |
|---|---|---|
| Pain location | Below lateral malleolus | Above ankle joint, anterolateral |
| Swelling pattern | Below and around lateral malleolus | More proximal, less dramatic |
| Recovery time | 1–6 weeks | 6–12+ weeks (non-surgical), longer surgical |
| Key tests | Anterior drawer test | Squeeze test, external rotation stress test |
Diagnosing Syndesmosis Injuries
Clinical tests: The squeeze test (compressing the fibula and tibia at mid-calf reproduces ankle pain), external rotation stress test (external rotation of the foot with the knee flexed produces pain at the syndesmosis), and palpation tenderness along the anterior syndesmosis are the key clinical tests. Any positive stress test in an ankle injury patient should prompt imaging evaluation.
Weight-bearing X-rays: Measure tibiofibular clear space and tibiofibular overlap on the mortise view. Widening of the clear space (>5mm) or loss of tibiofibular overlap indicates frank syndesmotic instability — a surgical indication.
Stress radiographs: An external rotation stress view with fluoroscopy can unmask dynamic syndesmotic instability that is not evident on static weight-bearing films.
MRI: The most sensitive study for syndesmotic ligament injury — demonstrates partial vs. complete tears of the AITFL, PITFL, and interosseous membrane, and identifies associated chondral and bone injuries.
Conservative Treatment — Stable Syndesmosis Injuries
Stable syndesmosis injuries (intact mortise on stress views, complete AITFL tear without IOL/PITFL involvement) are managed non-operatively with 4–8 weeks in a walking boot, followed by progressive rehabilitation with proprioceptive and peroneal strengthening. Return to sport is guided by resolution of squeeze test pain and restored function — typically 6–12 weeks for high-level athletes.
Surgical Treatment — Unstable Syndesmosis Injuries
Unstable syndesmosis injuries (widened mortise on stress views) require surgical fixation. Dr. Biernacki performs direct arthroscopic-assisted reduction and fixation with syndesmotic screws or suture-button (TightRope) devices. The suture-button construct provides more physiologic syndesmotic motion than rigid screws and has become increasingly preferred in athletic patients.
Dr. Tom's Product Recommendations
Aircast AirSelect Elite Walking Boot
⭐ Highly Rated
Pneumatic walking boot providing circumferential support for high ankle sprain management. The air cell compression system accommodates swelling while maintaining excellent fixation — commonly used for syndesmotic injury immobilization.
Dr. Tom says: “”My podiatrist put me in this boot for my high ankle sprain. The air cells let me adjust compression as swelling changed and the rigid support kept my ankle stable while the syndesmosis healed.””
Syndesmosis injury immobilization, high ankle sprain protection
Use under physician supervision — syndesmotic injuries vary widely in severity
Disclosure: We earn a commission at no extra cost to you.
BioSkin TriLok Ankle Brace
⭐ Highly Rated
Low-profile ankle brace with figure-8 lacing providing both lateral and syndesmotic support. Appropriate for return-to-sport after syndesmosis healing, providing residual joint protection.
Dr. Tom says: “”After my high ankle sprain healed and I came out of the boot, my podiatrist recommended this brace for return to soccer. It provides real support without the bulk of a hard brace.””
Return to sport after syndesmosis injury, ongoing ankle support
Transitional brace — not for acute phase before healing is confirmed
Disclosure: We earn a commission at no extra cost to you.
✅ Pros / Benefits
- Accurate grading of syndesmosis injury severity guides treatment — preventing undertreated unstable injuries from developing chronic problems
- Suture-button fixation for unstable syndesmosis allows more physiologic ankle motion and excellent athletic return-to-sport outcomes
- MRI-guided diagnosis identifies chondral and osteochondral injuries often associated with syndesmotic trauma
❌ Cons / Risks
- High ankle sprains take 2–3 times longer to recover from than lateral ankle sprains — requiring patience from athletes
- Missed syndesmosis instability leads to chronic anterior ankle pain, subtle instability, and early arthritis if untreated
- Surgical syndesmotic fixation requires significant rehabilitation and carries risk of hardware complications (loose or broken screws)
Dr. Tom Biernacki’s Recommendation
High ankle sprains are the most commonly under-treated significant ankle injury I see. Athletes come in having been told to ‘walk it off’ after a high mechanism sprain that was actually an unstable syndesmosis. Three months later they’re still not right and the imaging shows a widely separated mortise. The key is stress testing and stress views at the first evaluation — if the mortise is unstable, surgery is the right answer, and doing it early leads to much better outcomes than doing it after months of failed conservative treatment.
— Dr. Tom Biernacki, DPM | Board-Certified Podiatric Surgeon | Balance Foot & Ankle
Frequently Asked Questions
How long does a high ankle sprain take to heal?
Stable high ankle sprains take 6–12 weeks for most athletes to return to full sport participation — significantly longer than the 2–4 weeks typical for lateral ankle sprains. Unstable injuries requiring surgical fixation require 4–6 months for complete recovery and return to full athletic activity.
Do I need surgery for a high ankle sprain?
It depends on whether the ankle mortise is stable. Stable syndesmosis injuries (intact on stress testing) heal with immobilization and rehabilitation. Unstable injuries — where the mortise widens under stress — require surgical fixation for reliable healing. Dr. Biernacki performs stress X-rays at the first evaluation to make this determination.
Can a high ankle sprain heal completely?
Yes — with appropriate treatment, the vast majority of syndesmosis injuries heal completely. Stable injuries managed conservatively have excellent outcomes. Surgical cases also achieve high rates of full recovery. The key is accurate diagnosis and not allowing an unstable injury to heal in a widened position.
What is the difference between a high ankle sprain and a broken ankle?
Both can involve the syndesmosis. A Maisonneuve fracture is a specific injury pattern where the syndesmosis is disrupted along with a proximal fibular fracture — it can be missed on ankle X-rays if the fibula is not fully imaged. Any ankle injury with significant tenderness along the full length of the fibula should prompt knee-to-ankle X-rays to evaluate for this fracture pattern.
What is a TightRope syndesmosis repair?
The TightRope (suture-button) device is a modern alternative to traditional syndesmotic screws. It consists of small buttons on the tibia and fibula connected by a high-strength suture, providing dynamic fixation that allows slight physiologic movement (as opposed to rigid screw fixation). Studies show equivalent or better outcomes to screws with the advantage of not requiring routine removal hardware removal.
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When should I see a podiatrist?
If symptoms persist past 2 weeks, affect your normal activity, or are accompanied by red-flag symptoms (warmth, redness, swelling, inability to bear weight).
What does treatment cost?
Most diagnostic visits and conservative treatments are covered by Medicare and major insurers. Out-of-pocket costs vary by your specific plan.
How quickly can I get an appointment?
Most non-urgent cases see us within 5 business days. Urgent cases (sudden pain, possible fracture) typically same or next business day.
Visit Balance Foot & Ankle — Same-Day Appointments Available
Our podiatry team serves patients throughout Michigan including Howell, Brighton, and Bloomfield Hills. Whether you’re dealing with heel pain, ingrown toenails, or a foot injury, we have same-day appointment availability.
American Academy of Orthopaedic Surgeons: High Ankle Sprain (Syndesmosis)
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Dr. Tom Biernacki, DPM is a board-certified foot & ankle surgeon (ABFAS & ABPM) 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 made him one of the most-followed foot & ankle educators on YouTube.