Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

What the Syndesmosis Does and How It Gets Injured

The syndesmosis is the ligamentous complex that binds the distal tibia and fibula together, maintaining the critical width of the ankle mortise. It consists of the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), transverse ligament, and the interosseous membrane.

Syndesmosis injuries occur when an external rotation force is applied to a planted foot — the classic mechanism is a tackle from behind in football or a twisting fall in skiing. The talus rotates within the mortise, wedging the tibia and fibula apart and tearing the syndesmotic ligaments.

In our clinic, we see syndesmosis injuries in contact sport athletes, skiers, and as a component of ankle fractures. Approximately 10-20% of all ankle sprains involve some degree of syndesmosis injury, but they are frequently underdiagnosed because initial X-rays may appear normal.

Diagnosis: Why High Ankle Sprains Are Missed

The squeeze test and external rotation test are the primary clinical examinations. Squeezing the tibia and fibula together at mid-calf reproduces pain at the ankle syndesmosis in positive cases. The external rotation test externally rotates the foot with the knee flexed and reproduces syndesmotic pain.

Standard X-rays may show widening of the tibiofibular clear space (greater than 6mm) or decreased tibiofibular overlap (less than 6mm), but many syndesmosis injuries show normal X-rays when the ligaments are partially torn but not completely disrupted.

Weight-bearing CT has emerged as the gold standard for assessing subtle syndesmotic widening and malreduction. We use weight-bearing CT when clinical suspicion is high despite normal X-rays, and for post-operative assessment of reduction quality.

MRI demonstrates the specific ligaments torn (AITFL, PITFL, or both), the degree of interosseous membrane disruption, and concurrent injuries including deltoid ligament tears and osteochondral defects.

Conservative vs Surgical Treatment

Stable syndesmosis injuries — those without tibiofibular widening on weight-bearing imaging — can be managed conservatively with a walking boot for 4-6 weeks, followed by progressive weight-bearing and rehabilitation. Recovery is 2-3 times longer than a lateral ankle sprain.

Unstable injuries with documented widening of the syndesmosis require surgical fixation. Without stabilization, the widened ankle mortise allows abnormal talar motion that rapidly accelerates cartilage damage and arthritis development.

The decision between conservative and surgical management hinges on syndesmotic stability, which is why proper imaging — including stress views or weight-bearing CT — is essential. Treating an unstable syndesmosis conservatively leads to poor outcomes.

Surgical Fixation Options

Syndesmotic screws are the traditional fixation method. One or two screws are placed through the fibula into the tibia, bridging the syndesmosis and holding the bones in their correct position while the ligaments heal. Screw removal at 3-4 months may be necessary.

Suture button devices (TightRope, InternalBrace) provide flexible fixation that allows physiologic motion at the syndesmosis while maintaining reduction. Unlike rigid screws, suture buttons typically do not require removal surgery and may allow earlier return to activity.

The trend in our practice has shifted toward suture button fixation for isolated syndesmosis injuries because it eliminates the need for hardware removal surgery, allows earlier ankle motion, and produces equivalent or superior outcomes to screws in recent studies.

When syndesmosis injury accompanies an ankle fracture, the fracture is fixed first with standard ORIF techniques, and the syndesmosis is assessed intraoperatively. If unstable after fracture fixation, syndesmotic fixation is added.

Recovery and Return to Sport

Weeks 0-2: Non-weight-bearing in a splint. Suture button patients may begin gentle ankle range of motion earlier than screw patients.

Weeks 2-6: Progressive weight-bearing in a boot. Physical therapy begins with ankle mobility, progressing to light strengthening.

Weeks 6-12: Transition to supportive shoes with an ankle brace. Functional rehabilitation with sport-specific exercises. Screw removal surgery, if needed, typically occurs around week 12-16.

Months 3-6: Gradual return to full sport participation. Most athletes return to competitive sport at 4-6 months. The syndesmosis should be fully healed on imaging before clearance for contact sports.

Doctor Hoy’s gel manages residual inflammation throughout rehabilitation, and PowerStep Pinnacle insoles provide ankle stability support during the return-to-activity phase.

In-Office Treatment at Balance Foot & Ankle

Dr. Tom Biernacki performs syndesmotic fixation using both screw and suture button techniques, selecting the optimal approach based on injury pattern and patient factors. Our weight-bearing CT imaging provides precise pre- and post-operative syndesmosis assessment.

Same-day appointments available. Call (810) 206-1402 or visit michiganfootdoctors.com/book-appointment/ to schedule.

The Most Common Mistake We See

The most common mistake is treating a high ankle sprain like a regular ankle sprain with the same 2-4 week recovery expectation. Syndesmosis injuries take 2-3 times longer than lateral sprains to heal, and rushing return to activity before the ligaments have healed risks chronic instability and arthritis.

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In-Office Treatment at Balance Foot & Ankle

Our team provides sport-specific evaluation and treatment to get you back to your activity safely. We offer same-day X-ray, in-office ultrasound, and custom orthotic fabrication.

Same-day appointments available. Call (810) 206-1402 or book online.

Frequently Asked Questions

What is a syndesmosis injury?

A syndesmosis injury (high ankle sprain) tears the ligaments connecting the tibia and fibula above the ankle joint. It is more severe than a lateral ankle sprain, takes longer to heal, and may require surgical fixation if the ankle mortise is widened.

How long does a high ankle sprain take to heal?

Conservative treatment takes 6-12 weeks with a boot and rehabilitation. Surgical fixation patients typically return to activity at 3-6 months. Recovery is 2-3 times longer than a standard lateral ankle sprain.

Do syndesmosis screws need to be removed?

Traditional syndesmosis screws may need removal at 3-4 months to restore normal tibiofibular motion. Suture button devices typically do not require removal and allow earlier physiologic motion.

Does insurance cover syndesmosis surgery?

Yes, syndesmotic fixation is covered as a medically necessary surgical procedure. The evaluation, imaging, surgery, hardware, and rehabilitation are all covered under surgical benefits.

The Bottom Line

High ankle sprains are among the most underdiagnosed ankle injuries. If your ankle sprain is taking much longer to heal than expected, or you have pain above the ankle joint rather than below it, you may have a syndesmosis injury that needs different treatment.

Sources

1. Clanton TO, et al. Syndesmosis injuries in athletes. Foot Ankle Int. 2025;46(2):88-99.
2. van den Bekerom MP, et al. Diagnosing syndesmotic instability in ankle fractures. BMC Musculoskelet Disord. 2013;14(1):45.

High Ankle Sprain Surgery in Michigan

Syndesmotic (high ankle) sprains are more severe than typical ankle sprains and often require surgical fixation to restore ankle stability. Board-certified podiatric surgeon Dr. Tom Biernacki performs syndesmotic fixation using both suture button and screw techniques at Balance Foot & Ankle.

Learn About Our Ankle Surgery Options | Book Your Appointment | Call (810) 206-1402

Clinical References

1. Dattani R, et al. Injuries to the tibiofibular syndesmosis. Journal of Bone and Joint Surgery British. 2008;90(4):405-410.
2. Naqvi GA, et al. Fixation of ankle syndesmosis injuries: comparison of TightRope fixation and syndesmotic screw fixation. American Journal of Sports Medicine. 2012;40(12):2828-2835.
3. Hunt KJ, et al. High ankle sprains and syndesmotic injuries in athletes. Journal of the American Academy of Orthopaedic Surgeons. 2015;23(11):661-673.