Syndesmotic Repair Surgery: Treating High Ankle Sprains with TightRope and Screw Fixation

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

Understanding the Syndesmosis

The ankle syndesmosis is the fibrous joint connecting the distal tibia and fibula — the two bones of the lower leg that form the “mortise” of the ankle joint. The syndesmosis is stabilized by four ligaments: the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), the transverse tibiofibular ligament, and the interosseous ligament, which runs the length of the leg between the tibia and fibula. Together, these structures maintain the precise width of the ankle mortise — essential for equal distribution of load across the tibiotalar joint.

A high ankle sprain — correctly termed a syndesmotic sprain — disrupts one or more of these ligaments, potentially widening the mortise and destabilizing the ankle in ways that standard lateral ankle sprains do not.

How High Ankle Sprains Differ from Standard Sprains

Standard lateral ankle sprains — the most common ankle injury — involve the ligaments on the outer side of the ankle (ATFL, CFL). High ankle sprains involve the syndesmotic ligaments above the ankle joint. High ankle sprains typically result from external rotation and dorsiflexion mechanisms — a foot planted while the body rotates externally, as seen in football, skiing, and rugby. The injury mechanism, examination findings, and recovery timeline all differ significantly from lateral ankle sprains.

High ankle sprains are graded by the degree of syndesmotic disruption. Grade I involves AITFL sprain without instability. Grade II involves partial disruption with mild widening. Grade III involves complete syndesmotic disruption with frank instability and mortise widening.

Diagnosis

The squeeze test — compressing the fibula and tibia together at mid-calf — reproduces syndesmotic pain. The external rotation stress test provokes pain at the syndesmosis when the foot is externally rotated while the tibia is stabilized. Weight-bearing X-rays assess mortise width — any widening of the clear space between the medial malleolus and the talus on the mortise view indicates syndesmotic instability. CT scan identifies subtle widening and associated fibular fractures. MRI characterizes ligamentous integrity when X-rays are equivocal.

Non-Operative Management for Stable Injuries

Grade I and some Grade II syndesmotic sprains without mortise widening can be managed non-operatively with immobilization in a boot for four to six weeks followed by progressive rehabilitation. Return to sport from a stable high ankle sprain takes six to twelve weeks — significantly longer than a comparable lateral ankle sprain. Athletes who return too quickly risk developing chronic syndesmotic instability and post-traumatic ankle arthritis.

Surgical Treatment for Unstable Syndesmosis

Traditional Syndesmotic Screw Fixation

One or two large screws are placed across the fibula, through the interosseous membrane, and into the tibia to maintain the reduced syndesmosis while ligamentous healing occurs. The screws are inserted at the level of the tibiotalar joint under fluoroscopic guidance with the ankle in neutral dorsiflexion. Traditional screws are typically removed at eight to twelve weeks, as retained screws across a mobile joint fatigue and break. During the screw removal period, weight-bearing is protected to prevent screw breakage.

Dynamic Fixation: TightRope (Suture Button) Repair

The TightRope construct — a suture button device threaded through drill holes in the fibula and tibia — provides fixation strength comparable to screws while allowing micro-motion at the syndesmosis. This dynamic fixation more closely approximates normal syndesmotic biomechanics than rigid screw fixation and does not require routine hardware removal. Studies comparing TightRope to screw fixation generally show equivalent or superior functional outcomes with TightRope, particularly for athletes who require return to rotational activities.

Direct Ligament Repair

When the AITFL is avulsed with a fibular bony fragment (Tillaux fracture), direct repair or fixation of the fragment is performed in addition to syndesmotic fixation. Primary AITFL suture repair through anchors may be performed alongside bony fixation for complete disruptions in high-demand athletes.

Recovery After Syndesmotic Repair

Non-weight-bearing is maintained for two to four weeks after syndesmotic fixation. Progressive weight-bearing in a boot follows, with transition to regular footwear at six to eight weeks. Athletes undergoing TightRope fixation may avoid screw removal and begin progressive rehabilitation earlier than those with screws. Return to contact sport typically occurs at four to six months. Without appropriate surgical treatment, unstable syndesmotic injuries lead to chronic ankle instability, arthritis, and potentially permanent functional limitation.

Evaluation for Suspected High Ankle Sprain

High ankle sprains are frequently underdiagnosed — the injury mechanism and examination findings distinguish them from lateral sprains, but this distinction requires a knowledgeable examiner and appropriate imaging. If you sustained an ankle injury during external rotation or have persistent ankle pain after a diagnosed “sprain,” contact Balance Foot & Ankle for hands-on exam plus imaging when needed to rule out syndesmotic instability.

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High Ankle Sprain Surgery at Balance Foot & Ankle

Syndesmotic (high ankle) sprains are more severe than typical ankle sprains and may require surgical stabilization. Dr. Tom Biernacki at Balance Foot & Ankle performs tightrope and screw fixation for high ankle sprains at our Howell and Bloomfield Hills offices.

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

Clinical References

1. Nussbaum ED, et al. “Prospective evaluation of syndesmotic ankle sprains without diastasis.” American Journal of Sports Medicine. 2001;29(1):31-35.
2. Cottom JM, et al. “Fixation of syndesmotic disruptions: current evidence and practice.” Foot and Ankle Clinics. 2017;22(1):35-52.
3. Clanton TO, et al. “Acute syndesmosis injury in athletes.” Sports Health. 2014;6(3):227-234.

In-Office Treatment at Balance Foot & Ankle

If home care isn’t resolving your ankle pain, a visit with a board-certified podiatrist is the fastest path to accurate diagnosis and a personalized plan. At Balance Foot & Ankle Specialists, Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin offer same-day and next-day appointments at both our Howell and Bloomfield Hills offices. We perform on-site diagnostic ultrasound, digital X-ray, conservative care, advanced regenerative treatments, and minimally invasive surgery when indicated.

Call (810) 206-1402 or request an appointment online. Most insurance plans accepted, including Medicare, Blue Cross Blue Shield, Aetna, Cigna, and United Healthcare.

Differential Diagnosis: What Else Could It Be?

Several conditions share symptoms with Ankle Sprain and are commonly misdiagnosed in the first office visit. Considering these alternatives is part of every Balance Foot & Ankle exam:

• Peroneal tendon tear. Snapping behind the lateral malleolus or weakness everting the foot.
• High-ankle (syndesmosis) sprain. Pain over the syndesmosis with squeeze + external rotation — needs longer recovery.
• Lateral malleolus fracture. Bone-point tenderness positive on Ottawa rules — get an X-ray.

If your symptoms don’t fit the textbook pattern, ask your podiatrist which differentials they ruled out — that conversation often shortcuts months of trial-and-error treatment.

Most Common Mistake We See

The most common mistake we see is: Returning to sport as soon as the pain resolves. Fix: first pass a 30-second single-leg balance test with eyes closed and complete a graded return-to-sport progression.

Warning Signs That Need Same-Day Care

Dr. Tom’s Top 3 — The Premium Foot Pain Stack (2026)

If you only buy three things for foot pain, get these. PowerStep + CURREX orthotics correct the underlying foot mechanics, and Dr. Hoy’s pain gel delivers fast topical relief. This is the exact stack Dr. Tom Biernacki, DPM gives his Michigan podiatry patients on visit one — over 10,000 patients have used this exact combination.

Frequently Asked Questions

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.

What is Ankle sprain?

Ankle sprain is a common foot/ankle condition that affects mobility and quality of life. Understanding the underlying cause is the first step in successful treatment. Our podiatrists at Balance Foot & Ankle perform a hands-on biomechanical exam, review your activity history, and use diagnostic imaging when appropriate to identify the root cause—not just treat the symptom. Many patients have been told to “rest and ice” without a deeper diagnostic workup; our approach is different.

Symptoms and warning signs

Common signs of ankle sprain include pain that worsens with activity, morning stiffness, swelling, tenderness when palpated, and difficulty bearing weight. If you experience sudden severe pain, inability to walk, visible deformity, numbness or color change, contact our office the same day or visit urgent care—these can signal a more serious injury such as a fracture, tendon rupture, or vascular compromise. Diabetics with any foot wound should seek same-day care.

Conservative treatment options

Most cases of ankle sprain respond to non-surgical care: structured rest, supportive footwear changes, custom orthotics, targeted stretching and strengthening protocols, anti-inflammatory medications when medically appropriate, and in-office procedures such as ultrasound-guided injections. We also offer advanced therapies including MLS laser therapy, EPAT/shockwave, regenerative injections, and image-guided procedures. Treatment is sequenced from least invasive to most invasive, and we explain the rationale at every step.

When is surgery considered?

Surgery is reserved for cases that fail 3-6 months of well-structured conservative care, when there is structural pathology (severe deformity, complete tear, advanced arthritis), or when imaging shows damage that will not heal without intervention. Our surgeons have performed 3,000+ foot and ankle procedures and prioritize minimally-invasive techniques whenever appropriate. We discuss recovery timelines, return-to-activity milestones, and realistic outcome expectations before any procedure is scheduled.

Recovery timeline and prevention

Recovery from ankle sprain varies based on severity and chosen treatment path. Conservative cases often improve within 4-8 weeks with consistent adherence to the protocol. Post-procedural recovery may range from a few days (in-office procedures) to several months (reconstructive surgery). Long-term prevention involves footwear assessment, activity modification, structured strengthening, and regular check-ins with your podiatrist if you have a history of recurrence. We provide written home-exercise plans and digital follow-up support.