Understanding Syndesmotic Injury: Symptoms, Diagnosis, and Treatment Options

When you injure your ankle, it’s easy to assume it’s just a simple sprain. But sometimes, the damage runs deeper — especially if the injury involves the syndesmosis, the strong ligaments that connect your tibia and fibula (the two long bones in your lower leg).

A Syndesmotic injury, often called a “high ankle sprain,” is a more complex type of ankle injury that requires careful diagnosis and, in many cases, specialized treatment. Understanding this condition early — and getting the right care — is key to protecting your ankle’s long-term stability and function.

What Is a Syndesmotic Injury?

The syndesmosis is a group of tough ligaments located just above the ankle joint. These ligaments keep the tibia and fibula properly aligned when you walk, run, or pivot.

When the syndesmosis is stretched or torn — usually from a twisting injury, sports accident, or trauma such as a fall or car accident — the ankle joint becomes unstable. This instability can make it difficult to bear weight or move your foot normally.

Unlike a regular ankle sprain, a Syndesmotic injury often involves more significant damage and can take longer to heal. Left untreated, it can lead to chronic pain, arthritis, or long-term loss of function.

Common Symptoms of a Syndesmotic Injury

People with a Syndesmotic injury often describe their symptoms as more severe than a typical ankle sprain. You may notice:

• Pain above the ankle joint — especially between the tibia and fibula
  
• Swelling or bruising around the front or outer side of the ankle
  
• Difficulty bearing weight or feeling like the ankle “gives way”
  
• Tenderness when the leg is squeezed just above the ankle (a classic sign of syndesmosis injury)
  
• Pain during twisting or outward rotation movements of the foot

If you’ve had a recent ankle injury and these symptoms sound familiar, it’s important to see an orthopedic specialist as soon as possible. Early evaluation prevents long-term damage and ensures you receive the most effective Syndesmotic injury treatment.

How a Syndesmotic Injury Is Diagnosed

Diagnosis usually begins with a thorough physical examination. Your orthopedic surgeon will gently press around the ankle and leg, checking for areas of tenderness, swelling, or instability.

Physical Tests

Certain maneuvers help identify syndesmotic involvement, such as the squeeze test (compressing the leg bones together) or the external rotation test, which can reproduce the pain if the syndesmosis is injured.

Imaging Tests

To confirm the diagnosis, your doctor may order:

• X-rays – to look for widening between the tibia and fibula or associated fractures
  
• MRI scan – to visualize the ligaments and soft tissues in detail
  
• CT scan – in more complex cases, to assess alignment and bone injury

These tools help your surgeon determine how severe the injury is and whether the syndesmosis is unstable — an important factor in deciding whether surgery is necessary.

Treatment Options for Syndesmotic Injury

Treatment depends on the severity of the ligament damage and whether the ankle joint remains stable.

Non-Surgical Treatments

For mild injuries where the bones remain properly aligned, treatment usually involves:

• Rest, ice, compression, and elevation (RICE)
  
• A supportive boot or brace to limit motion
  
• Physical therapy to restore strength and flexibility

Most patients with mild syndesmotic sprains recover well within 6–8 weeks.

However, when the syndesmosis is significantly torn or unstable, surgical treatment provides the best chance for full recovery and long-term ankle stability.

Surgical Treatment: ORIF of Ankle Syndesmosis +/- Tightrope Fixation

When the syndesmotic ligaments are severely damaged, the tibia and fibula can separate slightly — disrupting the alignment of the ankle joint. In these cases, surgery called ORIF (Open Reduction and Internal Fixation) is often recommended to restore normal anatomy and stability.

What Is ORIF of Ankle Syndesmosis?

ORIF stands for “Open Reduction and Internal Fixation.”

• Open Reduction means your surgeon carefully repositions the bones into their proper alignment.
  
• Internal Fixation involves securing the bones together with small screws or a Tightrope fixation system — a modern device that holds the bones together while allowing slight natural movement.

What Is Tightrope Fixation?

The Tightrope fixation uses strong, flexible suture material instead of rigid screws. It stabilizes the syndesmosis while allowing the bones to move normally during healing — which may improve comfort and speed up recovery.

Many surgeons combine ORIF with Tightrope fixation to achieve both strength and flexibility during the healing process.

Benefits of ORIF of Ankle Syndesmosis +/- Tightrope Fixation

This procedure has become the gold standard for treating unstable syndesmotic injuries because it:

• Restores ankle stability and alignment
• Prevents long-term complications such as arthritis or chronic pain
• Allows earlier rehabilitation compared to older screw-only methods
• Has a high success rate, with most patients returning to normal activities and sports

Research shows that patients who undergo ORIF with Tightrope fixation often experience excellent functional outcomes, minimal pain, and long-term joint stability.

When to See an Orthopedic Specialist

If you’ve had a recent ankle injury and your pain feels worse than a typical sprain, don’t wait. A Syndesmotic injury can be subtle on X-rays but serious in its impact. The sooner it’s evaluated by an orthopedic specialist, the better your chances for a complete and lasting recovery.

The Bottom Line

A Syndesmotic injury may sound complicated, but with modern techniques like ORIF of Ankle Syndesmosis +/- Tightrope Fixation, patients can expect excellent outcomes. Early diagnosis, expert surgical care, and guided rehabilitation make all the difference in getting you back to your normal, active lifestyle.

If you’ve been diagnosed with a Syndesmotic injury — or suspect you might have one — schedule a consultation with your local orthopedic specialist today. With the right treatment, your ankle can heal strong, stable, and ready to move again.