Syndesmosis Injury (High Ankle Sprain)

A high ankle sprain composes an injury to the ligaments above the ankle. These ligaments connect your tibia (shin bone) to your fibula (outside shin bone). The main ligament that connects these two bones is called the Syndesmosis ligament

If you have a high ankle sprain, recovery will take a while longer than a normal ankle sprain and be more disabling. It is essential to be diagnosed and managed well in the early stages so that you can return to your desired activity quicker.


A Syndesmosis injury most commonly occurs when your foot is planted on the ground and then an external twisting of your foot occurs.

High ankle ligaments can also sprain when your foot goes into severe dorsiflexion.


Symptoms will vary pending the degree of injury: Mild, Moderate, Severe

  • You have a history of traumatic injury to the ankle
  • There is increasing pain as you turn your foot outwards
  • Pain with walking and some bruising / swelling above the ankle
  • You are unable to do a single leg calf raise


Your physiotherapist will assess your ankle ligaments integrity. If a high ankle sprain is suspected a weight bearing XRAY & MRI can confirm diagnosis

Syndesmosis (High Ankle Sprain) Treatment

Syndesmosis (High Ankle Sprain) Treatment

Medical Management

The treatment of a high ankle sprain will depend on the degree of injury. If you have a high-grade injury with a mild widening between the tibia and fibula your foot will be immobilised. This requires a boot for 4-8 week pending on pain, recovery & time to diagnosis.

A higher-grade injury excluding a fracture will recommend an orthopaedic review. If there is a degree of instability and a significant widening between the two shin bones than surgery may be required. With surgery, pins may be put in place to allow the ligament to have a better healing capacity.

Physiotherapy Treatment Progressions

There is no specific time frame for when to progress from each stage to the next. Your injury rehabilitation will be determined by goals set between phases. As you improve you will progress from phase to phase.

Phase 1 – Injury Protection: Pain Relief & Anti-inflammatory Tips

As with most soft tissue injuries the initial treatment is RICE – Rest, Ice, Compression and Elevation.

(Active) Rest

In the early phase you’ll most likely be unable to walk on your sprained ankle. Herre you will limit any movements that cause pain. This may include a phase of non-weight bearing in a brace with crutches.

Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot.

Compression: A compression bandage to both support the injured soft tissue and reduce excessive swelling.

Elevation: Elevating your injured ankle above your heart will assist gravity to reduce excessive swelling around your ankle.

Anti-inflammatory medication -it is best to avoid anti-inflammatory drugs during the initial 48 to 72 hours. They may encourage additional bleeding. Most people can tolerate paracetamol as a pain reliever.

Phase 2: Regain Full Range of Motion

If you protect your injured ankle ligaments appropriately the torn ligaments will successfully reattach and heal a normal functional length. Mature scar formation takes at least six weeks.

It is important to begin exercises at this time to improve range of motion. Just as importantly, you should not overstretch ligaments and soft tissue, or you may develop a passively unstable ankle. Your physiotherapist will prescribe the exercises that are best suited to your needs.

Phase 3: Restore Muscle Strength

Your calf, ankle and foot muscles will require strengthening after a high ankle sprain. It is important to regain normal muscle strength to provide normal dynamic ankle control and function.

Your strength and power should be gradually progressed from non-weight bear to partial and then full weight bear and resistance loaded exercises. Your physiotherapist will guide you.

Phase 4: Restore High Speed, Power, Proprioception and Agility

Most sprained ankle injuries occur during high-speed activities, which place enormous forces on your ankle and adjacent structures.

Balance and proprioception (the sense of the relative position of neighbouring parts of the body) are both known to be adversely affected by injuries such as a sprained ankle. To prevent a re-injury, both aspects need to be assessed and re-trained.

In order to prevent a recurrence as you return to your sport, your physiotherapist will guide you through exercises to address these important components of rehabilitation to both prevent a recurrence and improve your sporting performance.

Depending on what your sport or lifestyle entails, a speed, agility, proprioception and power program will be customised to prepares you for light sport-specific training.

Phase 6: Return to Sport

If you play sport and depending on the demands of your chosen sport, you may require specific sport-specific exercises and a progressed training regime to enable a safe and injury-free return to your chosen sport. You must be able to hop at least 15 to 20 times pain-free before even considering returning to the sport.

Your physiotherapist will discuss your goals, time frames and training schedules with you to optimise you for a complete and safe return to sport. The perfect outcome will have you performing at full speed, power, agility and function with the added knowledge that a thorough rehabilitation program has minimised your chance of future injury.