Foot & Ankle
Syndesmosis Injury
Non-Operative & Operative management
About Your Injury
The syndesmosis is the strong ligament complex joining the tibia and fibula just above the ankle joint. Injury to this joint (a 'high ankle sprain') can occur alone or alongside an ankle fracture, and often requires more careful assessment than a standard ankle sprain, including stress X-rays or an ankle arthroscopy to confirm stability.
Non-Operative Management
Syndesmosis injuries can often be safely and effectively managed without surgery when confirmed to be stable. This is based on careful clinical examination and review of weight-bearing X-rays. If any concern remains, an MRI is sought. However, the gold standard assessment of syndesmosis injuries is an ankle arthroscopy, and if ongoing concern remains after review of all of the above, this may be recommended.
Recovery Timeline
Weeks 0–2
Boot immobilisation, protected weight-bearing as advised, swelling control.
Weeks 2–6
Gradual increase in weight-bearing and introduction of gentle ankle movement.
Weeks 6–8
Progression to physiotherapy-guided strengthening and balance work.
3–4 months
Return to daily activities and low-impact exercise.
4–6 months
Return to sport, as high ankle sprains typically take longer to fully settle than standard ankle sprains.
Follow-Up Schedule
2 weeks
Clinical review and progression of weight-bearing.
6 weeks
Reassessment of stability and strength.
3 months
Review of return to activity and sport-specific rehabilitation.
Operative Management
Injury to the syndesmosis can occur in isolation, without an accompanying ankle fracture, but still requires careful assessment to confirm instability before surgery is recommended.
The gold-standard test for syndesmosis instability is an ankle arthroscopy, using the "drive-through sign" to directly visualise and probe the joint under anaesthetic. Occasionally, a syndesmosis that looked injured on MRI turns out to be stable when directly examined at arthroscopy — because arthroscopy allows the joint to be physically probed, it is the more reliable of the two. If the joint is confirmed stable, no hardware is placed and no further fixation is needed.
If the arthroscopy confirms instability, the syndesmosis is most commonly reconstructed with one or two suture-button devices ("tightropes"), which allow a small amount of natural give at the joint. In select cases, Dr Hogan may instead opt for one or two screws. This procedure is performed under general anaesthetic, with local anaesthetic infiltration at the time of surgery for good pain control in the first 12–24 hours afterward. It is usually done as day surgery.
Recovery Timeline
Weeks 0–2
Boot, protected and non-weight-bearing while the wound heals.
2 weeks onward
Weight-bearing as tolerated commences in the CAM boot.
6 weeks
X-ray to assess healing; transition out of the boot begins.
3–4 months
A gradual, protocol-based return to sport and heavy activity, guided by a good physiotherapist — high ankle injuries typically take longer to fully settle than a standard ankle sprain.
Follow-Up Schedule
2 weeks
Wound check and the start of weight-bearing in the boot.
6 weeks
X-ray to assess healing and progress weight-bearing.
3–4 months
Review of strength and a gradual, protocol-based return to sport guided by a good physiotherapist.
Hardware Removal
A tightrope device is not routinely removed. If screws were used instead, these are routinely removed at 12 weeks postoperatively to prevent breakage under load.