Ankle syndesmosis sprain

An ankle syndesmosis injury (ASSI) involves the ligaments of the distal tibiofibular syndesmosis, which is formed by the distal portions of the tibia and fibula. Injuries can occur with any movement of the ankle, but the most common movements are excessive external rotation or dorsiflexion of the talus.

Lateral malleolus ligaments

The dome of the talus is wider at the front, and these movements push the tibia and fibula apart. Sufficiently large separation of the distal tibiofibular bones can cause sprain or rupture of one or more of the ligaments: the anterior inferior tibiofibular ligament, the superficial posterior inferior tibiofibular ligament, the transverse tibiofibular ligament, the interosseous membrane, the interosseous ligament, and the inferior transverse ligament. Ligamentous injuries are also commonly associated with a fracture of either the malleolus (lateral malleolus fracture is the most common) or a fracture (Maissonneuve spiral fracture) of the proximal fibula.

Medial ankle ligaments

Epidemiology/Etiology

RSGS usually occurs in athletes involved in American football and alpine skiing. Football injuries typically result from forced external rotation of the foot while the athlete is lying face down. Injuries can also result from a lateral impact to the knee while the foot is planted on the ground and in dorsiflexion, resulting in an eversion or external rotation moment at the ankle joint.

You can read more about ankle syndesmosis here.

When skiing downhill, bindings limit dorsi- or plantar flexion of the foot, which can lead to excessive external rotation of the ankle joint and injury to the anterior or posterior tibiofibular ligaments, as well as the interosseous membrane. Research suggests that ankle syndesmosis injuries account for 1-11% of all injuries. The incidence among professional American football players has been reported to be much higher, up to 29%, as described by Boytim et al.

Features of syndesmosis injuries

Tibiofibular syndesmosis rupture usually occurs during sports involving running and jumping. Injury can occur as a result of running on uneven surfaces or wearing high heels. More often than others, ballet and circus performers encounter this type of damage.

Articulation rupture occurs in 13% of cases of ankle fractures and in 0.5% of cases of injury to the ligamentous apparatus of the ankle joint.

Injury to the claviosternal syndesmosis is a consequence of a direct blow to the shoulder girdle. Quite often it is not accompanied by a fracture of the collarbone.

Dehiscence of the sutures of the skull bones occurs with traumatic brain injuries.

Damage to the spinal ligaments is a consequence of microtraumas received during work (working in an inclined position, lifting weights) or as a result of playing sports associated with power loads. Incorrect posture, prolonged sitting or standing, and excess weight also have a detrimental effect on the ligaments.

Characteristics/Clinical picture

It has been noted that damage to the ankle syndesmosis is accompanied by less swelling than a sprain of the lateral malleolus, as well as severe limitation of plantar flexion and inability to put weight on the foot. Ecchymosis may appear several days after injury due to damage to the interosseous membrane. Difficulty or inability to walk on toes is often noted. History: chronic pain, long recovery, recurrent sprains, formation of heterotopic ossification within the interosseous membrane. The most common mechanisms are when the leg is in external rotation and excessive dorsiflexion.

Degenerative lesions look like this in stages:

the amount of moisture in the cartilage decreases - it loses functionality;
chondrocytes in cartilage tissue partially die and are not restored;
the amount of protein glycons decreases – mainly chondroitin;
blood circulation in the articular ends of bones is impaired;
the biochemical composition of the synovial fluid changes;
cartilage experiences even more moisture deficiency, loses elasticity, and becomes less stable;
in the joint the balance of damage and recovery processes is disturbed - in the direction of damage;
degenerative lesions start – arthrosis begins.

The whole process takes years. A person has no idea that his joints are damaged and deteriorating. At certain stages, it is still possible to stop the destruction and restore the water balance with the help of a synovial fluid prosthesis. Sometimes it is enough to increase your daily water intake to normal. But, if arthrosis has already been diagnosed, treatment cannot be avoided.

Every glass of beer instead of a glass of clean water is another step towards arthrosis

Differential diagnosis

During clinical evaluation, it is important to exclude pathologies with a similar mechanism of injury. First of all, fractures of the tibia, fibula and/or talus should be excluded. Secondly, the physician must address lateral malleolus sprains, since the mechanism of occurrence of these conditions is almost identical. Norwig writes, “Syndesmotic ankle sprains can usually be distinguished from ankle inversion sprains by the history of the external rotation component.” Other possible pathologies include medial ankle sprain, compartment syndrome, ankle instability, severe contusion, dystrophic calcification, inflammation or swelling. These pathologies must be excluded before treatment for RSGS begins.

Rating scales

Foot and Ankle Disability Index (FADI).
Lower Extremity Functional Scale (LEFS).

Symptoms of tibiofibular membrane injury

Symptoms of damage to the tibiofibular joint appear instantly and are very painful. The main sign of injury is a sharp, aching pain. When palpating the lower leg, increased pain is observed.

The foot is in an unnatural position: usually turned outward. There is severe swelling with a purple tint and areas of internal hemorrhage in the area of injury.

Symptoms of a rupture can easily be confused with a sprain or dislocation. Therefore, it is very important to correctly diagnose.

Survey

Gait analysis: checking for inconsistencies.
Palpation: tenderness over the anterior tibiofibular ligament and proximally along the interosseous membrane;
palpation of the medial and lateral malleoli to identify a fracture;
The fibula should be palpated proximally, including the proximal tibiofibular joint, to rule out a Maissonneuve fracture.

Pulse assessment: ensure that pulses are present in the arteries of the lower extremities.
Girth measurements: detecting swelling.

Special tests

Stress test: dorsiflexion-external rotation (Kleiger test)

Allows identification of rotational damage to the deltoid ligament or distal tibiofibular syndesmosis.
It is performed by bending the knee 90 degrees (with the foot in neutral) and then externally rotating the foot and ankle.
The test is considered positive if pain occurs in the area of the anterior outer surface of the ankle joint. Also an indicator of damage to the deltoid ligament is displacement of the talus away from the medial malleolus.

Compression test

Separation of the tibia and fibula.
Allows you to identify a fibular fracture or sprain of the syndesmosis.
It is performed by squeezing the tibia and fibula bones at the site of the suspected injury.
The test is considered positive if pain occurs along the body of the fibula (if there is a fibular fracture or damage to the distal tibiofibular syndesmosis).

Cotton test

Assess for instability of the syndesmosis and the presence of diastasis.
Performed by: stabilizing the distal part of the lower leg with one hand, grasping the plantar part of the heel with the other hand and moving the heel from side to side.
The test is considered positive if there is excessive lateral translation, which is a sign of instability.

Fibula translation test

Beumer et al. (2011): sensitivity 77%, specificity 88%

Rupture of the tibiofibular syndesmosis of the ankle joint

A syndesmotic or “high” ankle sprain is a sprain of the ligaments that connect the tibia and fibula at the distal tibiofibular syndesmosis. Injuries can occur with any movement of the ankle, but the most common movements are extreme external rotation or dorsiflexion of the talus. The dome of the talus is wider anteriorly than posteriorly, and these movements push apart the medial and lateral portions of the groove, respectively the tibial and fibular malleolus. Sufficient separation of the distal fibula from the tibia can cause sprain or rupture of one or more of the following ligaments: anterior inferior tibiofibular ligament, superficial posterior inferior tibiofibular ligament, transverse tibiofibular ligament, interosseous membrane, interosseous ligament, and inferior transverse ligament [ 1]. Rupture injuries are also usually accompanied by concomitant ankle fractures (usually lateral) or a proximal spiral fracture of the fibula, known as a Mezzonneuve fracture [2].

Epidemiology/etiology

Syndesmotic ankle sprains commonly occur in athletes who participate in American football and alpine skiing. Football injuries are usually the result of forced external rotation of the foot. Injuries can also be caused by a lateral impact to the knee with the foot on the ground and in dorsiflexion, resulting in an eversion or external rotation moment at the ankle joint.

In alpine ski racing, the boot does not allow dorsiflexion and plantar flexion, which can lead to excessive external rotation of the ankle and damage to the anterior or posterior tibiofibular ligaments, as well as the interosseous membrane.

Studies have confirmed that syndesmosis injuries account for 1-11% of all injuries [1]. The incidence among professional American football players is reported to be much higher, up to 29%, as documented by Boytim et al [3].

Characteristics/clinical picture

Syndesmosis injury has been observed to exhibit significantly less swelling than a lateral ankle sprain and also demonstrates complete loss of plantar flexion and inability to bear weight on the leg [2]. Ecchymosis may appear several days after injury due to damage to the interosseous membrane. Difficulty or inability to walk on toes is often noted. The history includes chronic pain, prolonged convalescence, recurrent sprains, and heterotopic ossification within the interosseous membrane [4]. The most common mechanism of injury is when the foot is in external rotation with excessive dorsiflexion [5].

Differential diagnosis

Due to the insidious nature of high ankle sprains, it is important to rule out pathologies with a similar mechanism of injury during clinical evaluation. First of all, fractures of the tibia, fibula and/or talus should be excluded [6]. Second, the clinician must address lateral ankle sprains because the mechanism of injury for the two injuries is very similar. Norvig writes, “Syndesmotic ankle sprains can usually be distinguished from inversion ankle sprains by the history of the external rotation component.” Other possible pathologies include medial ankle sprain, compartment syndrome, joint laxity [2], severe contusion, degenerative calcification, infection, or tumor. It is preferable to exclude these pathologies before treatment for syndesmotic ankle sprain syndrome begins.

Survey

Mechanism of injury: see clinical picture

Observation/Gait Analysis: Check for inconsistencies
Palpation: tenderness proximally over the anterior tibiofibular ligament and proximally along the interosseous membrane [7]
Palpate the medial and lateral malleolus for fracture [8]
The fibula must be palpated from the distal to the proximal end, including the proximal tibiofibular joint, to rule out a Mezzonneuve fracture [2].

Distal pulse: Make sure there is a pulse in the foot [8]

Girth Measurements: Detecting Swelling

Special testing

External rotation dorsiflexion stress test (Kleiger test)

Allows you to determine rotational damage to the deltoid ligament or distal tibiofibular syndesmosis.
It is performed by bending the knee 90 degrees with the ankle in neutral and applying an external rotational force to the affected foot and ankle [6].
(+) test: Pain in the anterolateral ankle. An indicator of damage to the deltoid ligament is displacement of the talus from the medial malleolus.
Interim kappa coefficient = 0.75 (best) - [9]; [2]

Compression test

Separation of the tibia and fibula [10]
Identifies a fibular fracture or syndesmotic sprain.
It is performed by pressing the tibia and fibula bones together over the injury.
(+) test: Pain will be reproduced along the body of the fibula if it is a fracture of the fibula and sprain of the distal tibiofibular syndesmosis.
Intermediate coefficient = 0.5 (moderate) [9].

Cotton test

Assessment of instability of syndesmosis with diastasis.
Performed: holding the distal part of the leg with one hand, while simultaneously grasping the plantar part of the heel with the opposite hand and moving the heel from side to side [2]
(+) test: Any lateral translation will indicate instability of the syndesmosis [11]

Fibula Translation Test

Beumer et al. (2011): Sensitivity 77%, specificity 88%

Treatment

Imaging is still considered the diagnostic standard and should be performed as quickly as possible to rule out any expected fractures and assist in restoring normal anatomy. A displacement of the fibula to the side by one millimeter leads to a decrease in the available area of the tibiotalar contact when leaning on the leg by 42% [12]. It's easy to see how such a “minor” but misdiagnosed injury can lead to lifelong chronic sprains. Plain films are the recommended minimum, but because of the complexity of the structures and tissues, a CT scan is recommended to detail the bones, an MRI provides an accurate picture of the ligament injury, and is the gold standard imaging for this injury. Only arthroscopy surpasses it in accuracy [2]. Images should be taken bilaterally to better identify injury from natural tearing or overlap. Syndesmotic ankle sprains without diastasis are considered stable and are treated symptomatically. These patients are advised to increase their weight bearing as tolerated. Those patients who present with a sprain with occult diastasis, where reduction of the tibiofibular joint can be documented by CT or MRI, do not necessarily require surgery. Patients with these results are often treated with immobilization in a non-weight-bearing cast or walking boot for 4 to 6 weeks. Patients with high syndesmotic ankle sprains who have diastasis of the syndesmosis without a fibular fracture require surgical intervention. Surgical stabilization should be performed immediately. Surgical repair involving open repair of torn ligaments and closed ligament repair through open or percutaneous screw fixation has been shown to produce favorable results [2].

Physiotherapy

Calf muscle stretch

Goals:

First two weeks: regain range of motion, reduce pain and swelling, protect ligaments from further injury
Week 3 onwards: Restore normal range of motion, strengthen ligaments and supporting muscles, train to improve endurance and balance [13] (Evidence Level 5)
The most important long-term goal is to prevent re-injury! [14] (Level of Evidence 1A)

Patient education:

Surgeon/physiatrist recommended loading protocol
Caution against vigorous physical activity until full load and dynamic balance have returned to normal [8]. (Level of Evidence 3A)
Gait training with crutches or boot/brace [2] (Evidence Level 1A)
Fall risk [8]

Auxiliary devices:

Crutches - must be used until normal, pain-free gait is achieved [7]
Walking boot or brace for unstable injuries [2]

Methods:

RICE (rest, ice, compression, elevation) initially for 15 minutes 3 times daily [13]. However, Bleakley et al. suggested that there is little evidence to support the use of RICE, although it is a widely accepted treatment
Nonsteroidal anti-inflammatory drugs and comfrey ointment have been shown to improve short-term recovery from acute ankle sprains [15].

Physical therapy / neuromuscular retraining:

First two weeks: active flexion, ankle alphabet, dorsiflexion/plantarflexion and inversion/eversion with theraband
Weeks 3-4: Standing stretch, seated dorsiflexion stretch with theraband, heel raises transitioning to single heel raises, and seated stool stretch [13]
Progressive weight bearing and gait training on a treadmill to develop normal gait [7][8].
Neuromuscular retraining: ankle proprioception, postural reflexes and balance, eg single leg stand, plate or balance board training, aquatic therapy
Progress to jogging, cycling, agility exercises, jumping, and sport-specific drills [8]. (Level of Evidence 3A)
Modify exercises to avoid hyperdorsiflexion, subtalar eversion, and loaded external rotation [7].

Manual therapy:

Passive assisted motion of the ankle and subtalar joints and passive stretching may promote mobility [8]. (Level of Evidence: 3A)
Green et al: Those subjects who used RICE with manual therapy were more likely to achieve normal range of motion within the first 2 weeks after an ankle sprain than those who received RICE alone [16].
Collins et al: Subjects demonstrated an immediate increase in range of motion when Mulligan motion with mobilization was used for subacute sprains and in patients with recurrent sprains [17].
Landrum et al: Reported that a single 30-second anteroposterior ankle mobilization immediately increased ankle flexion after prolonged immobilization [18].

Results

Syndesmotic ankle sprains, although less common than other ankle pathologies, are an important factor when assessing leg pain. This injury is more common in athletes after forced external rotation and dorsiflexion. May be accompanied by concomitant injury to bones and ligaments. While surgery is rarely indicated in the absence of a fracture, conservative physical therapy treatment may promote a faster recovery.

Sources

Norkus S, Floyd RT, The Anatomy and Mechanisms of Synedesmotic Ankle Sprains. J Athletic Training. 2001;36:68-73
Clanton T. Syndesmotic ankle sprains in athletes. International SportMed Journal. 2003;4(4):1-10.6
Boytim MJ, Fischer DA, Neumann L. Syndesmotic ankle sprains. Am J Sports Med. 1991;19:294–298
Nussbaum E, Hosea T, Sieler S, Incremona B, Kessler D. Prospective Evaulation of Syndesmotic Ankle Sprains Without Diastasis. The American Journal of Sports Medicine. 2001;29(1):31-35.
Lin CF, Gross ML, Weinhold P. Ankle syndesmosis injuries: anatomy, biomechanics, mechanism of injury, and clinical guidelines for diagnosis and intervention. JOSPT. 2006; 36(6):372-384. 3. Fincher L. Early Recognition of Syndesmotic Ankle Sprain. Athletic Therapy Today. 1999; 42-42.
Norwig JA. Injuring Management Update: Recognizing and Rehabilitating the High Ankle Sprain. Professional Jrnl of Athletic Trng Ther. 1998, July; 12-13.
Fincher L. Early Recognition of Syndesmotic Ankle Sprain. Athletic Therapy Today. 1999; 42-42.
Dressendorfer R. Clinical Review: Syndesmotic Ankle Sprain. CINAHL. 2009.
Alonso A, Khoury L, Adams R. Clinical tests for Ankle Syndesmosis Injury: reliability and prediction of return to function. JOSPT. 1998; 27(4):276-84
Starkey C, Ryan JL. Evaluation of Orthopedic and Athletic Injuries. Philadelphia, PA: F. A. Davis; 1996. pp. 86–95
Magee D. Orthopedic Physical Assessment. 4th Edition. St. Louis, Missouri: Saunders Elsevier; 2006
Pajaczkowski A. Rehabilitation od distal tibiofibular syndesmosis sprains: a case report. JC CA 2007; 51(1):42-49
Recovering from an ankle sprain. Harvard Women's Health Watch. Feb 2007; 14(6):4-6.
Bleakley CM, McDonough SM, MacAuley DC. Some conservative strategies are effective when added to controlled mobilization with external support after acute ankle sprain: a systematic review. Aust J Physiother. 2008;54(1):7-20.
Dolan, MG (2009) Clinical Research Review: Conservative Strategies in Ankle Sprain Management 14(5):8-10.
Green T, Refshauge K, Crosbie J, Adams A (2001) A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains. Physical Therapy 81:984-994
Collins N, Teys P, Vicenzino B (2004) The initial effects of a Mulligan's movilization with movement technique on dorsiflexion and pain in subacute ankle sprains. Manual Therapy 9: 77-82.
Landrum EL, Kelln BM, Parente WR, Ingersoll CD, Hertel J. Immediate effects of anterior-to-posterior talocrural joint mobilization after prolonged ankle immobilization: a preliminary study. J Man Manip Ther 2008;16(2):100-105

Treatment

Imaging is still considered the gold standard and should be addressed as quickly as possible to rule out any expected fractures and aid in the restoration of normal anatomy. One millimeter of lateral displacement of the fibula results in a 42% reduction in the available tibiotalar contact area during weight bearing. It is clear that such a “minor” but misdiagnosed injury can lead to a chronic sprain.

Friends, the seminar “Lower limbs, diagnosis and therapy, analysis of walking and running” will take place very soon. Find out more...

RSGS without diastasis are considered stable and are treated symptomatically. Those patients who have a sprain with latent diastasis, where reduction of the tibiofibular joint can be documented by CT or MRI, do not necessarily require surgery. Patients with such findings are often given immobilization using a plaster cast or apparatus for 4-6 weeks. Patients with ankle syndesmosis injuries who have diastasis without a fibular fracture require surgical treatment. Surgical stabilization should be performed immediately. Surgical repair involving open repair of torn ligaments and closed ligament repair through open or percutaneous screw fixation has been shown to have favorable results.

Physical therapy

Stretching the calf muscle on a step platform.
Exercises to strengthen the calf muscle.
Stretch the calf muscle in a lunge.

Goals

First 2 weeks: increase range of motion, reduce pain and swelling, protect ligaments from re-injury.
Week 3 and beyond: restoration of normal range of motion, strengthening of ligaments and muscles, training for endurance and balance.
The most important long-term goal is to prevent re-injury!

Patient education

Weight-bearing protocol recommended by your surgeon/physical therapist.
Caution patients against vigorous physical activity until full weight bearing capacity and dynamic balance have normalized.
Walking training with crutches or an orthosis/apparatus.
Risk of falls.

Assistive devices

Crutches should be used until normal, pain-free walking is restored.
An ankle brace or brace may be used for unstable injuries.

Methods of influence

Rest, ice, pressure, elevation (RICE protocol) - initially 15 minutes 3 times a day. (However, Bleakley et al suggested that there is little evidence to support the use of this protocol, although it is a fairly common approach).
Nonsteroidal anti-inflammatory drugs have been shown to improve acute ankle sprains.

Physical therapy/neuromuscular training

First 2 weeks: performing active movements, dorsiflexion/plantar flexion and inversion/eversion using the terabend.
3-4 weeks: standing stretches, sitting stretches (dorsiflexion with terabend), calf raises (progression - on one leg), dorsiflexion on a step platform.
Progressive weight loading (treadmill) to restore gait pattern.
Neuromuscular training: Improves ankle proprioception, postural reflexes and balance.

Example: one-leg stand, hemisphere training, aquatherapy.

Progression to jogging, cycling, jumping and sport-specific exercises.
Modify exercises to avoid excessive dorsiflexion (which leads to ankle strain), subtalar joint eversion, and external rotation.

Manual therapy

Passive incremental ankle and subtalar joint motion and passive stretching improve mobility.
Green et al: Patients treated with the RICE protocol plus manual therapy were more likely to achieve normal range of motion within the first 2 weeks after an ankle sprain than those treated with the RICE protocol alone.
Collins et al: Subjects showed an immediate increase in range of motion when motion mobilizations were used in the subacute stage.
Landrum et al: Reported that a single 30-second anteroposterior ankle mobilization immediately increased ankle dorsiflexion range after prolonged immobilization.

NB: The recovery time for an ankle sprain is twice as long as for a typical ankle sprain.

Recovery after injury and surgical treatment - recommendations for patients

After surgical treatment of the injury in question, patients are sent home the next day.

The first two weeks after surgery, the damaged area is fixed with plaster. During the specified period of time, the load on the operation area should be minimized. To do this, you need to ensure rest, and when moving, use crutches.

To reduce swelling, the foot should be kept elevated, but only in a horizontal position.

After the swelling has partially subsided, the cast is replaced with an orthopedic boot , and the patient is allowed to take short walks and perform simple exercises for flexion/extension of the foot.

Until the wound is completely healed, the foot must be kept cool and dry, otherwise infection may occur.

It is recommended to start driving a car no earlier than 6 weeks after the operation.

It is mandatory to wear an orthosis after removing the screws, as well as during physiotherapeutic procedures - their use will ensure stabilization of the ankle joint.

Regardless of what treatment the patient received - conservative or surgical - he should undergo a course of rehabilitation . The duration of this course will depend on the degree of damage to the ligament: from 1 month to 1 year.

Surgical intervention

The problem is solved surgically when the injury is neglected. This method is used when conservative treatment has failed. Also, surgery is the only correct solution in cases where a complicated rupture occurs.

Surgical methods are presented below.

Replacement of the syndesmosis or part of the fibula (tendoplasty)

In this case, manipulations are carried out with the tibia bones: a new ligament is implanted through channels specially created in these bones by drilling. As a result of the replacement, the damaged area is completely renewed and the function of the ankle joint is guaranteed to be restored.

Using a compression screw or tie bolt

The above auxiliary elements are attached at the correct distance in relation to each other and allow you to fix the bones of the lower leg in a position that will not allow them to move or grow together.

When using a surgical treatment method, it should be taken into account that when the tibiofibular syndesmosis ruptures, the functioning of the vascular system is seriously disrupted and the risk of thrombosis in the legs increases.

To avoid this kind of complications, drugs are prescribed that prevent the formation of blood clots, improve metabolism in the vascular walls and maintain their healthy integrity. Together, surgery and medications promote rapid rehabilitation after injury.