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A woman in her early thirties sustained an ankle injury after losing her footing stepping off a sidewalk. Initially, the injury appeared to be a typical ankle sprain. She applied basic RICE principles — rest, ice, compression, and elevation — and waited for improvement.
After two weeks with no real change in her symptoms, she visited her GP. An X-ray was performed, which ruled out a broken bone, and she was given pain medication and advised to rest. However, her ankle pain continued to worsen rather than improve.
By the four-week mark, she sought a physiotherapy consultation — and this is where the picture became much clearer.
An immediate referral to a new GP triggered a cascade of appropriate intervention:
For the more astute clinicians or health practitioners, many would know that I’m immediately referring to a syndesmosis injury – otherwise known as a high ankle sprain. This case was poorly managed, as the follow-up with the doctor should have included further investigation. Especially because the ankle pain wasn’t resolving. Usually, seeking out a physiotherapist before a doctor is beneficial for most simple ankle sprains.
Unfortunately for this individual, had the right assessments been completed and monitored over weeks, a surgery would have been avoided. With prompt and correct management — including a thorough physical examination and appropriate imaging — this individual would have recovered in a much shorter timeframe and returned to her daily gym and sport routine without the need for surgical intervention. This case is a strong reminder of why high ankle sprains must not be managed like a traditional ankle sprain.
Epidemiological data suggests as many as 1-2 out of 10 people will suffer a syndesmosis ankle sprain (Williams & Allen, 2010). Although it’s an injury that largely occurs in athletic populations, there have been many cases – like the one above – where syndesmosis injuries happen in everyday life.
The syndesmosis joint is made up of several key structures that work together to maintain ankle stability:
In a syndesmosis sprain, the primary concern is the connection between the two shin bones — the tibia and fibula — being pushed apart. Disruption of the injured ligaments holding these leg bones together causes excessive movement and instability through the ankle joint. This is extremely detrimental to all aspects of daily life, including walking, running, climbing stairs, and any form of lower limb exercise.
It’s important to stay away from excessive weight-bearing and activities that provoke pain during recovery, as this allows the damaged ligaments to heal back into their natural position. Long-term complications — including chronic ankle instability, recurrent ankle sprains, chronic pain, and loss of strength and range of motion — can all arise if syndesmosis injuries are not treated properly.
The following symptoms are indicators that you should have your ankle assessed as soon as possible by a qualified health professional:
The following guidelines for recovery are based on the recommendations suggested by Williams & Allen (2010). These are only ‘guidelines’ and do not reflect the recovery that you or anyone else may experience. A host of individual factors can influence the speed in which you recover back to your baseline and must be considered in any injury.
Progress to the next stage when: you are able to fully bear weight on the affected leg and manage stairs and uneven ground with minimal discomfort.
Progress to the next stage when: hopping and light running produce minimal discomfort.
Steadily build your fitness and ankle strength, and progressively advance sport-specific activities. Return to full sport-level activity is appropriate when you can train pain-free and with minimal discomfort across all movement planes.
A few warning signs to be wary of include:
If you experience any of these, go to the emergency department or your local GP immediately. During this stage, it is essential to rule out an ankle fracture — a broken bone left undiagnosed will have serious long-term consequences for your recovery.
This specific ankle injury can potentially have serious consequences on your long-term ankle function. If you are unsure about the severity of your ankle sprain, please seek professional advice — including a consultation with our physiotherapy team, who can assess the ankle joint, perform the appropriate stress tests, and refer you for further imaging if needed.
The purpose of this post is to make you aware that a more serious type of ankle sprain exists. A syndesmosis ankle sprain — or high ankle sprain — cannot be managed like a usual lateral ankle sprain, takes considerably longer to heal, and carries a genuine risk of long-term complications if it isn’t identified and treated correctly.
The main messages to take away: contact a medical professional if you exhibit any of the caution signs above, if your ankle pain is not improving after a week or two of basic management, or if you are concerned about the nature of your sprain. And if something doesn’t feel right, trust that instinct and get it properly assessed.
Like any injury, syndesmosis sprains can heal. But proper management and a structured rehabilitation program are essential to ensure a favourable outcome. The earlier the right care begins, the better.
