Syndesmotic Ankle Sprain Recovery: Treatment, Rehab and Return to Sport
What Is Syndesmosis in the Ankle?
The syndesmosis is a group of strong ligaments that connect the two long bones of your lower leg — the tibia (shinbone) and fibula — just above the ankle joint. These ligaments don’t allow much movement, but they play an important role in keeping the bones tightly aligned so the ankle stays stable when you walk, run, or push off the ground.
When people talk about a syndesmosis injury, they’re usually referring to damage to these ligaments, often caused by a twist, heavy tackle, or awkward landing. This type of injury is commonly known as a high ankle injury or syndesmotic ankle sprain because it occurs higher up than the more familiar ankle sprains that affect the outer ligaments.
Unlike a simple ankle roll, an injury to the syndesmosis in the ankle can be more painful and take longer to heal, which is why athletes and physios treat it more seriously. Left untreated, it can lead to long-term instability and recurring problems with movement.
What Is a Syndesmotic Ankle Sprain (High Ankle Injury)?
A syndesmotic ankle sprain, often called a high ankle injury, happens when the ligaments of the syndesmosis are stretched or torn. Unlike the more common ankle sprain, which affects the ligaments on the outside of the ankle, this injury sits higher up between the tibia and fibula bones.
High ankle injuries usually occur when the foot is planted and the leg is forcefully twisted outward — a common scenario in sports like AFL, rugby, and soccer. Tackles, awkward landings, or sudden changes of direction can all put intense stress on the syndesmosis ligaments, leading to injury.
Because the syndesmosis helps hold the lower leg bones together, damage to this area makes weight-bearing painful and unstable. That’s why a syndesmotic ankle sprain typically takes longer to heal than a standard ankle sprain and often requires physiotherapy to restore proper strength and stability.
Syndesmosis Injury Symptoms You Should Watch For
A syndesmosis injury can feel very different from a standard ankle sprain. Instead of sharp pain on the outside of the ankle, the discomfort sits higher up between the shin and the ankle joint. That’s why this type of injury is often called a high ankle injury.
Common symptoms include:
Pain above the ankle – especially when walking, running, or turning.
Swelling and tenderness – not just at the joint but spreading up the leg.
Difficulty pushing off the foot – activities like climbing stairs, sprinting, or jumping feel weak or unstable.
Bruising – sometimes present, though not always obvious.
Increased pain with twisting movements – rotating the foot outward usually makes the pain worse.
Unlike a simple sprain, a syndesmotic ankle sprain can make even walking painful, and athletes often struggle to return to sport without proper rehab. If these symptoms sound familiar, getting an assessment from a physio or sports doctor is crucial for an accurate diagnosis and recovery plan.
How Is a Syndesmotic Ankle Sprain Diagnosed?
Diagnosing a syndesmosis injury can be tricky because the symptoms often overlap with other ankle sprains. The key difference is that pain sits higher up, which alerts physios and doctors to look closely at the ligaments between the tibia and fibula.
A thorough diagnosis usually includes:
Clinical Tests
Squeeze Test: the physio gently squeezes the tibia and fibula together higher up the leg. If this causes pain near the ankle, it’s a sign of a syndesmotic ankle sprain.
External Rotation Test: rotating the foot outward while the knee is bent can reproduce the pain of a high ankle injury.
Imaging
X-ray: checks for fractures or widening between the tibia and fibula.
MRI or CT scan: provides detailed images of ligament damage and helps determine the severity of the syndesmosis in the ankle injury.
Getting the diagnosis right is vital because treatment for a syndesmosis injury is often longer and more involved than for a standard ankle sprain. Early assessment by a physio or sports doctor ensures you start the right treatment plan and avoid long-term ankle instability.
Treatment for Syndesmosis Injury
Managing a syndesmosis injury takes more care than a standard ankle sprain, because the ligaments between the tibia and fibula are crucial for ankle stability. The right treatment depends on the severity of the sprain, but in most cases, the goal is to reduce pain, protect the ligaments, and gradually restore strength and movement.
Immediate Care (First 48 Hours)
Rest – avoid weight-bearing if walking is painful.
Ice – apply for 15–20 minutes every couple of hours to control swelling.
Compression and Elevation – bandages or strapping can limit swelling and provide support.
Non-Surgical Management
Bracing or Boot – a supportive brace or moon boot may be needed to keep the ankle stable while the ligaments heal.
Physiotherapy – once pain and swelling settle, rehab focuses on restoring mobility, building ankle strength, and retraining balance (proprioception). This is vital for a safe return to sport.
Surgical Options
In more severe cases, where the syndesmosis is unstable or the tibia and fibula have separated, surgery may be required. This usually involves fixing the bones together with screws or a special device until the ligaments heal. Post-surgery, physiotherapy is essential to rebuild function.
A syndesmotic ankle sprain often takes longer to recover than a regular sprain, so sticking to a structured treatment plan is key. Returning to sport too soon risks re-injury or long-term instability in the ankle.
How Long Until You’re Back?
Recovery from a syndesmosis injury takes longer than a typical ankle sprain, because the ligaments between the tibia and fibula are under constant stress whenever you walk, run, or push off the ground. How long you’ll be sidelined depends on the severity of the sprain and whether surgery is needed.
Mild syndesmotic ankle sprain (Grade 1) – Usually heals in 2–6 weeks with rest, bracing, and physiotherapy.
Moderate syndesmosis injury (Grade 2) – Often requires 6–10 weeks of rehab. Athletes can expect a gradual return-to-play program with physio support.
Severe high ankle injury (Grade 3) – If the ligaments are completely torn or unstable, surgery is often needed. Recovery may take 3–6 months or longer, depending on how well the joint heals and responds to rehabilitation.
Athletes often find that a high ankle injury keeps them off the field much longer than a standard ankle sprain. The key is not rushing back too soon — returning before the syndesmosis is fully healed can lead to chronic pain, weakness, and repeated injuries.
Rehabilitation and Return to Sport
Rehab after a syndesmosis injury is all about rebuilding stability, strength, and confidence in the ankle so you can get back to full performance without setbacks. Because a syndesmotic ankle sprain affects the ligaments that keep the tibia and fibula aligned, physios take a step-by-step approach to avoid reinjury.
Phase 1: Protect and Settle
Rest, bracing, or a boot to limit movement.
Gentle range-of-motion exercises once pain allows.
Phase 2: Restore Mobility and Strength
Targeted stretches to improve ankle flexibility.
Strengthening exercises for the calf, shin, and hip to support the ankle.
Weight-bearing progressions to safely reintroduce load.
Phase 3: Balance and Control
Proprioception (balance) training to retrain the stabilising muscles.
Functional drills like single-leg hops or controlled changes of direction.
Phase 4: Sport-Specific Training
Sprinting, cutting, and agility exercises that mimic game demands.
Gradual reintroduction to team training under physio or coach guidance.
Phase 5: Return to Play
A tailored program ensures you meet strength and mobility benchmarks before returning to competition.
With consistent physiotherapy, most athletes can return to their sport confidently, but patience is key. A high ankle injury that’s rushed can easily flare up again and set recovery back weeks or months.
Stronger Ankles Start Here – Claim Your Complimentary Session
At Ducker Physio Adelaide, we help patients recover from all types of injuries — from a syndesmosis ankle sprain or high ankle injury to workplace injuries and chronic pain. Our experienced physios create tailored rehab programs in our specialised Salisbury gym, guiding you from early recovery right through to full return-to-sport training.
Book your appointment today and receive a complimentary 20-minute initial consultation.
Ducker Physio Salisbury
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Salisbury, SA 5108 (Get Directions)
(08) 8283 3760
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Magill SA 5072 (Get Directions)
(08) 8333 0322