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Ankle Syndesmosis Normal Anatomy • Distal tibiofibular syndesmosis made up of several ligaments • • • • Anterior tibiofibular ligament Posterior tibiofibular ligament Transverse tibiofibular ligament Interosseous tibiofibular ligament • Strongest connection between tibia and fibular is by the interosseous tibiofibular ligament • During dorsiflexion the fibula moves laterally and posteriorly • During plantarflexion the fibula moves medially and anteriorly • From plantarflexion to dorsiflexion the distance between the medial and lateral malleolus increases • The syndesmotic ligaments restrict lateral movement of the fibula Pathology • External rotation of the foot causes disruption of the anterior syndesmotic ligaments • Disruption to the syndesmotic ligaments can increase fibula lateral movement and therefore lead to instability • Large external rotation force and increased fibula movement can lead to complete tibiofibular diastasis (separation) • Diastasis usually occurs in combination with medial and sometimes lateral malleolus fractures Mechanism of Injury • Traumatic • Forced external rotation of the foot • Rapidly pivoting internally with the foot planted in an externally rotated position • Valgus force to a planted foot in a tackle • Direct blow to the lateral aspect of the heel • Forced Dorsiflexion Classification • Grade 1 • • • • Injury to anterior deltoid ligament Injury to distal interosseous ligament Nil tear of proximal syndesmosis or deep deltoid ligament Stable • Grade 2 • Disruption of anterior and deep deltoid ligaments • Tear in syndesmosis • Unstable Ankle with normal alignment on radiographs • Grade 3 • Complete disruption of deltoid, anterior and syndesmotic ligaments • Proximal fibula fracture (Maisonneuve fracture) • Unstable clinical and on radiographs Associated Pathology • Deltoid ligament sprains • Weber Type B Fracture • Lateral malleolus fracture level with the talar dome • Weber Type C Fracture • Lateral malleolus fracture above the ankle joint • Maisonneuve fractures • Spiral fracture of the proximal third of the fibula • Osteochondral Lesions Subjective Examination • Pain above ankle joint line • Traumatic history of forced external rotation • Pain with pivoting internally with a planted foot • Pain with “pushing off” during gait or running • History of sports requiring a boot that fixes the ankle such as skiing or hockey Objective Examination • Swelling anterior medial ankle joint • Painful Dorsiflexion • Painful External rotation of the foot • Tenderness over distal anterior tibiofibular ligament • Tenderness along the interosseous membrane Special Test • Passive dorsiflexion • Squeeze test • External Rotation Stress Test • Crossed Leg Test • Cotton Stress Test • Fibular Translation Further Investigation • X-ray (rule out fracture) • Ultrasound • MRI Management • Prolonged recovery time • Surgery not always considered if a fracture is present • Weber Type C Fracture is unstable and usually operated on • Weber Type B Fracture maybe stable or unstable • Conservative management considered where injury is stable • If symptoms persist longer than 6 months surgery is considered Conservative • Reduce pain and inflammation • • • • Immobilisation NSAID’s Ice Massage • Restore Normal Range of Movement • Ankle • Massage • Joint mobilisation • Joint manipulation • Restore Normal Muscle Activation • • • • • Evertors Invertors Plantarflexors Dorsiflexors Intrinsic Foot Muscles • Restore Dynamic Stability • Proprioceptive Training • Sport Specific Training Plan B • Dependent on instability and fracture sites • Arthroscopic debridement • Screw fixation • Arthrodesis (joint fusion) References • Bloemers, F. W. and F. C. Bakker (2006). "Acute Ankle Syndesmosis Injury In Athletes." European Journal of Trauma 32(4): 350-356. • Magan, A., P. Golano, N. Maffulli and V. Khanduja (2014). "Evaluation and management of injuries of the tibiofibular syndesmosis." Br Med Bull 111(1): 101-115. • McCollum, G. A., M. P. van den Bekerom, G. M. Kerkhoffs, J. D. Calder and C. N. van Dijk (2013). "Syndesmosis and deltoid ligament injuries in the athlete." Knee Surg Sports Traumatol Arthrosc 21(6): 1328-1337. • Miller, T. L. and T. Skalak (2014). "Evaluation and treatment recommendations for acute injuries to the ankle syndesmosis without associated fracture." Sports Med 44(2): 179-188. • Porter, D. A., R. R. Jaggers, A. F. Barnes and A. M. Rund (2014). "Optimal management of ankle syndesmosis injuries." Open Access J Sports Med 5: 173-182. • Sman, A. D., C. E. Hiller and K. M. Refshauge (2013). "Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review." Br J Sports Med 47(10): 620-628. • Van Heest, T. J. and P. M. Lafferty (2014). "Injuries to the Ankle Syndesmosis." The Journal of Bone & Joint Surgery 96(7): 603-613. • Williams, G. N. and E. J. Allen (2010). "Rehabilitation of Syndesmotic (High) Ankle Sprains." Sports Health: A Multidisciplinary Approach 2(6): 460-470.