Skip to main content
Log in

Current trends in the diagnosis and management of syndesmotic injury

  • Foot and Ankle Sports Medicine (M Drakos, section editor)
  • Published:
Current Reviews in Musculoskeletal Medicine Aims and scope Submit manuscript

Abstract

Ideal management of the various presentations of syndesmotic injury remains controversial to this day. High quality evidentiary science on this topic is rare, and numerous existing studies continue to contradict one another. The primary reasons for these discrepancies are that previous studies have failed to (1) properly distinguish between isolated (non-fractured) and non-isolated injuries, (2) accurately define stable from unstable injuries, and (3) sufficiently differentiate between acute and chronic injuries. The purpose of this review is to summarize today’s body of literature regarding diagnosis and management of syndesmotic injury and discuss current trends and important future directions to optimize care of this very heterogeneous population.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Vosseller JT, Karl JW, Greisberg JK. Incidence of syndesmotic injury. Orthopedics. 2014;37(3):e226–9.

    Article  PubMed  Google Scholar 

  2. Porter DA, et al. Optimal management of ankle syndesmosis injuries. Open Access J Sports Med. 2014;5:173–82.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Switaj PJ, Mendoza M, Kadakia AR. Acute and chronic injuries to the syndesmosis. Clin Sports Med. 2015;34(4):643–77.

    Article  PubMed  Google Scholar 

  4. • Hunt KJ, et al. High ankle sprains and syndesmotic injuries in athletes. J Am Acad Orthop Surg. 2015;23(11):661–73.

    Article  PubMed  Google Scholar 

  5. Mak MF, Gartner L, Pearce CJ. Management of syndesmosis injuries in the elite athlete. Foot Ankle Clin. 2013;18(2):195–214.

    Article  PubMed  Google Scholar 

  6. McCollum GA, et al. Syndesmosis and deltoid ligament injuries in the athlete. Knee Surg Sports Traumatol Arthrosc. 2013;21(6):1328–37.

    Article  PubMed  Google Scholar 

  7. Czajka CM, et al. Ankle sprains and instability. Med Clin North Am. 2014;98(2):313–29.

    Article  PubMed  Google Scholar 

  8. Symeonidis PD, et al. Common pitfalls in syndesmotic rupture management: a clinical audit. Foot Ankle Int. 2013;34(3):345–50.

    Article  PubMed  Google Scholar 

  9. Franke J, et al. Intraoperative three-dimensional imaging in the treatment of acute unstable syndesmotic injuries. J Bone Joint Surg Am. 2012;94(15):1386–90.

    Article  PubMed  Google Scholar 

  10. Cancienne JM, Crosen MP, Yarboro SR. Use of a hybrid operating room to improve reduction of syndesmotic injuries in ankle fractures: a case report. J Foot Ankle Surg. 2015.

  11. Tucker A, et al. Functional outcomes following syndesmotic fixation: a comparison of screws retained in situ versus routine removal—is it really necessary? Injury. 2013;44(12):1880–4.

    Article  PubMed  Google Scholar 

  12. Roemer FW, et al. Ligamentous injuries and the risk of associated tissue damage in acute ankle sprains in athletes: a cross-sectional MRI study. Am J Sports Med. 2014;42(7):1549–57.

    Article  PubMed  Google Scholar 

  13. Gerber JP, et al. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int. 1998;19(10):653–60.

    Article  CAS  PubMed  Google Scholar 

  14. • Lubberts B, van Dijk PAD, Donovan N. Stable and unstable grade II syndesmotic injuries require different treatment strategies and vary in fuctional outcomes: a systematic review. JISAKOS. 2016;1(3):1–6. An in-depth review of current recommendations on how to diagnosis and treat stable and unstable grade II syndesmotic injuries

    Google Scholar 

  15. Osbahr DC, et al. Syndesmosis and lateral ankle sprains in the National Football League. Orthopedics. 2013;36(11):e1378–84.

    Article  PubMed  Google Scholar 

  16. Hunt KJ, et al. Epidemiology of syndesmosis injuries in intercollegiate football: incidence and risk factors from National Collegiate Athletic Association injury surveillance system data from 2004 to 2005 to 2008-2009. Clin J Sport Med. 2013;23(4):278–82.

    Article  PubMed  Google Scholar 

  17. Kaplan LD, et al. Incidence and variance of foot and ankle injuries in elite college football players. Am J Orthop (Belle Mead NJ). 2011;40(1):40–4.

    Google Scholar 

  18. Lubberts B, van Dijk PAD, Calder JD, DiGiovanni CW. There is no best surgical treatment for chronic isolated syndesmotic instability: a systematic review. J ISAKOS. 2016;1(5).

  19. • Lilyquist M, et al. Cadaveric analysis of the distal tibiofibular syndesmosis. Foot Ankle Int. 2016. Cadaveric study that evaluated the anatomy of distal tibiofibular syndesmosis and the incidence of a prominet tranverse ligament. They found the transverse ligament was only prominent 70% of the time .

  20. • van Dijk CN, et al. Classification and diagnosis of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1200–16. A literature review by ESSKA-AFAS where they described consensus guidelines for classification and diagnosis of acute isolated syndesmotic injuries

    Article  PubMed  Google Scholar 

  21. Takao M, et al. Diagnosis of a tear of the tibiofibular syndesmosis. The role of arthroscopy of the ankle. J Bone Joint Surg Br. 2003;85(3):324–9.

    Article  CAS  PubMed  Google Scholar 

  22. Colcuc C, et al. Treatment strategies for partial chronic instability of the distal syndesmosis: an arthroscopic grading scale and operative staging concept. Arch Orthop Trauma Surg. 2016;136(2):157–63.

    Article  CAS  PubMed  Google Scholar 

  23. • Watson BC, et al. Arthroscopic evaluation of syndesmotic instability in a cadaveric model. Foot Ankle Int. 2015;36(11):1362–8. Cadaveric study that evaluated how a physician can evaluate syndesmotic instability in multiple planes using arthroscopy. The authors found stability in the sagittal plane is more accurate to diagnosis syndesmotic instability when compared to the coronal plane

    Article  PubMed  Google Scholar 

  24. • Calder JD, et al. Stable versus unstable grade II high ankle sprains: a prospective study predicting the need for surgical stabilization and time to return to sports. Arthroscopy. 2016;32(4):634–42. This study presents describes a possible method to arthroscopically diagnose syndesmotic instability in grade II high ankle sprains. Also, this study compared how different physical exam tests correlated with stability of the syndesmosis by accessing this arthroscopically

  25. Sikka RS, et al. Correlating MRI findings with disability in syndesmotic sprains of NFL players. Foot Ankle Int. 2012;33(5):371–8.

    Article  PubMed  Google Scholar 

  26. Yeung TW, et al. Can pre-operative axial CT imaging predict syndesmosis instability in patients sustaining ankle fractures? Seven years' experience in a tertiary trauma center. Skelet Radiol. 2015;44(6):823–9.

    Article  Google Scholar 

  27. Sman AD, et al. Diagnostic accuracy of clinical tests for ankle syndesmosis injury. Br J Sports Med. 2015;49(5):323–9.

    Article  PubMed  Google Scholar 

  28. Miller BS, et al. Time to return to play after high ankle sprains in collegiate football players: a prediction model. Sports Health. 2012;4(6):504–9.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Lin CF, Gross ML, Weinhold P. Ankle syndesmosis injuries: anatomy, biomechanics, mechanism of injury, and clinical guidelines for diagnosis and intervention. J Orthop Sports Phys Ther. 2006;36(6):372–84.

    Article  PubMed  Google Scholar 

  30. Mulligan EP. Evaluation and management of ankle syndesmosis injuries. Phys Ther Sport. 2011;12(2):57–69.

    Article  PubMed  Google Scholar 

  31. Chen Y, et al. A reliable radiographic measurement for evaluation of normal distal tibiofibular syndesmosis: a multi-detector computed tomography study in adults. J Foot Ankle Res. 2015;8:32.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Pneumaticos SG, et al. The effects of rotation on radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle Int. 2002;23(2):107–11.

    Article  PubMed  Google Scholar 

  33. Schairer WW, et al. Arthroscopically assisted open reduction-internal fixation of ankle fractures: significance of the arthroscopic ankle drive-through sign. Arthrosc Tech. 2016;5(2):e407–12.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Milz P, et al. Lateral ankle ligaments and tibiofibular syndesmosis. 13-MHz high-frequency sonography and MRI compared in 20 patients. Acta Orthop Scand. 1998;69(1):51–5.

    Article  CAS  PubMed  Google Scholar 

  35. Krappel F, Schmitz R, Harland U. Sonographic diagnosis of anterior syndesmosis rupture. Z Orthop Ihre Grenzgeb. 1997;135(2):116–9.

    Article  CAS  PubMed  Google Scholar 

  36. Durkee NJ, et al. Sonographic evaluation of lower extremity interosseous membrane injuries: retrospective review in 3 patients. J Ultrasound Med. 2003;22(12):1369–75.

    Article  PubMed  Google Scholar 

  37. Mei-Dan O, et al. Standardization of the functional syndesmosis widening by dynamic U.S examination. BMC Sports Sci Med Rehabil. 2013;5:9.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Laver L, et al. Plasma rich in growth factors (PRGF) as a treatment for high ankle sprain in elite athletes: a randomized control trial. Knee Surg Sports Traumatol Arthrosc. 2015;23(11):3383–92.

    Article  PubMed  Google Scholar 

  39. Doughtie M. Syndesmotic ankle sprains in football: a survey of national football league athletic trainers. J Athl Train. 1999;34(1):15–8.

    CAS  PubMed  PubMed Central  Google Scholar 

  40. Drakos M, et al. Corticosteroid and anesthetic injections for muscle strains and ligament sprains in the NFL. HSS J. 2014;10(2):136–42.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Schepers T, et al. The management of acute distal tibio-fibular syndesmotic injuries: results of a nationwide survey. Injury. 2012;43(10):1718–23.

    Article  PubMed  Google Scholar 

  42. McBryde A, et al. Syndesmotic screw placement: a biomechanical analysis. Foot Ankle Int. 1997;18(5):262–6.

    Article  CAS  PubMed  Google Scholar 

  43. Verim O, et al. Biomechanical evaluation of syndesmotic screw position: a finite-element analysis. J Orthop Trauma. 2014;28(4):210–5.

    Article  PubMed  Google Scholar 

  44. Stuart K, Panchbhavi VK. The fate of syndesmotic screws. Foot Ankle Int. 2011;32(5):S519–25.

    Article  PubMed  Google Scholar 

  45. Taylor DC, et al. Aggressive surgical treatment and early return to sports in athletes with grade III syndesmosis sprains. Am J Sports Med. 2007;35(11):1833–8.

    Article  PubMed  Google Scholar 

  46. Liu Q, et al. Analysis of the stress and displacement distribution of inferior tibiofibular syndesmosis injuries repaired with screw fixation: a finite element study. PLoS One. 2013;8(12):e80236.

    Article  PubMed  PubMed Central  Google Scholar 

  47. van den Bekerom MP, et al. Complications of distal tibiofibular syndesmotic screw stabilization: analysis of 236 patients. J Foot Ankle Surg. 2013;52(4):456–9.

    Article  PubMed  Google Scholar 

  48. Lalli TA, et al. Economic impact of syndesmosis hardware removal. Foot (Edinb). 2015;25(3):131–3.

    Article  Google Scholar 

  49. Gennis E, et al. The fate of the fixed syndesmosis over time. Foot Ankle Int. 2015;36(10):1202–8.

    Article  PubMed  Google Scholar 

  50. Song DJ, et al. The effect of syndesmosis screw removal on the reduction of the distal tibiofibular joint: a prospective radiographic study. Foot Ankle Int. 2014;35(6):543–8.

    Article  PubMed  Google Scholar 

  51. Hong CC, Lee WT, Tan KJ. Osteomyelitis after TightRope((R)) fixation of the ankle syndesmosis: a case report and review of the literature. J Foot Ankle Surg. 2015;54(1):130–4.

    Article  PubMed  Google Scholar 

  52. Qamar F, Kadakia A, Venkateswaran B. An anatomical way of treating ankle syndesmotic injuries. J Foot Ankle Surg. 2011;50(6):762–5.

    Article  PubMed  Google Scholar 

  53. Rigby RB, Cottom JM. Does the Arthrex TightRope(R) provide maintenance of the distal tibiofibular syndesmosis? A 2-year follow-up of 64 TightRopes(R) in 37 patients. J Foot Ankle Surg. 2013;52(5):563–7.

    Article  PubMed  Google Scholar 

  54. Gough BE, et al. Novel flexible suture fixation for the distal tibiofibular syndesmotic joint injury: a cadaveric biomechanical model. J Foot Ankle Surg. 2014;53(6):706–11.

    Article  PubMed  Google Scholar 

  55. • van Dijk CN, et al. Conservative and surgical management of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1217–27. This is a literature review by ESSKA-AFAS that described consensus guidelines for conservative and surgical management of acute dislocated syndesmotic injuries

    Article  PubMed  Google Scholar 

  56. Xenos JS, et al. The tibiofibular syndesmosis. Evaluation of the ligamentous structures, methods of fixation, and radiographic assessment. J Bone Joint Surg Am. 1995;77(6):847–56.

    Article  CAS  PubMed  Google Scholar 

  57. Kortekangas T, et al. A prospective randomised study comparing TightRope and syndesmotic screw fixation for accuracy and maintenance of syndesmotic reduction assessed with bilateral computed tomography. Injury. 2015;46(6):1119–26.

    Article  PubMed  Google Scholar 

  58. Westermann RW, et al. The effect of suture-button fixation on simulated syndesmotic malreduction: a cadaveric study. J Bone Joint Surg Am. 2014;96(20):1732–8.

    Article  PubMed  Google Scholar 

  59. Laflamme M, et al. A prospective randomized multicenter trial comparing clinical outcomes of patients treated surgically with a static or dynamic implant for acute ankle syndesmosis rupture. J Orthop Trauma. 2015;29(5):216–23.

    Article  PubMed  Google Scholar 

  60. Cottom JM, et al. Transosseous fixation of the distal tibiofibular syndesmosis: comparison of an interosseous suture and endobutton to traditional screw fixation in 50 cases. J Foot Ankle Surg. 2009;48(6):620–30.

    Article  PubMed  Google Scholar 

  61. Wang L, et al. Biomechanical comparison of bionic, screw and endobutton fixation in the treatment of tibiofibular syndesmosis injuries. Int Orthop. 2016;40(2):307–14.

    Article  PubMed  Google Scholar 

  62. Seyhan M, et al. Comparison of screw fixation with elastic fixation methods in the treatment of syndesmosis injuries in ankle fractures. Injury. 2015;46(Suppl 2):S19–23.

    Article  PubMed  Google Scholar 

  63. Naqvi GA, Shafqat A, Awan N. Tightrope fixation of ankle syndesmosis injuries: clinical outcome, complications and technique modification. Injury. 2012;43(6):838–42.

    Article  PubMed  Google Scholar 

  64. Gardner MJ, et al. Technical considerations in the treatment of syndesmotic injuries associated with ankle fractures. J Am Acad Orthop Surg. 2015;23(8):510–8.

    Article  PubMed  Google Scholar 

  65. Kennedy JG, et al. Evaluation of the syndesmotic screw in low Weber C ankle fractures. J Orthop Trauma. 2000;14(5):359–66.

    Article  CAS  PubMed  Google Scholar 

  66. Pakarinen HJ, et al. Syndesmotic fixation in supination-external rotation ankle fractures: a prospective randomized study. Foot Ankle Int. 2011;32(12):1103–9.

    Article  PubMed  Google Scholar 

  67. Yang Y, et al. Operative exploration and reduction of syndesmosis in Weber type C ankle injury. Acta Ortop Bras. 2013;21(2):103–8.

    Article  PubMed  PubMed Central  Google Scholar 

  68. van den Bekerom MP, de Leeuw PA, van Dijk CN. Delayed operative treatment of syndesmotic instability. Current concepts review. Injury. 2009;40(11):1137–42.

    Article  PubMed  Google Scholar 

  69. Kelikian H, Kelikian A. Disorders of the ankle. Philadelphia: WB Saunders; 1985.

    Google Scholar 

  70. Hansen Jr ST, Repair of distal tibiofibular syndesmosis. In Functional construction of the foot and ankle. Philadelphia: Lippincott Williams & Wilkins; 2000. p. 507–508.

  71. van Dijk CN. Syndesmotic injuries. Tech Foot Ankle Surg. 2006;5(1):34–7.

    Article  Google Scholar 

  72. Beumer A, et al. Late reconstruction of the anterior distal tibiofibular syndesmosis: good outcome in 9 patients. Acta Orthop Scand. 2000;71(5):519–21.

    Article  CAS  PubMed  Google Scholar 

  73. Grass R, et al. Peroneus longus ligamentoplasty for chronic instability of the distal tibiofibular syndesmosis. Foot Ankle Int. 2003;24(5):392–7.

    Article  PubMed  Google Scholar 

  74. Lui TH. Endoscopic distal tibiofibular syndesmosis arthrodesis. Arthrosc Tech. 2016;5(2):e419–24.

    Article  PubMed  PubMed Central  Google Scholar 

  75. Olson KM, Dairyko Jr GH, Toolan BC. Salvage of chronic instability of the syndesmosis with distal tibiofibular arthrodesis: functional and radiographic results. J Bone Joint Surg Am. 2011;93(1):66–72.

    Article  PubMed  Google Scholar 

  76. Kortekangas T, et al. Effect of syndesmosis injury in SER IV (Weber B)-type ankle fractures on function and incidence of osteoarthritis. Foot Ankle Int. 2015;36(2):180–7.

    Article  PubMed  Google Scholar 

  77. Gill SL, et al. The use and efficacy of intra-operative stress tests in supination-external rotation IV ankle fracture fixation. Surgeon. 2015;13(1):9–14.

    Article  PubMed  Google Scholar 

  78. Gardner R, et al. Stabilization of the syndesmosis in the Maisonneuve fracture—a biomechanical study comparing 2-hole locking plate and quadricortical screw fixation. J Orthop Trauma. 2013;27(4):212–6.

    Article  PubMed  Google Scholar 

  79. van der Werken C, Zeegers EV. Fracture of the lower leg with involvement of the posterior malleolus; a neglected combination? Injury. 1988;19(4):241–3.

    Article  PubMed  Google Scholar 

  80. Franke J, et al. Predictors of a persistent dislocation after reduction of syndesmotic injuries detected with intraoperative three-dimensional imaging. Foot Ankle Int. 2014;35(12):1323–8.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Matthew L. Vopat.

Ethics declarations

Conflict of interest

Matthew L. Vopat, Bryan G. Vopat, and Bart Lubberts declare that they have no conflict of interest.

Christopher W. DiGiovanni reports stock options with Wright Medical, Paragon 28, and CreOsso. He is a consultant for Wright Medical and Extremity Medical. He also reports royalties from Extremity Medical.

Human and animal rights and informed consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Foot and Ankle Sports Medicine

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Vopat, M.L., Vopat, B.G., Lubberts, B. et al. Current trends in the diagnosis and management of syndesmotic injury. Curr Rev Musculoskelet Med 10, 94–103 (2017). https://doi.org/10.1007/s12178-017-9389-4

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12178-017-9389-4

Keywords

Navigation