What is the treatment for ankle syndesmosis injuries?

Treatment of Ankle Syndesmosis Injuries

Functional treatment combined with exercise therapy is the preferred approach for ankle syndesmosis injuries, as it provides better outcomes compared to immobilization. 1

Classification and Initial Assessment

• Ankle syndesmosis injuries are classified into three grades based on severity 2:

  • Grade 1: Partial ligament tear without instability
  • Grade 2: Partial tear with occult instability
  • Grade 3: Complete disruption with frank instability

• Key physical examination findings associated with more severe syndesmosis injuries include swelling, hematoma, pain on palpation, and a positive anterior drawer test 1

• Evaluate the severity of swelling, pain, and functional limitations within 4-5 days post-injury when clinical assessment is most accurate 3

Treatment Algorithm Based on Injury Grade

Grade 1 (Stable) Injuries

• Conservative management with short-term immobilization (1-3 weeks) followed by gradual return to activity 2
• Functional support using semi-rigid or lace-up ankle braces is more effective than elastic bandages or tape 1, 4
• Limit immobilization to a maximum of 10 days to avoid prolonged recovery 1

Grade 2 (Partially Stable) Injuries

• Most cases benefit from surgical treatment, though some stable variants may be managed conservatively 2
• If treated conservatively, use functional support combined with exercise therapy 1
• Close monitoring is essential as these injuries may be occultly unstable and lead to chronic problems if undertreated 5

Grade 3 (Unstable) Injuries

• Surgical reconstruction is required 2
• Surgical options include:
  • Syndesmosis screws (metallic or bioabsorbable) 2
  • Dynamic fixation systems like TightRope® 6, 7
  • Fibular intramedullary nails 2

Surgical Considerations

• TightRope® fixation shows advantages over traditional screw fixation 6:

  • Similar clinical outcomes
  • No need for hardware removal
  • Earlier return to activities
  • Grade A evidence supports its use over metallic screws 6

• Traditional syndesmosis screws require a second surgery for removal and carry risk of screw breakage during rehabilitation 6, 7

• Anatomical reduction and effective fixation are crucial to reduce post-surgical complications 8

Rehabilitation Protocol

• Begin exercise therapy as soon as pain allows to restore joint functionality 1, 4

• Exercise therapy should include:

  • Proprioceptive training
  • Strength exercises
  • Coordination exercises
  • Functional exercises 3

• Manual joint mobilization combined with exercise therapy provides better outcomes than exercise therapy alone 1

• Progressive weight-bearing should be initiated as tolerated 4

Recovery Timeline

• Return to light work: 3-6 weeks for partial ligament injuries 4
• Full return to work: 6-8 weeks depending on job requirements 4
• Return to sports may take longer and requires progressive rehabilitation 4

What to Avoid

• Prolonged immobilization (>10 days) delays recovery and is less effective than functional treatment 1, 4
• Ultrasound, laser therapy, and electrotherapy have not shown effectiveness in treatment of acute ankle injuries 1
• Returning to activities too quickly before adequate rehabilitation increases risk of recurrent injury 4