High Ankle Sprain (Syndesmosis Injury) Treatment in Singapore

A high ankle sprain, medically known as a syndesmosis injury, is a ligament injury affecting the connection between the tibia and fibula (the two long bones of the lower leg) just above the ankle joint. Unlike common ankle sprains, which often heal within a few weeks, syndesmosis injuries typically require medical assessment and may take longer to recover. If not properly diagnosed and managed, this condition may affect mobility and everyday activities. An orthopaedic surgeon can assess the injury and recommend appropriate treatment options to support recovery and a return to usual activities.

Dr Zackary Chua

Senior Consultant Orthopaedic Surgeon (Adult & Paeds)

MBBS (Aus)MMed (SG)MRCS (Glasgow)FRCSEd (Orth)

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High Ankle Sprain (Syndesmosis Injury) Treatment in Singapore

Types Causes & Risks Symptoms When to see a Doctor Diagnosis Treatment Complications Prevention FAQ Conclusion

What is a High Ankle Sprain (Syndesmosis Injury)?

A high ankle sprain involves injury to the syndesmotic ligaments, which stabilise the tibia (shinbone) and fibula (the smaller bone alongside it) above the ankle joint. These ligaments are strong connective tissues that help maintain ankle alignment during movement. The syndesmosis is made up of several key structures, including the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), and the interosseous membrane. Damage to these structures may compromise ankle stability.

This type of injury differs from a common lateral ankle sprain, which affects the ligaments on the outer side of the ankle. High ankle sprains often occur during sports activities and are commonly associated with rotational forces combined with ankle dorsiflexion. Because these violent twisting motions travel up the leg, athletes should also be mindful of concurrent knee injuries, and may need to seek ACL tear treatment if they experience a popping sensation or instability further up the leg.

Types of Syndesmosis Injuries

Grade 1 – Mild Syndesmosis Sprain

Grade 1 injuries involve stretching or minor tearing of the syndesmotic ligaments. The ligament fibres remain largely intact, with only microscopic fibre damage. There is minimal instability, and patients can usually bear weight with mild discomfort.

Grade 2 – Moderate Syndesmosis Injury

Grade 2 injuries feature partial tearing of one or more syndesmotic ligaments, resulting in moderate instability. Stress testing (assessed by an orthopaedic specialist to determine joint stability) may reveal some widening of the syndesmosis, but the overall structure remains intact. Weight-bearing may be painful or limited.

Grade 3 – Severe Syndesmosis Rupture

Grade 3 injuries involve complete rupture of the syndesmotic ligaments, causing significant instability between the tibia and fibula. These injuries are often associated with ankle fractures, such as Maisonneuve fractures, and may require surgical intervention. Imaging studies, including X-rays or MRI scans, typically reveal widening of the syndesmosis.

Causes

External rotation of the foot while the leg stays planted, causing the foot to twist outward
Direct impact on the lateral ankle, pushing the tibia and fibula apart
Hyperdorsiflexion injuries, where the foot is forced upward beyond its normal range
Twisting combined with downward pressure on the ankle during sports movements
Falls from height that result in awkward landings and stress the syndesmosis frequently

Risk Factors

Participation in collision sports such as rugby, football, or ice hockey
Court sports involving rapid direction changes, such as basketball or netball
Previous ankle injuries that may compromise supporting ligaments or muscles
Ankle hypermobility or ligament laxity, allowing greater than normal joint movement
Inadequate warm-up before athletic activity
Reduced ankle proprioception and balance, decreasing joint stability – Inappropriate footwear for specific activities
Training on uneven or unstable surfaces, which increases stress on the ankle

Signs & Symptoms

During Acute Phase (First 72 Hours)

Pain above the ankle joint, especially when pressing between the tibia and fibula
Difficulty bearing weight on the affected leg
Swelling that extends above the ankle joint
Inability to perform a single-leg heel raise
Pain when the foot turns outward

Subacute Phase (3 Days to 2 Weeks)

Persistent pain while walking, especially when pushing off. It is important to monitor your walking habits during this phase; altering your gait to avoid ankle pain can place excessive stress on the bottom of your foot. If you develop a sharp, stabbing heel pain from limping, you may need to explore plantar fasciitis treatment in Singapore alongside your ankle rehabilitation.
Swelling that does not resolve with rest and elevation
Bruising along the lateral ankle and lower leg
Stiffness in the ankle joint
Pain when climbing stairs or walking on uneven surfaces

Chronic Phase (Beyond 2 Weeks)

Ongoing sensation of ankle instability
Pain during twisting or rotational movements
Difficulty returning to sports activities
Swelling that persists after activity
Feeling of the ankle “giving way” during pivoting movements

Pain in syndesmosis injuries can radiate up the lower leg along the interosseous membrane, which connects the tibia and fibula. Recovery times vary, and athletes may need an extended period before resuming full sports activity.

Experiencing these symptoms?

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When to See a Doctor

Seek urgent medical attention if you cannot bear weight within a few steps after injury, experience significant pain above the ankle joint, or notice a visible deformity such as an unusual bend or bone protrusion. These may indicate a serious injury that requires immediate assessment.

Consult an orthopaedic surgeon if pain persists despite rest and ice, or if swelling extends far above the ankle joint. In complex sports injuries, the impact often affects multiple joints, so having your leg evaluated by an experienced knee specialist in Singapore ensures that no secondary damage to the upper leg or knee goes unnoticed.

During your consultation, the orthopaedic surgeon will perform specific tests to assess knee stability. These tests include:

The squeeze test (applies pressure to the lower leg bones to check for pain)
External rotation stress test (gently rotates the foot outward)
Cotton test (checks joint stability)

Imaging, such as X-rays and, if needed, an MRI, can show the extent of ligament damage and rule out fractures. Accurate diagnosis guides effective treatment and may help prevent chronic ankle instability.

Diagnosis & Testing Methods

Clinical examination is essential for diagnosing syndesmosis injuries. During the assessment, our orthopaedic surgeon evaluates ankle stability using specific provocative tests. The squeeze test involves compressing the tibia and fibula at mid-calf, which can reproduce pain if the syndesmotic ligaments are injured. The external rotation stress test rotates the foot outward while stabilising the leg to assess discomfort and detect ligament damage.

Imaging studies provide further detail on the extent of the injury. Weight-bearing X-rays can identify syndesmotic widening and associated fractures, with key measurements including the tibiofibular clear space and tibiofibular overlap. Comparison with the uninjured ankle provides additional reference. Stress radiographs, taken while applying controlled pressure, can help evaluate how the syndesmosis responds under load.

MRI scans allow detailed visualisation of ligament integrity and surrounding soft tissues, detecting partial tears and bone bruising patterns that may not appear on X-rays.

For complex cases or surgical planning, CT scans can offer precise bone detail and three-dimensional reconstructions, helping surgeons identify subtle fractures or alignment issues and plan operative approaches if needed.

Treatment Options Overview

Conservative Management

Conservative treatment is typically recommended for stable Grade 1 and most Grade 2 syndesmosis injuries, where the ligaments are sprained but the bones remain properly aligned. Initial management follows the RICE protocol, which involves rest, ice, compression, and elevation, combined with protected weight-bearing using crutches or a walking boot. Anti-inflammatory medications may be prescribed to control pain and swelling during the acute phase, and the ankle is often immobilised in a Controlled Ankle Movement (CAM) walker boot for several weeks, depending on the severity of the injury.

Injection Therapies

Injection therapies may be considered for persistent inflammation after the acute phase. Corticosteroid injections target the syndesmotic region to reduce inflammatory response and pain. Platelet-rich plasma (PRP) injections use growth factors from the patient’s own blood to stimulate tissue repair and potentially enhance ligament healing. In chronic cases with cartilage irritation, viscosupplementation injections may provide lubrication and relieve discomfort.

Surgical Stabilisation

Surgical stabilisation is generally reserved for Grade 3 injuries involving complete ligament tears or significant widening of the syndesmosis. During surgery, the orthopaedic surgeon may insert screws or suture-button devices to maintain proper alignment of the tibia and fibula while the ligaments heal. Arthroscopic techniques allow for minimally invasive assessment, removal of damaged tissue, and evaluation of cartilage surfaces. The choice between rigid fixation with screws and dynamic fixation with suture-button devices depends on the injury pattern and the patient’s specific circumstances.

Physiotherapy and Rehabilitation

Physiotherapy and rehabilitation form a key part of recovery, progressing through phases tailored to the stage of healing. Once initial ligament healing occurs, gentle range-of-motion exercises help maintain flexibility, while early mobilisation helps prevent stiffness. Strengthening exercises target the calf muscles, peroneals (muscles on the outer ankle), and intrinsic foot muscles, while proprioceptive training restores balance and neuromuscular control to reduce the risk of reinjury.

Advanced Therapeutic Modalities

Advanced therapeutic modalities may complement standard rehabilitation for chronic or slow-healing injuries. Shockwave therapy can stimulate tissue repair, low-level laser therapy may reduce pain and inflammation, and electrical stimulation techniques such as transcutaneous electrical nerve stimulation (TENS) or interferential therapy can provide analgesic benefits and reduce muscle guarding.

Every patient’s condition is unique.

Consult with our Senior Consultant Orthopaedic Surgeon to assess your specific situation and discuss appropriate treatment options.

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Complications if Left Untreated

If syndesmosis injuries are left untreated, they may lead to chronic ankle instability, often presenting as recurrent episodes of the ankle “giving way” during daily activities. Altered biomechanics (changes in how your ankle moves and bears weight) may place abnormal stress on the ankle joint cartilage, accelerating degenerative changes and increasing the risk of post-traumatic arthritis.

Persistent instability can also cause abnormal motion between the tibia and fibula, leading to chronic pain and impingement of surrounding soft tissues. Scar tissue formation may further restrict ankle mobility and contribute to ongoing discomfort.

Long-term complications may include heterotopic ossification, in which abnormal bone forms within the syndesmosis, creating a rigid and painful connection between the bones. Chronic synovitis, or inflammation of the joint lining, can develop from repetitive irritation, causing persistent swelling and stiffness. These complications may necessitate more complex interventions in the future, such as complex reconstructive surgery or ankle fusion procedures, to restore stability and function.

Prevention

Proper warm-up routines that incorporate dynamic stretching and progressive loading help prepare the ankle for the demands of activity. Emphasis on calf muscle flexibility, specifically the gastrocnemius and soleus, along with ankle mobility exercises, supports controlled foot and ankle movement. Practising sport-specific movement patterns at gradually increasing intensity helps prepare the ankle for full participation.

Proprioceptive training, including balance boards, wobble cushions, and single-leg drills, can enhance neuromuscular control and improve the body’s ability to respond to unexpected balance shifts. Progressive plyometric exercises, such as jumping and landing drills, help develop explosive strength while reinforcing proper landing mechanics.

Appropriate footwear selection based on activity type and playing surface provides external support, and high-top shoes or ankle braces may be considered for individuals with prior ankle injuries. Taping techniques can offer additional stability during higher-risk activities. Regular monitoring and adjustment of training loads help prevent overuse and reduce the likelihood of injury.

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Frequently Asked Questions

How long does recovery from a high ankle sprain typically take?

Recovery time varies depending on the severity of the syndesmosis injury. Mild injuries (Grade 1) may require several weeks before returning to normal activity, while moderate injuries (Grade 2) may take longer. Severe injuries (Grade 3), particularly those requiring surgery, often need several months for full recovery. Athletes generally require extended rehabilitation to return to competitive sports, as resuming activity too soon may increase the risk of reinjury or chronic instability. Our orthopaedic surgeon will guide recovery using clinical markers of healing and functional assessments.

How can I tell if I have a high ankle sprain versus a regular ankle sprain?

High ankle sprains differ from lateral ankle sprains in pain location and mechanism. Pain occurs above the ankle joint between the tibia and fibula rather than below the outer ankle bone. These injuries often result from rotational forces rather than simple inward rolling of the foot. Weight-bearing is usually more painful, swelling may extend higher up the leg, and clinical tests such as the squeeze test may reproduce pain. Accurate diagnosis requires professional assessment.

Will I need surgery for my syndesmosis injury?

Many Grade 1 and stable Grade 2 syndesmosis injuries may heal successfully with conservative treatment, including immobilisation, protected weight-bearing, and structured rehabilitation. Surgery may be necessary for complete ligament rupture, significant widening between the tibia and fibula, or associated fractures. Some injuries initially treated conservatively may later require surgical stabilisation if instability persists. Our orthopaedic surgeon determines treatment based on clinical examination, imaging results, and functional demands.

Can I play sports after recovering from a high ankle sprain?

Return to sports is possible after appropriate treatment and rehabilitation. The timeline depends on injury severity, treatment method, and sport-specific demands. Functional testing, including hop tests, agility drills, and sport-specific movements, helps determine readiness. Gradual return-to-play protocols allow safe progression from individual training to full competition. Some athletes may use taping or braces during early return phases. Recovery outcomes vary depending on individual healing and injury characteristics.

What’s the difference between syndesmotic screws and suture-button devices?

Syndesmotic screws provide rigid fixation and may require removal after several months, while suture-button devices allow limited movement while preventing abnormal widening of the tibia-fibula gap and usually remain in place permanently unless irritation occurs. Both methods provide comparable outcomes, and the choice depends on injury pattern, activity level, and individual factors. Suture-button devices may allow earlier weight-bearing and have lower reoperation rates in some cases.

Why does my high ankle sprain hurt more than my previous regular ankle sprain?

High ankle sprains often cause more significant pain due to the stabilising role of the syndesmotic ligaments. Weight-bearing creates separation forces between the tibia and fibula, triggering pain. The greater involvement of structures and proximity to the interosseous membrane contribute to more extensive pain, and the inflammatory response tends to be more pronounced. The deeper ligament location makes traditional ice and compression less effective, potentially prolonging the acute pain phase.

Conclusion

High ankle sprains are complex injuries that require accurate diagnosis and appropriate management. These syndesmosis injuries, which involve damage to the ligaments connecting the two lower leg bones above the ankle, typically take longer to heal than common ankle sprains. Timely and appropriate treatment may support recovery and return to daily activities. Early recognition and intervention may help reduce the risk of chronic instability and long-term complications that could affect mobility.

Management of syndesmosis injuries requires understanding that recovery cannot be rushed. Adherence to recommended treatment protocols, whether conservative or surgical, may influence outcomes. Contemporary management approaches combine evidence-based medical care with individualised rehabilitation programmes tailored to injury severity and functional needs.

Take the First Step Towards Better Health

Living with a high ankle sprain can be challenging. Consider consulting with our Senior Consultant Orthopaedic Surgeon to discuss assessment and management options for syndesmosis injuries.

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Dr Zackary Chua (蔡克祥医生)

Senior Consultant Orthopaedic Surgeon (Adult & Paeds)

MBBS (AUS)|MMed (Singapore)|MRCS (Glasgow)|FRCSEd (Orth)

A senior consultant orthopaedic surgeon with dual specialisations in Foot & Ankle Surgery and Paediatric Orthopaedics. Backed by his extensive years of training and experience, Dr Chua brings the necessary knowledge and skills to ensure a smooth recovery journey.

Rooted firmly by two fundamental philosophies: “When one’s feet hurt, one hurts all over” and “Children are not little adults”, Dr Chua’s approach to patient care reflects his compassionate care for adults and children.

Singhealth Quality Excellence Award – Silver (2011)
Service From the Heart Award (2021)
Singapore Health Quality Service Award – Gold (2023)
NUS Medicine Dean’s Award for Teaching Excellence (2023)

His active participation in the medical community extends to mentoring, research supervision, and contributions to key professional forums and symposiums, both locally and internationally.