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Syndesmotic ankle injury (high ankle sprain)

Kevin deWeber, MD, FAAFP, FACSM
Section Editors
Patrice Eiff, MD
Francis G O'Connor, MD, MPH, FACSM
Deputy Editor
Jonathan Grayzel, MD, FAAEM


A syndesmotic ankle sprain is an injury to one or more of the ligaments comprising the distal tibiofibular syndesmosis; it is often referred to as a "high ankle sprain." Compared with the more common lateral ankle sprain, the high ankle sprain causes pain more proximally, just above the ankle joint, and is associated more often with significant morbidity. Diagnosis can be difficult and clinicians should consider the possibility of syndesmotic injury in athletes with pain or injury around the ankle or lower leg. Treatment too is different from typical ankle sprains and surgery may be necessary, making recognition important for optimal recovery.

The risk factors, clinical presentation, diagnosis, and management of high ankle sprains in the absence of any associated fracture is reviewed here. The common ankle sprain and other ankle-related injuries are discussed separately. (See "Ankle sprain" and "Foot and ankle pain in the active child or skeletally immature adolescent: Evaluation" and "Overview of ankle fractures in adults" and "Evaluation and diagnosis of common causes of foot pain in adults" and "Achilles tendinopathy and tendon rupture" and "Non-Achilles ankle tendinopathy" and "Talus fractures".)


High ankle sprains are much less common than the typical lateral ankle sprain. Using clinical diagnostic criteria (ie, not radiologic), the largest observational studies report that high ankle sprains comprise approximately 6 percent of acute ankle sprains without fracture. The incidence in the United States is 2.09 injuries per 100,000 person-years [1].

In the general population presenting to an emergency department, 5.7 percent of acute ankle sprains without fracture are high ankle sprains [2]. At the United States Military Academy, 6.7 percent of acute ankle injuries involve the syndesmosis, with an incidence rate of 4.8 per 1000 person-years [3]. A smaller study at the Academy found 16 percent of acute ankle sprains involve the syndesmosis [4]. The incidence reported in other subpopulations varies widely. High ankle sprains comprised 4 percent of all acute ankle sprains among professional English soccer players [5], 24.6 percent among American college football players [6], and 73 percent among professional American hockey players [7]. Other studies confirm the relatively high rates among American football players [8]. The high, rigid ankle support of a hockey skate, which transfers forces proximally along the leg, likely plays a role in the higher rate of syndesmotic injury among hockey players, although the actual incidence is unlikely to be as high as that reported in the study cited above.

Among studies using magnetic resonance imaging (MRI) to evaluate injury patterns, prospective studies of acute ankle injuries without fracture presenting to emergency departments reported syndesmotic injuries in 8 to 13 percent of injuries [9,10]. In other subpopulations, the proportion of acute ankle injuries with syndesmotic injury varies from 20 to 60 percent [11,12]. This wide range is likely due to inconsistencies in the literature related to the different subpopulations studied. As examples, some studies have looked only at winter athletes while others include only patients with "severe" ankle sprains.


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Literature review current through: Sep 2016. | This topic last updated: Apr 19, 2016.
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