The syndesmosis is the strong but flexible attachment between the tibia and fibula which is critical for ankle joint alignment and function. High ankle sprain is a synonym for injury of this ligament. Syndesmosis injury occurs in approximately 5 to 15% of ankle sprains, and in ankle fractures where the fibula is fractured well above the ankle joint level. There is an increased risk of this injury in hockey, football, and skiing, as well as in elite or high-performance athletes. The most common mechanism is an external rotation force. The diagnosis may be missed or delayed, causing significant disability and the possibility of long-term damage. Clinical findings include pain in the anterior lateral ligament area and persistent pain following ankle sprain. The external rotational stress test and the squeeze test are positive. X-rays may be normal, or may show a small avulsion fragment. MRI alone is not sufficient to make the diagnosis. Special stress x-rays will show the injury. The critical finding is the disruption of the
precise measurable relationship between the tibia and fibula, with widening of the normal distances. Fresh injuries without x-ray abnormalities may be treated by careful and prolonged immobilization, often in a cast. Injuries discovered late or with abnormal findings on x-rays benefit from surgery. New minimally invasive and outpatient surgical techniques are available to treat this condition. These techniques may allow the patient to resume weight-bearing immediately. The goal of treatment is to restore the relationship between the tibia and the fibula, and hold the two bones in appropriate alignment until healing is complete.
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