High Ankle (Syndesmosis) Sprains

High ankle sprains or syndesmosis complex injuries are mostly seen in sports or motor vehicle accidents and usually occur due to excessive twisting or flexing of the ankle. Depending on the severity of the injury, surgery may be required in a high grade injury or injuries with an associated fracture. It is important to obtain an accurate diagnosis, which may require an X-ray or MRI. In all cases, people who have sustained an injury to their syndesmosis will require Physiotherapy. Inadequate rehabilitation or returning to sport too early can result in further progression of the injury and frustratingly, more time on the sideline.

Your physiotherapist will be able to facilitate and monitor your progression through the stages of rehabilitation below.

Stage 1 - Pain Relief and Injury Protection

As with most soft tissue injuries the use of the RICE and No HARM principles are the best management for the first 48-72 hours.  

Rest:  This means that you should stop doing movements or activities that provokes ankle pain. In most cases, you will need to avoid putting weight through your injured ankle and use boot or supportive ankle brace whilst getting around using crutches.
Ice: Is a simple and effective modality to reduce pain and swelling. Please apply for 20 minutes every two hours during the initial phase or when you notice that your injury is warm or hot.
Compression: A compression bandage or taping will help to both support the injured soft tissue and reduce excessive swelling.
Elevation: Elevating your injured ankle above your heart will assist gravity to reduce excessive swelling around your ankle.


Heat, alcohol, running and massage all will increase bleeding to the injured area. Also it is best to avoid anti-inflammatory drugs during the initial 48 to 72 hours when they may encourage additional bleeding.

Stage 2: Regain Full Range of Motion

In the early stages it is important for the ankle to be protected to allow for scar formation, where mature scar formation normally takes at least six weeks. 

During this time, it is important to normalise length and orientate the fibres of the scar tissue. This can be achieved via massage and exercises designed to address your joint range of motion, muscle length and normal neural tissue motion. It is very important to avoid overstretching the healing ligaments as it could lead to ankle instability and ongoing issues. Your physiotherapist will prescribe the exercises that are best suited to your needs.

Stage 3: Restore Muscle Strength

The muscles around your foot, ankle and calf will require strengthening after a syndesmosis injury. It is important to regain normal muscle strength to provide normal ankle function and assist in protecting the ankle. Your physiotherapist will be able to provide you with appropriate strengthening exercises for your needs.

Stage 4: Normalise Foot Biomechanics

In order to prevent a recurrence or a secondary injury, an assessment of your foot biomechanics must be completed and if required, corrected with exercises and/or an orthotic innersole.

Stage 5: Restore High Speed, Power, Proprioception and Agility

To prevent a recurrence of the injury, your physiotherapist will need to prescribe exercises to address these important components of rehabilitation to both prevent a recurrence and improve sporting performance upon return.

Depending on your sport or lifestyle demands, a speed, agility, proprioception and power program will need to be customised to prepare you for the next stage.

Stage 6: Return to Sport

Depending on the demands of your sport, you will benefit from specific sport-specific exercises and a progressive training program to enable a safe return to your chosen sport.

As everyone is different your physiotherapist will need to discuss your goals, return to play time frames and training schedules to provide the best rehabilitation for a safe return to sport.