What it is

Following a tear to the syndesmoses, syndesmosis stabilisation is a surgical procedure, often arthroscopic, that involves securing the separation between the tibia and fibula, allowing injured ligaments to heal, typically after high ankle sprains with diastasis or instability.

While surgeons utilise several techniques, fixation is typically achieved using screws or suture button (tightrope) devices, and followed by a period of non-weight-bearing in a cast or boot, physiotherapy, and progressive rehabilitation to restore strength and mobility. The aim is to restore alignment so the ankle mortise loads evenly during walking and sport.

What happens when it occurs

  • Anatomy: The syndesmosis is the strong ligamentous joint connecting the tibia (shin bone) and fibula (smaller bone in the lower leg) just above the ankle joint.
  • Injury: A syndesmosis injury (also known as a high ankle sprain) occurs when these connecting ligaments are sprained or torn, causing instability in the ankle.
  • Purpose of Surgery: The goal of syndesmosis stabilisation is to restore the proper alignment and stability of the tibia and fibula so the damaged ligaments can heal effectively. Weight-bearing and range of motion advance in steps to protect fixation and rebuild capacity.

Common causes and risk factors

  • Twisting injuries with the foot planted, tackles, or skiing
  • Contact sports with boots that fix the ankle position
  • Return to play before control is restored

Who is most affected

Field and court athletes and skiers with high ankle sprains.

Typical symptoms pre-op

  • Pain above the ankle joint with turning and push off
  • Difficulty with weight bearing and swelling
  • Positive squeeze test higher on the shin

When to seek care

Post-operatively, seek review for wound issues, calf pain, or a feeling of giving way.

How we diagnose

Clinical stress tests, X-rays, and MRI. Surgical findings confirm instability and guide the choice of fixation.

Surgical Procedure

  • Assessment: An arthroscope (a small camera) is inserted into the ankle joint through small incisions to assess the extent of the injury and check for any loose cartilage or scar tissue.
  • Reduction: The surgeon uses instruments to realign the tibia and fibula.
  • Implant Placement:
    • Screws: Traditional screws are inserted through the fibula into the tibia to hold the bones together.
    • Suture-Button (Tightrope): A more modern technique that uses a strong suture and button system to provide dynamic, flexible stabilisation.
  • Verification: A stress X-ray is performed during surgery to confirm that the syndesmosis is stable after the implant is placed.
  • Closure: The incisions are closed with stitches, and the foot is placed in a splint or boot.

Recovery and Rehabilitation

  • Initial Phase: After surgery, the leg is placed in a backslab, splint, or moon boot for 1-2 weeks, during which the foot is kept elevated.
  • Non-Weight-Bearing: The patient remains non-weight-bearing on the affected leg for approximately six weeks.
  • Physiotherapy: A structured physiotherapy program commences, focusing on gentle range of motion exercises, scar management, and calf muscle strengthening.
  • Progression: Weight-bearing is gradually increased, and more strenuous exercises are introduced over several months.
  • Return to Sport: A full return to running and sports typically takes at least two months after surgery, with complete recovery potentially taking up to six months.

Management

  • Hardware removal is considered in some screw constructs, typically after 12 months or if there is irritation from the hardware.

Rehabilitation milestones

Phase 1 weeks 0 to 2: protect alignment, gentle range, swelling control.

Phase 2 weeks 2 to 6: increase weight bearing, strength basics, balance.

Phase 3 weeks 6 to 12: jogging, hopping preparation, and agility drills.

Phase 4 months 3 to 6: return to training and sport after testing.

Readiness to progress

  • Stable alignment on review
  • Strength and balance within 90 per cent
  • Hop and agility tests without next-day pain

Prevention / long-term care

  • Maintain balance and strength
  • Use graded contact exposure
  • Replace worn footwear and consider ankle support in early return

Australia snapshot

  • Seen across football codes and skiing communities
  • Fixation with screws or suture buttons is available in public and private centres.
  • Return to play protocols are common in sports clinics

Latest insights

Restored alignment, along with progressive loading, returns trust in push-off and turns.

Criteria-based testing reduces the risk of early re-injury.

Frequently Asked Questions

If the syndesmosis is disrupted, the anatomical relationship between the fibula and tibia must be maintained while the ligaments heal. The syndesmosis may be stabilised with screw transfixation or suture-button (suspensory) fixation.

After surgery, you may be immobilised in a splint for 10-14 days. You will typically be kept non-weight-bearing for 6-8 weeks and then allowed to put weight on your foot in a cast or boot. Swelling persists for many months after this surgery. Return to sport is approximately 4-6 months.

Your surgeon sets the timeline. Non-weight bearing is common early, followed by a graded increase.

Syndesmosis surgery with TightRope fixation uses a wire, which, when tensioned and positioned against the tibia and fibula, correctly aligns and stabilises the bones.

Sometimes, for screws that limit motion or cause symptoms or irritation. Suture buttons are often left in place.

Research comparing the success rates of treatment modalities for chronic syndesmosis injury fixation reported that success rates were 87.9% for screw fixation, 79.4% for arthrodesis, and 78.7% for arthroscopic debridement.

Often, between weeks 8 and 12, once strength and balance targets are met, clearance is given.

Possible with solid progress and testing in months 4 to 6.

Helpful in the early phases of return while balance and strength rebuild.

Keep balance and agility exercises in your weekly plan even after returning.