High Ankle Sprains: A Deeper Look at Syndesmosis Injuries

If you’ve ever been tackled awkwardly, heard a pop above your ankle, or felt like your foot’s been twisted beyond its limits — there’s a good chance you’ve copped a syndesmosis injury. These aren’t your run-of-the-mill ankle sprains. High ankle sprains hit deeper, take longer to heal, and, if not managed properly, can hang around like a bad smell.

We see syndesmosis injuries weekly across both our Mitcham and Aspendale Gardens clinics — especially in footy players, netballers, and sprinters who rely on powerful changes of direction. So, let’s break this down in plain English, based on what we know works on and off the park.

What Is a Syndesmosis Injury?

Unlike the classic “rolled ankle” where the outside ligaments cop the damage, a syndesmosis injury affects the ligaments that join the tibia and fibula — the two long bones in your lower leg. These ligaments sit just above the ankle joint and are crucial for keeping your ankle stable under load, especially during pivoting and pushing off.

Why is it called a “high” ankle sprain?
Because the damage occurs above the ankle joint, not down near the outer ankle bone like typical sprains. And because of that location and the depth of the ligaments involved, healing is slower, and rehab is more involved.

Real-Life Example

A 22-year-old winger from the NPL came in limping after a slide tackle in the second half. Pain was high above the ankle, not much bruising early, but he couldn’t hop or turn. We suspected syndesmosis straight away. He’d tried to “walk it off” after the game — classic move — but the next morning, he could barely get out of bed.

After assessment and an MRI referral, it confirmed a moderate-grade syndesmosis injury. With a structured plan, he was back on the pitch inside 10 weeks. That’s the power of early action and progressive rehab.

How Do You Know It’s a Syndesmosis Injury?

Here are some telltale signs we look for in the clinic:

Symptom	Description
Pain	Felt above the ankle, especially when twisting or pushing off.
Swelling	Can creep up the shin — not always massive early, but builds over time.
Tenderness	Pressing the front of the ankle (between the tibia & fibula) can be agony.
Reduced mobility	Turning, hopping, or walking uphill becomes difficult and painful.
Positive physio tests	We’ll often use the squeeze test or external rotation test for confirmation.
MRI scan	The gold standard for diagnosis, especially if your symptoms aren’t improving.

Pro tip: If it still hurts to twist your foot or go up stairs 5–7 days after the injury, get it looked at. Don’t wait.

What Causes a Syndesmosis Injury?

Syndesmosis injuries usually don’t happen from something as simple as stepping off a curb the wrong way. They’re high-load, high-torque injuries — most often seen on the footy oval, basketball court, or in contact sports where bodies collide and feet get caught underneath.

Here’s how we commonly see them happen in-clinic:

Common Mechanisms

Mechanism	Example
Twisting while planted	Changing direction in a game and the foot stays stuck while the body turns.
Forceful dorsiflexion & rotation	Tackled from behind with foot jammed, pushing the ankle up and outwards.
Tackles or awkward landings	Especially common in AFL or rugby where lower limb contact is frequent.

A good example? I treated a local U18s AFL player who copped a hip-drop tackle mid-marking contest. His boot got stuck in the turf and the opposition player landed straight on the back of his leg. He felt immediate pain above the ankle — that classic syndesmosis burn — and couldn’t put weight through it.

These injuries might not always look dramatic, but they’re often more severe than low ankle sprains and require a very different rehab approach.

Syndesmosis Injury Recovery Timeline

Recovery depends on severity, but here’s a general guide we use at Full Speed Performance. Keep in mind — these are just ballpark figures. Every athlete’s recovery pace varies based on how early they seek help, how compliant they are with rehab, and whether they return too soon.

Grade	Severity	Moon Boot	Weight Bearing	Return to Sport
Grade I	Mild sprain, no instability	Often not needed	As tolerated	4–6 weeks
Grade II	Partial ligament tear, some instability	2–4 weeks	After 7–10 days	6–10 weeks
Grade III	Complete tear or with fibula fracture	4–6+ weeks	Delayed	12+ weeks (surgical if unstable)

When managed early, even a moderate sprain can recover well in under 10 weeks. But if misdiagnosed or rushed, these injuries can drag out, sometimes leading to chronic instability or even requiring surgery.

Why “Walking It Off” Doesn’t Work

Here’s the thing: you can’t grit your way through a syndesmosis injury. It’s not just about pain — it’s about joint integrity. When those high ankle ligaments are damaged, the two bones of the lower leg (tibia and fibula) can start to move independently — a recipe for ongoing instability.

That’s why early diagnosis and proper load management is critical.

Rehabilitation Framework for Syndesmosis Injuries

We break down syndesmosis rehab into five key stages. Each stage has its own focus — and no, you can’t skip ahead without consequences. Think of it like building a house: you’ve got to get the foundation right before you start adding the roof.

Stage 1: Immediate Management – POLICE Protocol

In the first 0–7 days, our main goal is to protect the area, reduce swelling, and avoid aggravating the injury.

What we focus on:

• Protect: Crutches or a boot may be needed depending on pain and grade.
  
• Optimal Loading: This doesn’t mean rest — it means loading within pain-free limits.
  
• Ice: 15–20 minutes every 2–3 hours.
  
• Compression: Tubigrip or compression socks to manage swelling.
  
• Elevation: Keep the ankle above heart level when resting.
  

Common Mistake:
Trying to “test it out” by jogging too early. All that does is delay healing.

Stage 2: Range of Motion & Light Activation

This phase typically starts 1–2 weeks post-injury, once the acute pain settles. The aim here is to gently restore movement without straining the healing ligaments.

Sample mobility and activation work:

• Ankle ABCs (writing the alphabet with your toes)
  
• Towel scrunches to activate foot intrinsics
  
• Isometric holds for calf and peroneal muscles
  

We keep everything controlled and avoid any twisting or sudden loading.

Stage 3: Strength & Stability Training

Usually begins around weeks 3–6, depending on injury grade. This is where we build the muscle support system around the ankle.

Muscle Group	Key Exercises
Peroneals	Banded eversion, side-steps with resistance bands
Calf (gastroc/soleus)	Seated and standing calf raises, isometric heel holds
Glutes & Core	Glute bridges, single-leg RDLs, anti-rotation core drills

We test regularly in clinic — things like single-leg calf holds, hop-to-balance, and BOSU drills — to measure progress.

Case Example:
One of our clients, a female netballer, struggled with recurring ankle sprains after a poorly rehabbed syndesmosis injury in Year 10. We rebuilt her program from scratch with glute focus, and within 8 weeks she had better single-leg control than most of her teammates.

Stage 4: Proprioception & Reactive Control

This phase typically overlaps with strength work but starts to integrate more balance and unpredictability — the kind of movement you face in games.

Key drills:

• Single-leg balance with eyes closed
  
• Wobble board taps
  
• Jump and land with feedback (video or mirror)
  
• Reactive step drills — catch and stick landing, lateral bounds, etc.
  

This stage is essential to retrain the brain, not just the ankle. The goal is to rebuild joint awareness so you don’t get caught off guard again.

Stage 5: Return to Running & Sport

Once strength and proprioception are up to scratch, we transition to more dynamic work. This typically starts around week 6–8, depending on the person.

We use a stepwise return:

Phase	What it Looks Like
Walk-Jog Intervals	Short bursts of jogging mixed with walking (2:1 ratio)
Linear Running	Straight-line tempo runs, gradually increasing speed
Directional Work	Zig-zags, figure 8s, deceleration drills
Sport-Specific Drills	Agility ladders, small-sided games, contact drills

Clearance criteria before return to full sport:

• Hop test symmetry > 90%
  
• Y-balance test within normal range
  
• Pain-free change of direction
  
• Confidence rating ≥ 8/10
  

Avoiding Re-Injury: What to Watch For

The biggest trap we see is athletes returning too early. Just because you can jog in a straight line doesn’t mean you’re ready to play four quarters of footy or cover 10km in a game of soccer.

Red Flags You’re Not Ready

• Pain or pulling sensation above the ankle with cutting or jumping
  
• Limp or altered gait during high-speed running
  
• Trouble balancing on one foot with your eyes closed for 30+ seconds
  
• Fear or hesitation when changing direction or landing
  

We’ve seen many local footy players push through pain for finals, only to land in surgery post-season. It’s not worth it.

Having been on the other side of this — both as a player and physio — I know how frustrating these injuries can be. You feel like you’re almost right, then a small twist sets you back. The key is trusting the process, tracking your progress, and knowing that proper rehab pays off.

At Full Speed Performance, we treat syndesmosis injuries weekly — from junior netballers to semi-pro footballers — and the common thread across every success story is this: early diagnosis, consistent rehab, and structured return to play.

If your ankle still feels dodgy weeks after a sprain, don’t wait for it to “settle down.” Get it checked. It could be the difference between a 6-week recovery and a 6-month layoff.