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Ankle sprains and syndesmosis injury

I recently read an article in the Open Access Journal of Sports Medicine discussing ankle syndesmosis injuries, which can result in ankle instability and persistent dysfunction. Because of the common occurrence of ankle sprains and because these injuries can appear as a somewhat typical lateral ankle sprain, I thought the topic might be worth mentioning. The following is a very brief synopsis of points I thought were informative.[1]

A syndesmosis injury is a lateral ankle sprain involving the distal tibiofibular joint. Syndesmosis injuries occur relatively commonly, especially in collision sports, and often result in persistent disability.[2] External rotation of the foot relative to the tibia (foot planted and the leg internally rotated) is the typical mechanism of injury. The external rotation mechanism is distinct from the more common inversion ankle sprain and usually involves different ligaments. Because the injury is produced primarily by excessive ankle rotation, the deltoid ligament, on the medial side of the ankle, is often injured and ligaments are sprained on both the medial and lateral aspects.

Clinical presentation in an acute stage includes ecchymosis and tenderness around the lateral malleolus, pain with external rotation, dorsiflexion, and during the push-off phase of gait. The authors suggest that excessive passive external ankle rotation (when tolerated) can provide a clue toward grade 2 or 3 ligament injury resulting in some degree of instability.

Lower fibular fracture can accompany a syndesmosis injury and standard radiography sometimes does not demonstrate instability of the tibiofibular joint without stress views. Stress views are obtained in external rotation and sometimes in weight-bearing. However, stress views can be challenging and sometimes patients are in too much discomfort to tolerate them without a local analgesic injection(s). When stress views are obtained, widening of the tibiofibular distance indicates a grade 2 or 3 sprain and joint instability. Other imaging (musculoskeletal ultrasound, magnetic resonance imaging, or computed tomography) may be needed to rule out a suspected syndesmosis injury not readily apparent on standard radiographs.

The authors suggest that patients with grade 2 or 3 syndesmosis injuries, those with instability, should undergo surgical repair and stabilization to prevent accelerated joint degeneration, persistent pain, and loss of function. I recommend you read the article authored by Porter et al., which provides a solid foundation for understanding ankle syndesmosis injuries.
Reference List

1. Porter DA, Jaggers RR, Barnes AF, Rund AM: Optimal management of ankle syndesmosis injuries. Open Access J Sports Med 2014, 5: 173-182.
2. Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC: Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int 1998, 19(10): 653-660.

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