Syndesmotic Ankle Sprains

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Definition/Description

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Epidemiology/Etiology

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Characteristics/Clinical Presentation

Observationally the Syndesmotic will show significantly less swelling than a lateral ankle sprain, as well as demonstrate a loss of full plantar flexion and an inability to bear weight. Ecchymosis may appear several days post-injury due to the injury of the intereosseuos membrane. A difficulty or inability to toe walk are often noted.

Differential Diagnosis

Because of the occult nature of the high ankle sprain during clinical evaluation it is important to rule out pathologies with a similar MOI. First and foremost an x-ray should be taken to rule out fx of the tibia, fibula and/or the talus (Clinical Review, Norwig). Secondly, the clinician should address concerns of a lateral ankle sprain as the mechanism of injury are between the two injuries are very similar. Norwig writes “Syndesmotic ankle sprains can usually be distinguished from inversion ankle sprains by a history of an external rotation component.” Other possible pathologies are medial ankle sprain, compartment syndrome, severe joint laxity, severe contusion, dystrophic calcification, infection or tumor. These pathologies should be preferentially ruled out before tx of a syndesmotic ankle sprain begins.

Outcome Measures

• Foot and Ankle Disability Index (FADI)

Examination

Hx and MOI: see clinical presentation

• Observation/Gait analysis: Check for discrepancies
• Palpation:tenderness proximally over the anterior tibiofibular ligament and proximal along the interosseous membrane (anterior lateral ankle pain directly over the anterior syndesmosis- syndesmotic ankle sprains in atheletes)

         - Palpate the medial and lateral malleoli for exidence of a fracture (CLINICAL REVIEW- Syndesmosis Ankle SPRAIN)
         - Fibula needs to be palpated from distal to proximal, including the proximal tibiofibular joint to rule out Maissoneuve’s fracture . (Syndesmotic ankle sprains in athletes)

• Distal Pulses: Ensure pedal pulses are present (CLINICAL REVIEW SYNDESMOSIS ANKLE SPRAIN)
• Girth Measurements: Notable swelling of ankle do Figure 8 girth measurements (Andrews et. el)
• Special Test:

File:ER of the foot.JPG

1. External Rotation Test (Kleiger’s Test) (Evaluation handbook- chad starkey)

- Determines rotator damage to the deltoid ligament or the distal tibiofibular syndesmosis.

- Performed by having the knee flexed by 90 degrees with the ankle in neutral position and appyling an external rotational force to the affected foot and ankle. (Recognizing and rehabilitation the high ankle sprain)
-(+) test: Pain in the anterolateral ankle. An indicator of deltoid ligament damage would be if there is a displacement of the talus away from the medial malleolus.

- Interrater kappa= 0.75 (best)- Clinical tests for Ankle Syndesmosis Injury: reliability and prediction of return to function 1998
- Test that gives the best interrater reliability (Syndesmotic ankle sprains in athletes)

File:Squeeze Test.JPG

2. Squeeze Test- separation of the tibia and fibula (Evaluation Handbook)
- Identifies a fibular fracture or syndesmosis sprain.

- Performed by squeezing the tibia and fibula together above the injury.

-(+) test: Pain will be reproduced along the fibular shaft if it’s a fibular fracture and the distal tibiofibular jt for syndesmosis sprain.
- interrater= 0.5 (moderate) Clinical tests for Ankle Syndesmosis Injury: reliability and prediction of return to function 1998

3. Cotton Test (Magee)
- Assess for syndesmosis instability with diastasis.
- Performed: steadying the distal leg with one hand while grasping the plantar hell with the opposite hand and moving the heel directly from side to side (Syndesmotic ankle sprain in athletes)
- (+) test: Any lateral translation would indicate syndesmotic instability (Magee)

Medical Management

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Physical Therapy Management

Goals:
• First two weeks: ROM, decrease pain and swelling, protect ligaments against further injury (Harvard)
• Week 3 and onward: Restore normal ROM, strengthen ligaments and supporting muscles, training to improve endurance and balance (Harvard)

Patient Education:<u</u>

Assistive Devices:
• Crutches- must be maintained until normal, pain free gait is obtained

Modalities:
• RICE (rest, ice, compression, elevation) initially for 15 min 3x a day. (Harvard). However, Bleakley et al suggested that there is little evidence to support the use of RICE, although it is a widely accepted treatment (Dolan)

Therapeutic Exercise/ Neuromuscular Re-education:
• First two weeks: AROM flexion, ankle alphabet, dorsiflexion/plantarflexion and inversion/eversion with theraband (Harvard)
• Important to regain ROM early, however PTs need to be cautious when working on dorsiflexion because it stresses the mortise joint. (Fincher)
• Weeks 3-4: Standing Stretch, seated dorsiflexion stretch with theraband, heel raises and dorsiflexion stretching on step stool (Harvard)
• Progressive weightbearing to promote normal gait pattern.

Manual Therapy:

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