J Korean Foot Ankle Soc.  2018 Dec;22(4):145-150. 10.14193/jkfas.2018.22.4.145.

Management of High Ankle Sprain

  • 1Department of Orthopaedic Surgery, School of Medicine, Chosun University, Gwangju, Korea. leejy88@chosun.ac.kr


High ankle sprain (distal tibiofibular syndesmosis injury) occurs from rotational injuries, specifically external rotation, and may be associated with ankle fractures. The prevalence of these injuries may be higher than previously reported because they may be missed in an initial examination. Syndesmosis injury can lead to significant complications in injured ankle joints, so a precise physical examination and radiological evaluation is necessary. The most important treatment goal is to have the tibia and fibula located in the correct position with respect to each other and to heal in that position. The methods to fix these injuries is controversial.


Ankle; Syndesmosis; Tibiofibular joint

MeSH Terms

Ankle Fractures
Ankle Injuries*
Ankle Joint
Physical Examination


  • Figure 1 Illustration of the ligamentous anatomy of the syndesmosis: anterior-inferior tibiofibular ligament (AITFL), interosseous membrane (IOM), interosseous ligament (IOL), posterior-inferior tibiofibular ligament (PITFL), and transverse tibiofibular ligament (TTL).

  • Figure 2 (A) Sqeeze test is performed by compressive force is applied between fibula and tibia above midpoint of calf. Test is considered If produces distal pain. (B) External rotation test is positive if pain is reproduced with external rotation of the foot and ankle relative to the tibia.

  • Figure 3 Anterior posterior radiograph of the ankle joint demonstrating important landmarks checked above 1 cm of distal tibial articular line. α to β distance is a tibio-fibular clear space, β to γ distance is a tibiofibular overlap, and red arrow indicates medial clear space. α: lateral border of posterior tibial malleolus, β: medial border of fibula, γ: lateral border of anterior tibial tubercle.

  • Figure 4 (A) Coronal section of the ankle joint computed tomography (CT) showed medial clear space widening with avulsion fragment of medial malleolus (arrow). (B) Axial section of the ankle joint CT showed widening of syndesmosis (arrow). (C) Axial T2-weighted magnetic resonance image of the ankle joint magnetic resonance imaging showed ruptured anterior-inferior tibiofibular ligament (arrow).

  • Figure 5 Intraoperative fluoroscopic image. (A) Image showed widening of syndesmosis. (B) Syndesmosis reduction performed by using large reduction clamp. (C) And then the syndesmosis fixation with single 4.5 mm screws was performed.


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