Since the AFL has returned you may have noticed a spike in a particular type of ankle injury, the high ankle sprain or otherwise referred to as a syndesmosis injury. I thought it would be a good time to shed some light on its cause and treatment especially with key players like Jake Stringer, Dion Prestia, Toby Nankervis, Aaron Naughton all sustaining the injury in the past few rounds.
Syn-des-what!?
You may be asking yourself …’the syn-des-what..?’.
Yes, Syndesmosis it is a funny name and is referred to regularly in news reports or AFL injury updates. You might be curious about what it is and why it can leave players out of the game for some time to recover and rehabilitate.
The syndesmosis is a ligament located between the two shin bones (tibia and fibula) in the lower leg. There is very little movement between the tibia and fibula due to the strength of this ligament and others around it.
A syndesmosis injury is also known as a ‘high ankle sprain’ and occurs when the ligaments between tibia and fibula are damaged. Damage to these ligaments leads to a loss of stability at the shin and particularly the ankle. This often results in reduced ankle joint movement, reduced balance, stability and power output. These are all key attributes an AFL player must possess with fast changes in direction, speed and repeated jumping and landing during a game.
Possible long term changes in the quality of movement at the ankle joint due to this injury can likely lead to degenerative changes, such as arthritis. Syndesmosis injury is most common in contact sports, especially when landing heavily and being tangled up with another person during the landing. AFL, rugby and basketball are common sports which have increased risk.
Notice the increased width in image B between the two bones which indicates that the syndesmosis ligament has been damaged.
How is it different to an ankle sprain?
A syndesmosis injury, generally occurs in contact sports. This might occur during a tackle or one on one contest compared to a more traditional ankle sprain, which can occur simply by stepping on an uneven surface and rolling over on your ankle. Usually you need the traditional action of rolling your ankle combined with a load coming down across the ankle at the same time. Hence, the risk in AFL sport with tackling or pack marking contests.
The ankle has a number of ligaments and tendons that overall help stabilise the ankle. Even after a severe traditional ankle sprain these muscles and tendons will continue to offer some support to the ankle. With the right management a traditional ankle sprain will recover without requiring any surgical intervention.
There are different severities of syndesmosis related injuries. However, due to the overall influence this injury has on the ankles structural stability and function, they often need greater and longer intervention, sometimes requiring surgery. You only have to refer back to the previous x-ray imaging to see the dramatic influence it can have on the structure of the bones around the ankle.
AFL players have access to more extensive imaging compared to previous years. Syndesmosis injuries are not always clearly identified via X-ray and more extensive scans such MRI are routinely used to determine a more rapid diagnosis and understanding of its severity.
Can we blame Covid-19?
With the interruption to the early season schedule, can we blame the recent increase in syndesmosis injuries on Covid-19?
The Covid restrictions have definitely impacted players match fitness and conditioning this season. Some people have even pointed out that player’s match conditioning and awareness especially early on in the seasons return, has had an impact on player’s body movement and awareness around the ball. It is hard to say that Covid-19 has been influential in the increased number of syndesmosis related injuries this season, as it is always a risk in this style of contact sport. However, it is an interesting topic for discussion and for the other noted injuries we are seeing this season. There no doubt has been a vast variation to player’s preparation, living conditions, travelling schedules and training loads, recovery and fatigue levels this year. Could there be an influence? Will leave this to discuss further with your friends over a zoom catch up!
Management:
As shown in the picture of Aaron Naughton, the acute management is to offload and protect the injured tissues at all costs! A moon boot and crutches prevents any movement at the ankle and avoids placing any weight through the foot and ankle.
A mild syndesmosis ligament tear will require a period of offloading followed by a progressive rehabilitation plan to restore strength, balance and dynamic function of the foot and ankle.
For more severe injuries, surgery is generally recommended. In these instances, conservative management may not be enough to address structural widening between the two shin bones or the overall ankle stability.
Surgical Management:
There are a range of different surgical options to repair a syndesmosis injury depending on its severity. In some cases, there may also be a bone fracture due to the nature of the injury. Surgery may be required to repair any fractures that have occurred while also stabilizing the two shin bones. In the X-ray and image below you can see a common approach to repair a syndesmosis injury. Often screws and plates are used to realign the bones and offer structural stability to the joint longer term.
Post-surgical rehab:
There are generally 3 phases to post-surgical rehabilitation. This process is very individualised and will vary for each person. Below is a very general guide on the rehabilitation involved with surgical repair of syndesmosis injury. Obviously, this is not an exact time frame for everyone. Each person’s recovery and rehabilitation will be monitored closely to ensure the person continues to build up function and overall body conditioning specific to their given sport or activity.
Phase 1: (Week 1-6) – Recovery Phase:
Non-weight bearing and recovery with moon boot and crutches before progressing to slowly graduated weight bearing. This is often assisted with crutches, before moon boot is used alone. Rehab will include trying to ensure minimal loss of condition throughout the rest of the body where possible.
Phase 2: (Week 6-10):
General mobilisation and initial resistance exercises. The aim is to build load bearing stress, such as walking loads, functional balance stresses and muscles strengthening to the leg and ankle during this period.
Phase 3: (Week 10 onwards):
Progressing to dynamic types of exercises. This might include jogging and running loads. Hopping or jump to land exercises. Ideally this would progress to more varied movement patterns for agility and increased ankle stress. The aim is to build up load on the body and injury site to mimic sport specific movements, thus facilitate return to sport.
I hope you enjoyed and gained some further insight into syndesmosis injuries. Please keep your eye out for future posts as we explore common foot and ankle injuries that occur in the AFL over the coming weeks. Please feel free to like us on Facebook and Instagram so you will continue to be alerted to new content we post.
Fluid Movement Podiatry specialise in post-surgical rehabilitation for all your lower leg, foot and ankle injuries. Feel free to contact us if you have any questions or require assistance. We love helping our patients get back on their feet and return to their activity of choice!
All the best
Stuart Rudge
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