The ankle ligaments: consideration of syndesmotic injury and implications for rehabilitation

Injury to the distal tibiofibular syndesmosis (DTFS) may be more common than previously reported. This injury is typically caused by external forces which produce sudden ankle dorsiflexion or plantar flexion in combination with external rotation of the foot. Common mechanisms include direct contact with another player or uneven physical terrain. Improper diagnosis of this injury may greatly delay the return to normal functional status and promote the development of chronic instability, degenerative joint changes, and pain. The purpose of this clinical commentary is to review the ligamentous anatomy of the ankle and the incidence of injury to the lateral ligaments of the ankle, with emphasis on DTFS injury. Special tests which enhance the recognition of DTFS injury, such as the external rotation stress test and the distal tibiofibular compression test, and a rehabilitation progression are presented.