Physical Therapy in Sport 12 (2011) 57e69

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Physical Therapy in Sport

journal homepage: www.elsevier.com/ptsp

Masterclass

Evaluation and management of ankle syndesmosis injuries

Edward P. Mulligan*
UT Southwestern Medical Center School of Health Professions, Department of Physical Therapy, 5323 Harry Hines Blvd, Dallas, TX 75390-8876, United States

a r t i c l e i n f o
Article history: Received 16 November 2010 Received in revised form 7 March 2011 Accepted 9 March 2011 Keywords: Ankle injuries Tibiobular joint Syndesmosis Review

a b s t r a c t
Background: Ankle injuries are common in sporting activities with damage to the inferior tibiobular ligaments being notable for their resultant disability and prolonged recovery. Objective: To provide a synopsis of the current best evidence regarding the recognition and treatment of injury to the syndesmotic ligaments of the ankle. Design: Structured narrative overview. Methods: Keyword search of Medline, CINAHL, and PEDro databases for studies published in English from January 1985 to July 2010. In addition, the reference lists from articles obtained were manually searched for relevant literature. Summary: This manuscript provides an overview of the distal tibiobular pathologies, discusses the accuracy, limitations, and prognostic ability of clinical and radiographic examination techniques, and presents a philosophical approach to the rehabilitative management of syndesmotic injuries that integrates known biomechanical inuences. Conclusion: An appreciation for the mechanism of injury and a careful examination can distinguish these injuries from other forms of ankle instability. Proper recognition and immediate attention to the unique complexities of this joint can minimize morbidity and prevent a delayed return to sports. 2011 Elsevier Ltd. All rights reserved.

1. Introduction While the distal tibiobular and talocrural joints share geographic proximity, injuries to these articulations are quite distinct. Injury to the syndesmotic tibiobular joint is much less prevalent than lateral ankle sprains, but recognition has increased in recent years due to a heightened awareness of its mechanism, symptoms, signs of injury and poorer outcomes. Estimates on the incidence of this injury vary from 1 to 11% (Beumer et al., 2004; Cottom, Hyer, Philbin, & Berlet, 2009; Lin, Gross, & Weinhold, 2006; Norkus & Floyd, 2001; Nussbaum, Hosea, Sieler, Incremona, & Kessler, 2001; Pajaczkowski, 2007). This broad uctuation is attributable to inconsistent criteria used to diagnose their presence and the nature and intensity of the sporting activity in which epidemiological studies have evaluated their frequency. High intensity, athletic activities that have frequent cutting and twisting demands or limited mobility in a boot have been reported to have the highest incidence of this injury (Boytim, Fischer, & Neumann, 1991; Press, Gupta, & Hutchinson, 2009; Williams, Jones, & Amendola, 2007; Wright, Barile, Surprenant, & Matava, 2004).

The primary role of the syndesmosis is to maintain the congruency of the tibiotalar interface under physiologic, axial loads. Recognition of the subtle anatomical changes inherent to this pathology allows prompt attention to the signicant impairments that are notorious for delaying a functional recovery following this injury. 2. Anatomy/biomechanics The distal tibiobular joint is a syndesmotic articulation formed between the concave surface of the distal tibia and convex shape of the distal bula. The joint is rmly anchored by a number of ligaments and the stable morphology of this joint is critical to normal function (Fig. 1). Collectively, the ligaments prevent diastasis of the joint. Anteriorly, the anterior inferior tibiobular ligament (AITFL) courses in an inferior direction, medial to lateral, in the frontal plane. The posterior inferior tibiobular ligamentous (PITFL) structures also run in an inferior direction and are slightly stronger and thicker than their anterior counterpart (Fig. 1). The posterior and inferior transverse tibiobular ligaments combine to provide 40e45% of the resistance to diastatic stress. The AITFL contributes approximately 35% of the resistance to this stress with the remaining stability (20e25%) coming from the interosseus membrane (IOM) (Ogilvie-Harris, Reed, & Hedman, 1994). The IOM

* Tel.: 1 214 648 1553; fax: 1 817 684 7201. E-mail address: ed.mulligan@utsouthwestern.edu. 1466-853X/$ e see front matter 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ptsp.2011.03.001

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Fig. 1. Inferior Tibiobular Ligaments. A) Lateral view; B) Cross-sectional view; C) Posterior view; and D) Anterior view of the main ligamentous structures that support the tibiobular syndesmosis. 1) Posterior inferior tibiobular ligament (PITFL); 2) Anterior inferior tibiobular ligament (AITFL); 3) Interosseus membrane (IOM); 4) Inferior transverse tibiobular ligament (ITTFL).

also restrains posterolateral bowing of the bula and transmits a small portion of the load from the tibia to the bula during weight bearing (Evans & Schucany, 2006). Both the anterior and posterior tibiobular ligaments check excessive external rotation of the bula. The distal tibiobular joint is classied as a brous syndesmotic joint allowing minimal motion. The trapezoidal shape of the talus requires accessory motions to gap and approximate the mortise during sagittal plane ankle joint motion. The anterior aspect of the superior trochlear surface of the talus is 3e4 mm wider than the posterior portion. The distal tibiobular joint acts as a spring to spread the mortise to accommodate the wider portion of the talus with dorsiexion and recoils when the joint returns to a plantarexed position (Fig. 2). The talus also rotates during ankle plantar and dorsiexion. During non-weight bearing plantarexion, the distal bula moves anteroinferiorly and medially rotates following the internal rotation of the talus. Conversely, the distal bula glides in a posterosuperior direction during ankle dorsiexion as it laterally rotates to mirror the motion of the talus. Excessive external rotation of the foot in dorsiexion, particularly in weight bearing, challenges the ability of the syndesmotic ligaments to maintain the integrity of the mortise in a posterolateral direction (Fig. 3).

With both mechanisms of injury, the closed-pack congruency of the joint is unable to accommodate the transverse plane rotation of the talus within the mortise and the bula is displaced in a lateral direction. The hyperdorsiexion injury is most common in running or jumping sports when the foot is planted and the athlete falls forward, is pushed forward, or comes to an abrupt stop (Dattanni, Patnaik, Kantak, Srikanth, & Selvan, 2008).

4. Signs/symptoms of the injury Syndesmotic ankle injuries are distinguished from other varieties of ankle ligamentous injuries based on the mechanism of injury, self-report history, and/or physical examination. The classic feature of this sprain is palpatory tenderness over the anterior and posterior tibiobular ligaments. Often the athlete will point specically to this site as the area of maximal tenderness. If the mechanism of injury involves a hyperpronation force at the subtalar joint, the calcaneus will maximally evert and damage medial soft tissue structures. This stress can cause additional pain at the anterior portion of the deltoid ligament. As the severity of the injury increases, tenderness extends proximally over the anteromedial portion of the bula at the insertion of the IOM which is a couple of centimeters proximal to the ankle joint. Symptom reproduction with palpation of the AITFL has fair reliability and a positive predictive value of 70% (Alonso, Khoury, & Adams, 1998) (Fig. 5). These injuries are not prone to the severe swelling as seen in lateral inversion sprains and have less ecchymotic discoloration as the damaged tissue is considered extracapsular. The mild amount of swelling is usually seen just proximal to the ankle joint axis within the rst 24 hours (Fites, Kunes, Madaleno, & Johnson, 2006). Range of motion is typically limited in both directions of sagittal plane motion with an empty or painful end feel at terminal dorsiexion. Eversion or valgus stress at the subtalar joint may reveal a soft or boggy end feel suggesting concomitant deltoid ligament laxity. There is not typically an alteration in distal pulses suggesting that vascular compromise at the dorsalis pedis or posterior tibial pulses is unusual. If the athlete is able to ambulate after an injury they will display a gait pattern characterized by a decreased stride length and shortened stance phase. Both the initial contact and propulsive phases of gait are altered as the athlete tries to minimize end-range dorsiexion. A at foot initial contact and ineffective heel off in terminal stance are common compensatory patterns during the

3. Mechanism of injury Athletic activities such as football, rugby, and lacrosse, with the inherent intensity of play, twisting and cutting demands, and risk of contact are particularly susceptible to syndesmotic injuries. Additionally, sports that require rigid immobilization in a boot (hockey and skiing) are prone to the external rotation force that causes distal tibiobular stress. Wright et al. (2004) found that 74% of ankle injuries in the National Hockey League were of this nature. The extent of the injury can include sprains, sprains with latent or frank diastasis, and/or fractures. The two most commonly cited mechanisms of injury are forced external rotation of the foot on the tibia and/or hyperdorsiexion. The external rotation force comes in two varieties. First, the foot is xed in a toe-out position during an open cut and there is a direct blow to the lateral aspect of the knee while the body is turning away from the foot. The other mechanism of injury occurs when a player is prone on the ground with the foot xed in an externally rotated position and a force on the knee or heel (usually in a pileup) comes from a lateral direction (Norkus & Floyd, 2001) (Fig. 4).

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Fig. 2. A) Posterior talar glide in dorsiexion. The closed-pack position of the talocrural joint is due to the trapezoidal shape of the talus. The wider anterior portion of the talus is wedged between the malleoli to fully engage the mortise at end-range dorsiexion. B) Anterior talar glide in plantarexion. The resting position (maximal loose-pack position) is in slight plantarexion.

acute phase. If the athlete is unable to weight bear a few steps after the injury, the Ottawa fracture rule should be applied to determine the necessity of ankle radiographs (Stiell et al., 1994) (Fig. 6). Ligamentous stress tests are contraindicated until bony fractures have been ruled out. The combination of swelling, tenderness, laxity, weight bearing reluctance, and radiographic ndings allows the injury to be classied on a Grade I to III continuum. In the absence of a fracture, the West Point Ankle Grading System is an ordinal categorization

Fig. 3. With the ankle in dorsiexion, an external rotation force on the foot will cause the talus to rotate externally and separate the mortise.

Fig. 4. Typical mechanisms of injury for distal tibiobular sprains/fractures. A) The foot is xed in a position of external rotation with the ankle dorsiexing while a lateral force at the trunk or hip causes an internal rotation of the lower limb; B) The athlete is in a prone position and receives a direct blow to the lateral leg forcing the dorsiexed ankle into excessive external rotation.

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Fig. 5. Point tenderness is usually over the anterior inferior tibiobular ligament (AITFL) and distal portion of the interosseus membrane as opposed to the anterior talobular ligament (ATFL) that is injured with inversion sprains.

system that classies the injury in a range from minimal (Grade I), to moderate (Grade II), to denite (Grade III) instability (Gerber, Williams, Scoville, Arciero, & Taylor, 1998). 5. Imaging Radiographic evaluation for potential fractures and diastasis usually involve three views. These views are an anterior to posterior (AeP), mortise, and a lateral view. The mortise view is taken with the tibia internally rotated 15e20 to allow for better visual appreciation of the medial clear space. The AeP and lateral views should extend the entire length of the tibia and bula to rule out a Maisonneuve fracture of the proximal bula. Unilateral weight bearing lms are preferred to maximize displacement but most athletes will not tolerate this position immediately following the injury (Lin et al., 2006). In this case, bilateral weight bearing or nonweight bearing assessments are necessary. The mortise and lateral views are valuable in viewing the anatomical diastasis when an

external rotation stress is imposed (Doughtie, 1999; Fites et al., 2006; Xenos, Hopkinson, Mulligan, Olson, & Popovic, 1995). As with any clinical examination, it is important to evaluate the radiographic ndings in comparison to the non-injured side to account for inherent differences in physiological laxity. There are three parameters that are utilized to evaluate for syndesmotic injury. These indicators are the tibiobular clear space, medial clear space, and tibiobular overlap. Fig. 7 provides normative values. The tibiobular clear space is considered the most reliable of these indicators as it is not signicantly inuenced by tibial rotation (Press, Gupta, & Hutchinson, 2009). Excessive medial clear space correlates well with injury to the deltoid ligament and its inability to restrain lateral shift of the talus (Rammelt, Zwip, & Grass, 2008). It is important to note that normal tibiobular radiographs do not absolutely rule out an injury to the supporting ligaments due to a high rate of false negatives (44e58%) (Takao, Ochi, Oae, Naito, & Uchio, 2003); however, there is a high specicity with a low chance for false positives. While not typically necessary, CT scans are capable of detecting bony abnormalities and even smaller increments of diastasis while MRIs can assess for soft tissue damage and have been shown to have a sensitivity and specicity that approach 100% (Ebraheim, Lu, Yang, Mekhail, & Yeasting, 1997; Oae et al., 2003; Rammelt et al., 2008; Takao et al., 2003). Recent investigators have also shown that dynamic ultrasound can be used to accurately detect the presence of AITFL injuries (Mei-Dan, Kots, Barchilon, Massarwe, Nyska, & Mann, 2009). For athletes in whom the symptom response becomes stagnate, a radiograph may be used to evaluate for the presence of heterotopic ossication or development of a synostosis within the IOM. There is no consensus in the literature as to how long it takes for heterotopic ossication to occur; only that is a complication noted in chronic conditions. 6. Special tests Numerous clinical tests have been described for syndesmotic injuries yet relatively little is known regarding their clinical utility. Their diagnostic accuracy, prognostic potential, ability to distinguish severity of injury, or capability to correlate with the degree of instability present has yet to be well established. It is unlikely that any one test can consistently gauge the degree of tibiobular displacement and it would only be speculative to associate the degree of pain with the extent of laxity. Consequently, all ligamentous tests use the reproduction of symptoms as opposed to the perceived amount of

Fig. 6. Ottawa Fracture Rule. Plain radiographs should be obtained if there is pain in the zone around the malleoli with point tenderness in area A or B, pain in the zone around the midfoot with point tenderness in the area of C or D, or there is an inability to immediately bear weight. A e Distal 6 cm of the posterior edge of the bula or tip of the lateral malleolus; B e Distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus; C e Base of the 5th metatarsal; D e Navicular.

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Fig. 7. Syndesmotic Injury Imaging Criteria. A e Normal radiograph; B e Abnormal radiograph with no tibiobular overlap and increased tibiobular and medial clear space.

laxity as the basis for a positive test. The following tests are some of the more common provocative stress tests. 6.1. Squeeze test This test is performed by approximating the proximal third of the leg to cause a distal separation of the tibia and bula (Fig. 8). A

positive test is replication of pain in the area of the AITFL. This technique has been reported to have a low positive predictive value and poor intra-examiner reliability (Alonso et al., 1998; Beumer et al., 2004). This is likely due to the necessity of all major restraints (AITFL, PITFL, and IOM) being compromised to an extent that allows detection of the injury and the variability in the intensity of the compression squeeze needed to reproduce the pain

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tibiobular ligament and provide momentary relief prior to the rebound pain that is experienced when the examiner releases their pressure and the malleoli spring back to their original position. The diagnostic accuracy of this maneuver has not been investigated. 6.2. Dorsiexion-compression test Ward (1994) described a provocative maneuver in which an increase in ankle motion or a decrease in pain could be reproduced with a manual compression of the malleoli during passive dorsiexion. Alonso et al. (1998) described a similar maneuver to modify symptom awareness. For this test, the athlete performs a squatting maneuver driving the tibia as far forward as possible. An inclinometer is used to assess the end-range position in which symptoms are reproduced. The maneuver is repeated with the examiner providing a medial to lateral compressive force across the syndesmosis. If the symptoms decrease or the amount of motion achieved as measured by an inclinometer is improved the test is suggestive of a high ankle sprain (Fig. 9). The limitations of both of these tests are their dichotomous outcome nature and inability to distinguish mild from more severe degrees of injury. Alonso et al. (1998) reported fair intertester reliability for these techniques (K 0.35e36) and a positive predictive value of 47%. While these techniques have unknown diagnostic value, they can be used to reduce symptom reproduction during rehabilitative activities. 6.3. Dorsiexion-external rotation test Sometimes referred to as the Kleiger test, this provocative procedure is performed by stabilizing the leg and then externally rotating the foot (transverse plane abduction) with the ankle in maximal dorsiexion (Fig. 10). The largest displacement of the syndesmosis and tension on the restraining ligaments is created by these combinations of forces as the broader portion of the talus externally rotates within the mortise. Reproduction of anterolateral syndesmotic pain indicates injury to the tibiobular ligaments while medial ankle pain implicates deltoid ligament involvement. This test has the highest degree of inter-tester agreement, the lowest rate of false positives, and correlates with a protracted recovery if there is also palpatory tenderness and a positive squeeze test (Alonso et al., 1998). It is postulated that the relative accuracy of

Fig. 8. Squeeze test. Compression of the proximal third of the leg to cause a distal separation of the tibia and bula.

complaint. Two studies have indicated that a positive test correlates with an extended recovery time or the presence of heterotopic ossication (Hopkinson, St. Pierre, Ryan, & Wheeler, 1990; Taylor, Englehardt, & Bassett, 1992). A related test, the Malleolar CompressioneRebound Test, is a variation of the Squeeze Test. This test is performed by the examiner compressing the malleoli in the palms of their hands. Theoretically, this maneuver will slacken the

Fig. 9. Dorsiexion-compression test. Assessing the impact of manual compression of the malleoli during dorsiexion.

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this examination procedure is that unlike other special tests in that it does not have to rely on compromise to the IOM, decits in the medial collateral ligaments, or only challenge the structural stability of the bony architecture (Beumer et al., 2004). 6.4. Manual stability tests The Cotton (Shuck) and Fibular Translation (Drawer) Tests are direct assessments of the degree of bony translation available. The Cotton test is performed with alternating medial and lateral forces to the talus with the ankle in a neutral position while the Fibular Translation test stresses the bula in an anterior and posterior direction. A positive test is present if there is an excessive amount of translation or a boggy end feel. These tests have a high rate of false positives secondary to the examiners interpretation of looseness and the need to perform these tests in precise positions and in specic directions of stress (Beumer, Swierstra, & Mulder, 2002). These tests only tend to produce displacement within the normal physiological limits and excessive translation is probably only present with the most severe grade of injury. 6.5. Crossed-leg test Kiter and Bozkurt (2005) described a self-administered test that produces stress in the area of the syndesmosis. In this test the patient assumes a g. 4 sitting position with the involved mid-tibia resting just proximal to the knee. The patient then applies a gentle downward stress on the medial aspect of the involved side knee (Fig. 11). This provocative maneuver reproduces the concordant complaint by mimicking the aggravating mechanism of the squeeze test. A positive test reproduces the patients pain complaint in the area of the syndesmosis. The authors reported 7 of the 9 patients who had radiographic abnormalities tested positive with the maneuver. 6.6. Heel thump test Lindenfeld (Lindenfeld & Parikh, 2005) described a clinical procedure to target the tibiobular ligaments in the absence of a fracture. The patient is sitting with the leg dangling over the edge

Fig. 10. Dorsiexion-external rotation test. The lower leg is stabilized while the examiner externally rotates the foot with the ankle in maximal dorsiexion. The external rotation force should be sufcient to mildly gap the distal syndesmosis.

Fig. 11. Crossed leg test: sitting in a g. 4 position with tibia resting on the knee. Patient applies gentle downward stress on the medial aspect of the involved knee.

Fig. 12. Heel Thump Test. Thumping the heel forces the talus to contact the mortise and reproduce the athletes pain complaint.

64 Table 1 Grading of injury severity based on clinical presentation. Clinical presentation Symptoms Stability (manual bular translation) Plain radiograph Imaging Management strategy Weight bearing Immobilization

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Grade I e Sprain without diastasis Mild point tenderness over tibiobular ligaments Mild laxity with stable end point to stress Stable with stress on plain radiographs Weight bearing to tolerance 0e3 days

Grade II e Sprain with latent diastasis Point tenderness extends proximally over the IOM Moderate laxity with soft end point to stress Mild laxity present with stress but absent with plain radiographs Progress to full weight bearing after 1e2 weeks 3e7 days

Grade III e Sprain with frank diastasis Signicant tenderness and inability to weight bear Notable laxity with absence of end point Instability and/or fracture evident on plain radiograph Minimum of 2e3 weeks non-weight bearing 7 days

of the plinth in a position of gravity induced equinas with the examiner stabilizing the lower leg. From this position, the examiner delivers a rm thump to the bottom of the heel in line with the long axis of the tibia (Fig. 12). A positive test is present if the thump briey aggravates the patients pain complaint above the ankle or in the distal leg. The intent of this test is not to stress the syndesmosis but to screen for acute pain as the talus impacts the mortise during the thump. This test may have adjunctive value if there is enough swelling to decrease the specicity of palpation. The test is also valuable when the injury is too acutely uncomfortable to induce

dorsiexion and/or external rotation stresses. Its shortcoming is that it cannot differentiate an undiagnosed tibial stress fracture. The diagnostic accuracy of this test is unknown. The variety of special tests suggests there is a need for Level I and II diagnostic accuracy studies to determine the specicity, sensitivity, positive and negative likelihood ratios, and kappa reliability of these tests. The identication of a clinical cluster that best predicts the nature and severity of the injury using arthroscopic visualization or MRI as a reference standard would clarify the clinical utility of these examination techniques.

Table 2 General rehabilitation management strategies. Acute Phase Emphasis Symptom Management Joint protection and control of initial inammatory response  Protection: boot, posterior splint, and/or stirrup brace  Rest  Ice  Compression wrap  Elevation with retrograde massage  Pain-free ambulation  Pain and swelling under control Subacute Phase Restoration of strength, mobility, and neuromuscular control.  Contrast Thermal Therapy  Intermittent Compression Return to Activity Phase Restoration of activity specic skills Ice post-rehab or activity

Progression Criteriaa

Fitness Maintenance

 Upper body ergometer  Aquatic therapy

ROM

Manual Therapy

Therapeutic Exercise

Grade IeII joint mobilization for pain control at tibiobular, talocrural, or subtalar joints  Proximal hip/knee strengthening  Foot intrinsic muscle strengthening

 Normal gait pattern  Pain-free activities of activities of daily living including low-level plyometrics (gentle hop for 10 repetitions) Cycling on "tall" seat or NuStep with limited knee exion to minimize dorsiexion stress  Pain-free active range of motion  BAPS Board initially limiting posteromedial contact and adding weight bearing stress as tolerated Grade IIIeIV joint mobilization to increase mobility at joints that demonstrate restricted mobility Early 4-way elastic tubing exercises within pain-free range of eversion and dorsiexion Later  Short foot exercises  Progression from bilateral at foot to unilateral full arc heel raises  Non-weight bearing squats (shuttle, total-gym, leg press) progressing to decline retro squats to front squats  Lunges  Lateral step ups

Use outcome measurement tools and/or functional tests to determine readiness to play

Functional running progression and agility drills with careful progression from sagittal to frontal torotational activities in the transverse plane

Proprioceptive Activities
a

Bilateral progressing to unilateral balancing activities

Dynamic balancing activities and increasing plyometric overloads

No temporal criteria for progression with non-operative interventions; however, the phase of healing and tissue tolerance constraints should be recognized and honored.

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7. Injury management Syndesmotic injuries run the gamut from simple sprains to frank diastasis with concomitant ankle fractures. Surgery is generally indicated for a bular fracture at least 2 inches above the ankle joint in the presence of a deltoid ligament disruption or with complete diastasis. The goal of a surgical intervention is to restore normal bular length and restore the pre-morbid bular position with a syndesmotic screw. Considerations for surgical correction include the size, type (bioabsorbable vs. metal) and number of screws utilized, the number of cortices the screw(s) penetrate, the need for and/or timing of their removal, and length of time until weight bearing is allowed. More recently, the use of an interosseus suture and endobutton (Arthrex TightRope) has been described as an effective, minimally invasive means by which to provide semirigid dynamic stabilization of the syndesmosis (Coetzee & Ebeling, 2009; Cottom et al., 2009). Conversely, acute, stable sprains (absence of signicant radiographic mortise widening upon external rotation stress) can be managed with a non-operative rehabilitation program. Conservative management progress is determined by individual symptomatic response while post-surgical rehabilitation programs are governed by tissue healing rates. To ensure adequate protection following surgical intervention it is customary to immobilize the ankle in a boot for the rst 6 weeks (Clanton & Paul, 2002; Lin et al., 2006; Miller, Paul, & Boraiah, 2010; Williams et al., 2007). Progressive weight bearing can begin over the next 2e6 weeks in a stirrup splint with hardware removal at 8e12 weeks if metal cortical screws were used for xation. Ironically, surgical xation of unstable Grade II and III syndesmosis injuries may allow an earlier return to athletic activity because of the early anatomic reduction,

secure healing environment for the damaged ligaments, and potential to avoid chronic, latent diastasis. While there is general agreement that syndesmotic injuries are associated with a longer recovery time than lateral ankle sprains, there is no consensus in the literature regarding their optimal management. Due to the lack of prospective randomized trials to guide intervention strategies, one must rely on expert opinion and case studies to guide the rehabilitation strategy. There are many questions that need to be considered in designing the rehabilitation program. The need for immobilization, the necessity of weight bearing restriction, time frames for healing, return to activity parameters, and the inherent lower extremity alignment are all factors that should be carefully considered. For instance, a severe injury in an athlete with structural planovalgus that requires surgical stabilization is going to have a much slower and careful progression. The aggressiveness of the rehabilitation progression can also be monitored by the level of posterior tibiobular pain which tends to empirically correlate with a more severe injury. 7.1. Rehabilitation management A rationale for determining the severity of distal tibiobular injuries is provided in Table 1. Both conservative and post-surgical rehabilitation should use a similar philosophical approach. Table 2 provides a general management perspective to guide the rehabilitation process. As with any protocol, each athlete presents with unique needs and their individual circumstance will dictate the recovery process. Immobilization and weight bearing status are governed by the severity of symptoms, degree of instability, and ability to normalize gait. A period of non-weight bearing may be

Fig. 13. Decline inclination squat to minimize dorsiexion stress on distal tibiobular joint.

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Fig. 14. Dorsiexion range of motion can be controlled by the superior/inferior or fore/aft seat positions on aerobic exercise devices. A tall seat on a stationary bike or a more posteriorly positioned seat on the NuStep can limit the amount of knee exion and ankle dorsiexion that is required to perform the necessary movements. A) An extended seated position decreases the necessary dorsiexion to complete a exion-extension repetition cycle; B) Moving the seat forward requires a greater demand on knee exion and ankle dorsiexion; C) A tall seat allows the patient to maintain a more neutral ankle position at the top of the pedal revolution while in D) a short seat requires maximal dorsiexion to complete the pedal revolution. Table 3 Activity variables for proprioceptive balance training. Balance/Perturbation Training Variable Options Gravitational Inuence External Support Shoe Status Stance Position Full (anti-gravity) vs. partial (gravity minimized) Presence vs. absence of bracing e taping e orthotic insoles Shod e barefoot e short foot Bilateral vs. unilateral; Wide vs. narrow base of support; Staggered vs. symmetrical foot placement Locked in hyperextension vs. unlocked in slight exion Eyes open vs. eyes closed Stability, consistency, and/or distortions of visual background Position of head and presence or absence of cervical movement Hands on hips vs. hands folded across chest vs. hands overhead Stable vs. labile surface; Moving vs. stationary surface; Uni- vs. multi-axial movement Uphill (dorsiexed) vs. downhill (plantarexed) Cambered (inverted vs. everted) Addition of lower or upper extremity movements in sagittal, frontal, transverse, or diagonal planes Manual or mechanical perturbation and overloads in anterior/posterior or medial/lateral directions

required with secure, compressive xation in a walking boot as partial-weight bearing ambulation is allowed. In cases of latent instability this time period may be prolonged by an additional 2e3 weeks (Zalavras & Thordarson, 2007). If syndesmotic screws were utilized to stabilize the diastasis they will usually be removed after about 3 months to reduce the likelihood of screw breakage, osteolysis around the screw, or stagnation in reacquisition of normal ankle motion (Nussbaum, Hosea, Sieler, Incremona, & Kessler, 2001; Peter, Harrington, & Henley, 1994). Dorsiexion range of motion exercises should be introduced with caution. In the earlier stages of rehabilitation dorsiexion should be limited from a plantarexed to neutral position. In addition, end-range subtalar eversion and loaded exercises with the foot in an abducted (toe-out) position should be avoided. Dynamic stability can be enhanced with emphasis on restoring the eccentric control of pronatory forces by the posterior tibialis. In addition, eccentric control of dorsiexion with attention to the tensile capabilities of the triceps surae complex can protect against weight bearing dorsiexion stress on the syndesmosis. Any lower extremity rehabilitation program would be incomplete without attention to the transverse and frontal plane control of the lower quarter as provided by the gluteus medius and maximus. This perspective has been shown to be of particular importance in patients with ankle injuries (Bullock-Saxton, Janda, & Bullock, 1994; Nicholas, Strizak, & Veras, 1976; Beckman & Buchanan, 1995). Lower extremity strengthening activities can begin with various forms of the squat exercise (simultaneous eccentric hip and knee

Knee Position Visual Input

Vestibular Input Arm Position Surface Stability

Surface Inclination

Dynamic Movements

Overload

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exion with ankle dorsiexion). The progression begins in nonweight bearing on a Total-Gym, Shuttle, or Leg Press machine with the feet well anterior to the hips to minimize dorsiexion stress. As the tolerance for weight bearing improves the exercise can progress to a decline retro squat with the heels higher than the toes to allow deeper ranges of knee exion (Fig. 13). Likewise, stationary cycling or whole body exercise on the NuStep should initially limit ankle dorsiexion by manipulating the seat position (Fig. 14). Proprioceptive balancing activities are an important aspect of the rehabilitative process. Table 3 outlines many of the variables that can be used to provide appropriate challenge without overloading the stress that can be tolerated by the injured tissues. Lunges and lateral step up exercises are popular functional drills as they simulate many athletic movement patterns. Again, a logical progression of dorsiexion stress can be initiated by initially using longer forward steps with the reaching extremity before challenging the end-range dorsiexion requirement of the stationary stance limb. Often retro lunge steps are better tolerated early in the rehab process as the posterior shift of the center of gravity allows the stance limbs ankle to remain in a more neutral sagittal plane position. Similarly, a lower height in a step up exercise will

minimize the dorsiexion requirement to perform the movement. Rotational (cutting and pivoting maneuvers) activities and high intensity jumping, hopping, and bounding plyometrics should be introduced in a cautious manner as the athlete progresses to dynamic rotation training. 7.2. Taping and bracing considerations A number of taping, bracing and/or orthotic techniques can be utilized to protect the damaged soft tissue structures during the rehabilitative process. Athletic trainers from the National Football League use a variety of techniques to counter the dorsiexion and external rotation stresses that created the injury (Doughtie, 1999). Intuitive reasoning would suggest that circumferential straps at the distal tibiobular joint and/or stirrup bracing with secure distal compression should protect the tibiobular ligaments (Fig. 15). Wilkerson (2002) advocates a medial subtalar sling to reduce strain on the anterior inferior tibiobular syndesmosis (Fig. 16). Orthotic control of the medial longitudinal arch may limit excessive tibial internal rotation and calcaneal eversion as a component of pronation which stresses the medial deltoid and tibiobular ligaments.

Fig. 15. Example of commercially available semi-rigid stirrup braces to provide compressive force at the tibiobular joint and protect syndesmotic ligaments. A) Breg Ultra Ankle XT; B) Aircast Stirrup; C) Bauerfeind Malleoloc; and D) DonJoy Velocity.

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reliability, validity, and responsiveness of this assessment lend condence to the decision-making process in determining readiness for safe resumption of athletic activities (Eechaute, Vaes, & Van Aerschot, 2007; Hale & Hertel, 2005).

9. Conclusion The management of syndesmotic injuries in athletes is a challenging process secondary to impairments that cause a delayed restoration of pain-free function. Future research should rigorously evaluate the effectiveness of specic interventions and rehabilitation protocols based on the severity of injury and mode of management with the goal of expediting the safe return of the athlete to their pre-injury status. Conict of interest No conict of interest. Funding None declared.

References
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