It’s an injury that seems to have spiked in 2020. But what is syndesmosis and why has it become so prevalent? aflplayers.com.au has done a deep investigation into the high ankle sprain and what it entails. 

Each year there is an injury in the AFL which seems to have a higher occurrence than others.

In 2020, that injury is the high ankle sprain, or, as it has widely become referred to by commentators and fans alike (maybe without knowing exactly what it means): syndesmosis.

What is a syndesmosis ankle injury? And why has it become part of the football vernacular?

Leading orthopaedic surgeon David Young agrees with the notion that there has been a spike in syndesmosis injuries this season.

Young attributes the fast-paced nature of the game, the lack of training continuity across a condensed season (including the reduction of full contact training sessions) and the tweaking of the AFL’s holding the ball adjudication as possible factors in the increase of syndesmosis ankle injuries.

The injury often occurs in a tackle where a player falls across another player’s leg, with the impact causing the syndesmosis – a fibrous joint between the tibia and fibula, held together by ligaments, to split apart.

“Most people have sprained their ankle and the pain is below the lateral malleolus, the ‘knuckle’ on the ankle,” Young said.

“But with a syndesmosis injury the pain is above the malleolus, in the front of the ankle. You talk about high and low ankle sprains – the pain for the syndesmosis is mostly felt on the outside of the ankle.”

Up until five years ago, a player with a syndesmosis injury had an expected recovery time of up to eight months.

But two significant advancements in the diagnosis of the injury and treatment have reduced that recovery time down to an average of 6-10 weeks, depending on the severity of the injury.

However, Western Bulldogs midfielder Tom Liberatore returned to the field within four weeks in 2016 to be part of the club’s magical premiership run and Geelong captain Joel Selwood came back in five weeks in 2017.

The first major advancement has come in the way the injury is diagnosed.

Following a standard MRI scan, players are then put through a dynamic CT scanner, Dr Andrew Rotstein at Victoria House Medical Imaging is affiliated with Young, to determine how unstable the ankle has become following the injury.

What the dynamic CT scanner shows, which the MRI machine doesn’t, is the gap created (diastasis) between the two bones – the fibula and the tibia – in the lower leg.

Pic supplied: A patient using the Dynamic CT scanner

If the gap opens up by 12 per cent or more then the ankle is considered to be “unstable” and surgery is the recommended method to treat the injury.

Geelong midfielder Cameron Guthrie injured the syndesmosis joint in his right ankle against West Coast in Perth in April, 2018, and consulted with Young following the injury.

“I remember being told that I was on the borderline of whether to rehab it without surgery or go in for surgery and help the recovery process along,” Guthrie recalled.

“Chatting to the medical staff at Geelong, they had seen some ankles recover well at my percentage… so they thought the 6-10 week recovery with surgery was something worth aiming for and taking the uncertainty away if I didn’t have surgery.”

Like Liberatore and Selwood before him, Young performed the innovative “tightrope surgery” on Guthrie’s ankle.

The benefits of the tightrope surgery or tightrope fixation technique, which Young compares to a pulley system on a yacht, is that the player no longer requires having screws inserted into the ankle through surgery, which can create further issues, and then subsequently removed from the leg at a later date.

The tightrope acts as a replacement ligament with the cord threaded through a hole drilled between the tibia and fibula and fixed to the outside of the bones.

“What the tightrope does is immediately replace the ligament and so that means that there is no longer that down time after surgery which meant we were able to keep rehab going from when the wound has healed – essentially from day one,” Young said.

“It’s taken what was a season-ending injury into a ‘nuisance’ injury lasting for around eight weeks.”

Pic Supplied: An image of the tightrope fixation technique 

Guthrie had about two weeks in a moon boot before progressing to light walking and running on the Alter G treadmill (weight-bearing treadmill) and finally running outdoors once the swelling and pain had subsided.

He began full training six weeks following surgery and played his first match at week eight.

Even still it took him the rest of the season to get back to full capacity, which included one-legged proprioceptive movement as part of the recovery process.

“For a good 12 months after the injury, doing a lot of one-legged exercises you could really tell the difference between the injured ankle and the good one,” he said.

“The biggest thing that impacted me after surgery was when I was kicking.

“I couldn’t really point my toe as firmly as I wish I could have. I’m a big believer in having a really firm foot when I kick and I couldn’t really do that movement to the best of my ability, but it got better slowly and I haven’t had any issues since.”

Young’s job is to put the players in a position, following surgery, where they are able to return to the field as quickly as possible.

There is a feeling around the industry that the new holding the ball adjudication, which often sees “stacks on”, and the technique of dragging opponents back when tackling to avoid ‘in the back’ calls could be contributing to the rise in syndesmosis injuries.

Western Bulldogs forward Aaron Naughton returned from the injury a fortnight ago, Essendon’s Jake Stringer is close to playing and Richmond pair Toby Nankervis and Dion Prestia (following a minor procedure to ward off an infection) are nearing a return from their own syndesmosis injuries.

Young said the AFL would document each injury and look at the occurrence of how each injury happened, although he does not believe there’s a huge cause for concern long-term.

“The important thing is that the treatment and the investigation of the injury is so much better, so I don’t think it’s going to be a major problem for the AFL going forward,” Young said.