This 20-year-old national representative football player presented following an acute injury to her left ankle. She described an eversion type mechanism during a competitive match. While she was unable to play on, she did not immediately think that her injury was too bad. The following day however her ankle was very sore, and she was unable to weight-bear without assistance. The player described a long history of prior ankle sprains.
On examination she was found to have pain with external rotation of her ankle and with a squeeze test. There was also localised tenderness about the AITFL. She was also found to have an increased anterior draw (which was present after her last ankle injury).
X-ray imaging, including a weight bearing view, was normal. The MRI images show that the anterior tibiofibular syndesmotic ligament is ruptured from the fibular attachment. The posterior syndesmotic ligament has partial tearing at the tibial attachment with periosteal stripping and reaction. There is increased fluid within the tibiofibular syndesmotic space however the distal syndesmotic membrane is intact. There is ‘grade two’ tearing of the proximal ATFL which is thickened with partial tearing at the fibular attachment. The ligament is thickened and intermediate in signal and bulges into the anterolateral gutter. The PTFL is intact, the CFL is irregular with grade two tearing at the fibular attachment.
Give this player’s recurring problems with her ankle and the high-grade syndesmosis injury she was taken to the operating room for an MUA. Her syndesmosis was examined and was found to be unstable. As a result, she had a syndesmosis reconstruction and lateral ligament reconstruction.
Isolated syndesmosis injuries are generally considered to be rare. Their incidence in professional football does however appear to be on the increase (based on data from the UEFA Elite Club study. In this case series (and in this case) the majority of injuries occurred during competitive matches. There are generally considered to be three grades of isolated syndesmosis injuries. Grade one injuries are generally associated with mild pain, normal x-rays and a stable syndesmosis. These are generally managed with rehabilitation. Grade two injuries involve a partial disruption of the syndesmotic ligaments. These patients generally also have normal x-rays but will have a positive external rotation and squeeze tests. These injuries may be unstable and clinicians should consider an MUA to determine the integrity of the syndesmosis. An MRI scan is often useful to help make this decision. Grade three injuries involve complete rupture of the syndesmotic ligaments with widening of the syndesmosis on x-ray (increased medial clear space). These injuries should be managed with surgery to either repair or reconstruct the syndesmosis.
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