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Ankle Syndesmosis Repair: The Evolution of a Protocol Part I

Updated: Oct 28, 2019

What do Jalen Hurts, Tua Tagovailoa, and a softball coach have in common? They're all setting the standard for what's possible following a Syndesmotic Repair.


A series of unfortunate events (but thank goodness the nachos were saved) resulted in an ankle syndesmosis repair and early referral to therapy by a trusting surgeon. Just minus a protocol. In his defense, when you search this topic in PubMed, Google or even resources from other reliable medical institutions, there are very few evidence based protocols established. While we can debate the necessity of a rehab protocol, there are a few important things a therapist needs to know- whether this information comes directly from your surgeon or the protocol itself. I want to know what I need to protect and for how long, the mechanics of the joint/tissues, how confident my surgeon is in the repair, and what causes a repair like this to fail.


Phase I of any rehabilitation protocol is arguably the most variable but also the most important. The remaining phases typically look much like any other strengthening/prevention-type progression. But progression too quickly or too slowly can be a real beast to reverse later. Case studies published on rehab after a syndesmosis repair are largely on high performance athletes, like rugby, football players and downhill skiers. My patient is a very active female in her 40s. Pretty much the same thing, right? Uh huh, we think so too. So after some digging, discussion and general investigation, I share the answers to my questions, and thus the first phase of a newly developed rehabilitation protocol for a recently famous surgery:


1) What are we trying to protect and for how long?

Physiopedia does a great job discussing the mechanics of the distal tibiofibular syndesmosis. The talus is wider in the front than the back, thus when the ankle dorsiflexes,

Photo Credit: Jeannot Olivet / Getty Images

the tibia and fibula normally separate about 1mm to allow sufficient clearance of this bone. So, the mechanism of injury for a high ankle sprain is typically extreme dorsiflexion with forced external rotation of the talus (via eversion of the foot), where the tibia and fibula are forced widen further around the anterior aspect of the talus. Often times a fracture accompanies this injury, most commonly to the lateral malleolus (distal fibula).


Typically you don't see many ankle sprains sent to the OR unless conservative measures have failed miserably and instability persists. For lateral ankle sprains, the torn ligaments can be reconstructed (Brostrom procedure), and occasionally require reinforcement (ie internal bracing) in certain severe cases. A high ankle sprain is treated very similarly with conservative measures first, often including weeks in a Cam boot and therapy for balance/proprioceptive training. But most recently, syndesmotic repairs have been performed earlier (I'm lookin' at chu, Crimson Tide) due to the need of return high performance athletes back to sport sooner than traditional conservative measures can achieve. According to a hardware manufacturer, the recommended rehabilitation following tightrope placement looks very similar to a non-operative ankle sprain protocol (in the absence of a fracture) and "supports early weight-bearing and accelerated rehabilitation". Partial weightbearing can begin immediately post-operative in a boot or cast and progression is dependent on the case and surgeon. A recent push to return these athletes sooner has lead some individuals to running within 9-10 days of surgery. Some collegiate football players have even returned to the field within 16 days of surgery. Is this a safe enough protocol to be translated to the general population? I would argue no, but as with all things, time will tell. In a perfect world, a solid repair through good bone could potentially weightbear immediately. But in the presence of fracture or otherwise less-than-ideal bone health, weightbearing can be delayed for 2-6 weeks depending on surgeon preference. This is a prime example of why having good communication with your surgeon is key!


2) What is the surgeon afraid of in this specific case? How stable are the tissues and bone construct?

Arthrex Dual Syndesmosis Tightrope Implant System, Surgical Technique Guide, all rights reserved 2017

This specific case is pretty ideal- a healthy, active female with a good bone construct (no underlying osteoporosis/osteopenia) and no significant comorbidities that would impact her healing. So, our biggest concerns post-operatively are similar for any lower extremity surgery- DVT, infection, or fracture. The stress that is taken at the tibia and fibula is offset with a plate to share the load, however with excessive weightbearing to a fragile bone, there is a possibility of fracturing above/below the hardware. So while the manufacturer says the limb can handle weightbearing immediately, we have opted to slightly delayed weightbearing (2 weeks) for this case to allow sufficient healing. She will then be transitioned to weightbearing in the boot at 2 weeks, followed by full weightbearing without a boot at 6 weeks to minimize risks associate with age.


3) What causes this surgery to fail?

A failed syndesmotic repair typically occurs due to either failure of the hardware itself (creep/loosening developing in the tightrope), or fracture of the bone surrounding the surgical site. Further fracture of the bone is most likely related to either surgical technique and overall health of the patient's bone. Bone that has a fragile construct (such as from osteoporosis, osteopenia, calcium/vitamin D deficiencies, or other diseases) will not tolerate an accelerated weightbearing protocol. My 87 year old grandma, while still sharp as a tack & stubbornly independent, may be someone that we allow a little longer healing time before recommending she weightbear through her ankle to avoid fracture. Repairing a fractured bone and adding hardware to a previous surgical site is not ideal and certainly prolongs their recovery time. However, in the presence of good bone and no fracture, the outcomes look brighter.


So... what can we do early on in rehab? Seriously, a ton.

It's easy to fall back on doing passive modalities and gentle ROM home programs with the patient during this first post-operative phase, but there is really a LOT we can do to help prepare the patient (and their kinetic chain) for their soon release to full weightbearing. In this particularly case, we allowed 2 weeks of non-weightbearing to ensure the patient's bone has time to heal. Then it's game on- progressing the patient as her ankle tolerates it. Inflammation and swelling control come first, obviously, with numerous ways to carry out the RICE method and swelling control based on therapist/patient preference. But we can't forget to include preparation of the limb, joint and the surrounding soft tissues for efficient movement and weightbearing while we wait. This goes for nearly any foot/ankle procedure that limits weightbearing in the first phase...


Range of Motion and Soft Tissue Work: passive ROM to active-assisted ROM to active

ROM, grade I-III subtalar & forefoot mobilizations to tolerance, soft tissue mobilization (gastroc/soleus, achilles, peroneals, plantar aspect of foot), foam rolling to lower limb & spine


Foot & Ankle: Ankle pumps, gastroc stretching, intrinsic toe flexion, ankle isometrics in neutral, balance (with weightbearing approval), and toe yoga-- I love this video by Kinetic U for training the small muscles of the arch and foot! We are limiting inversion/eversion initially in this case, so I have delayed ROM exercises like circles, towel swipes and ankle ABCs.


Core Stabilization: Supine core activation (dead bug, LE scissors, LE alphabet, posterior pelvic tilts, marching on foam roll, pilates, reverse crunch, ball walkouts), plank on knees, side plank on unaffected limb or knee of affected side, cat/camel, bird dog

3 hip flexion positions for each (the trusty assistant helps): External rotator isometrics- band at knees, towel at ankles. Internal rotator isometrics- band at ankles, towel at knees

Kinetic Chain Strength & Stabilization:

Straight leg raises (flex/ext/abd/add), clam shells, multi-angle hip isometrics ER/IR (see photo), hip PNF patterns D1/D2, hamstring curls (prone, standing, seated), double limb kneeling on unstable surface with UE movements (cone taps, push/press), single leg balance (unaffected side), 4 way hip (unaffected side stance limb- see video), Single Leg RDL, single limb balance on affected knee (ie elevated on foam pad or Bosu) with any UE exercise (ball dribble, 4 way arm pull, biceps, triceps, standing T, standing Y, OH press, landmine press, etc)- see video.



Aerobic Activity: Upper Body Ergometer (UBE), upright bike (UE only)


Other options to consider:

Aquatic Therapy is a fantastic option for patients looking to improve their workout without weightbearing. I'm not recommending actually swimming laps yet due to the forces on the ankle joint with kicking. However, when the patient's incisions are fully healed (no more scabbing, drainage or erythema), deep water exercise can really challenge the hip, thigh, core and cardio system.

Blood Flow Restriction can also be added to the operative or nonoperative limb in any of these exercises. Blood flow restriction has been show to help reduce the degree of atrophy in the muscles surrounding the foot/ankle, which is especially helpful during the initial phases of rehab.


Progression to the next phase of rehabilitation (the initial weightbearing phase) should happen no sooner than 6 weeks (per general bony & soft tissue healing times) and requires physician clearance for full weightbearing outside of the walking boot. Phase 1 is ready to go, but stay tuned for details on the next phase!


P.S. I see a case study coming out of all this... #NerdAlert



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