Distal tibiofibular syndesmosis injury

Distal tibiofibular syndesmosis injuries are a relatively frequent ankle injury, although less common than a fracture or lateral ankle sprain. They are estimated to comprise ~10% (range 1-20%) of ankle injuries.


The mechanism of injury is uncertain but thought to be the combination of forceful foot external rotation with concomitant leg internal rotation . Injuries can occur to one or more of the structures that make up the distal syndesmosis:


Radiographic features

Plain radiograph

Distal syndesmotic injury can easily be inapparent and therefore missed on plain x-ray, especially if it is not accompanied by a nearby fracture or widening of the tibiofibular clear space. . Numerous measurements have been proposed for indirectly demonstrating syndesmotic injury but these vary across studies with no formed consensus. Some studies have shown :


Aside from being readily available, ultrasonography has the added benefit of being a real-time dynamic modality, allowing the operator to perform maneuvers on the ankle during imaging. The contralateral, uninjured, ankle can be imaged for comparison.

It can demonstrate:


MRI has been shown to accurately detect injuries to the ligamentous structures of the distal tibiofibular syndesmosis . The anterior inferior tibiofibular ligament is the one most often involved in such injuries and the most convenient to identify.  Direct signs of a ligamentous tear include:

  • ligament takes an abnormal course
  • ligament assumes an irregular contour
  • AITFL cannot be visualized

Indirect signs :

  • tibiofibular joint space fluid
  • prolapsed interspace fat
Signal characteristics
  • T2
    • acute ligamentous injury: hyperintense signal in the ligament with surrounding edema
    • chronic injury: thickened or disrupted ligament without edema
  • T1 C+
    • acute injury: injured ligaments enhance intensely

Practical points


Surgical management options include an ORIF with syndesmotic screw(s) or and cord device e.g. TightRope.

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