The Syndesmosis Sprain Challenge

Last year I had a really fun challenge (though as always these things cost you some sleep!!). I was working with a rugby team and in the second to last game of the season a player had a low grade high ankle sprain.

As always, there’s a certain urgency to get a starting player back on the pitch, which also has to be balanced with the risk of coming back too soon and making things worse.

Coming back early causes lots of potential problems. You could make things a lot worse for the injury you have, higher grade of syndesmosis sprain. This could result in an extended period of rehab or even surgery if you end up with a big multi-ligament tear. Though this seems like the worst case scenario, you have to keep in mind risk to other joints. If you are not able to protect yourself due to carrying the injury, you could leave other joints/structures vulnerable. Imagine the implications of an ACL injury!

From a different perspective, you have game day and performance related issues. If a player can’t perform their role, that’s a big problem for the team. If they break down early in the match, you have to use a substitute that you then can’t use later in the game.

In assessing the likelihood of such a quick return you have to consider many things. Though post game the ankle was pretty sore, weak and positive for a syndesmosis sprain, they did finish the game, so that’s a pretty good sign it was low grade. I’ve seen people try to play on with moderate syndesmosis sprains before and it just doesn’t work well!!

It’s always best to offload in a boot if you are even slightly suspicious of high ankle sprain. It’s a simple measure in the short term to allow things to settle and the true nature of the injury to reveal itself. In this case we were in the boot over the weekend.

We were lucky that we had an 8 day turn around between games. The extra day was likely to be a big help. 

Initial strategies day 0 and day 1 were to ice in a bucket regularly, seems to really help with these injuries.

Day 2

Though I couldn’t see the player the first couple of days we were in touch over the phone and I was happy for them to start weight bearing out of the boot a little and weight bearing and squatting in the ice bucket. I also sent over a pool rehab session, which really helped get things going in the right direction.

Day 3

First chance for assessment and treatment was on day 3. Re-assessment showed we were on track and the ankle had fired back up with good muscle strength and power. Now able to weight bear out of the boot and pain free with normal every day activity. Treatment included foot and ankle mobs, glute rehab, prep to run drills. All of this went really well and this allowed us to push on a bit, so we built up to 70% straight line running and some low level multi directional drills.

Before the rehab session we experimented with some strapping, which allowed for pain free jumping and hopping. Also, good to try these things out before a game so the player is comfortable and happy on game day.

Day 4

Unable to see the player today due to their work commitments I gave them a rehab session with balance, glute work etc for the morning and a pool session for the afternoon. They continued to ice regularly in the bucket.

Day 5

Another chance to assess and treat the player. Again, progress was right on track for game day on Saturday. Treatment was as day 3, but up to 100% running and then we added:

  • max accelerations
  • max decelerations
  • contact drills
  • offline running
  • reactive change of direction

We used the same strapping as it was working well and the whole session with done with only very mild awareness of the ankle. The player had good muscular strength and power throughout, no increase in pain.

I was happy at this stage that we would make the game and the player was named in the starting team…just got to make it now!

Day 6

Again, couldn’t see the player today, but there was no reaction to rehab session. Did the same rehab session as on day 4 with pool rehab in the afternoon.

Day 7

Again, very good response to rehab, with no increase in pain or swelling. Full strength and power. This allowed us to stop the ankle and return to team training and complete the team run. All aspects of the game were tested including landing from line outs, all completed with no issues and remained strong and powerful post training.

Day 8

Great outcome in this case, the player not only went on to start the game, but they played a full 80 minutes. Though there was some soreness post game they never lost strength or power. Great outcome 🙂


It’s fair to say that this was a close one. It would have had to be a very very low grade injury to turn around so fast, most likely more of a stress than a true ligament sprain…enough to make them weak initially, but allowed them to bounce back really quickly.  Each day we looked at where we were and what we could do to give us the best chance of playing. 

Lots of things went in our favour. Even a minor setback could have been enough to de-rail us! The player was very diligent what they could do, listened to the advice I gave them and followed the plans to the letter.

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