Syndesmosis Sprain – High Ankle Sprain

 In Foot

What is a Syndesmosis Sprain?

A Syndesmosis Sprain isn’t a term we hear of very often – But essentially, the syndemosis is the interosseous membrane located between the tibia and the fibula.  This can be sprained when someone suffers an inversion or a rotational sprain and invariably the sprain to the syndesmosis takes place at the distal ends of the tibia and fibula (closer to the ankle)

Types of Screens: 

There are 4 screens which can test the integrity of the Syndesmosis.

These are:

  • Cotton Test
  • Squeeze Test
  • External Rotation Stress Test
  • Fibula Translation Test

It’s important to be thinking about the possibility that your client might have a fracture, contusion or compartment syndrome. And so with that in mind, you would need a medical practitioner to rule these out before doing these tests.

How to Screen:

Cotton Test

Have your patient laying supine, and with one hand take hold of the tibia and fibula and squeeze lightly. This in itself might cause pain to someone with a Syndesmosis Sprain.  With the other hand, you will need to hold the foot and translate the hindfoot laterally. If your client reports any pain or discomfort during this motion then the test would be positive. Alternatively, if you can feel between 3-5mm of translation, then this might also indicate a positive screen.

Squeeze Test

Again, have your client laying supine, bending their knee with their feet on the floor and as the name suggests, you’re going to squeeze! Taking the heels of your hands either sides of the tibia and fibula, starting at the proximal end (closer to the knee) and lightly squeezing the leg. By applying this light pressure, what you’re doing is bringing the interosseous membrane and the two bones together – So if your client reported any pain during this, then this would indicate a positive screen.  It’s indicated that the more proximal the sensitivity, the more severe the injury might be. The sprain would be more severe if they got pain at the proximal end upon squeezing compared to the distal.

External Rotation Stress Test

Your client now needs to be sitting with their leg hanging at a 90° angle. Take the foot into a plantigrade position (this is a neutral foot that you would be standing on the ground with) Now fix the tibia and fibula with one hand, and with the other hand take the foot into an eversion / lateral rotation. If your client reports any pain or discomfort then this would indicate a positive screen for a Syndesmosis Sprain

Fibula Translation Test

The last of the 4 in Syndesmosis Sprain Series is the Fibula Translation Test. Start by having your client laying on their side, the bottom leg can be bent but the ankle you’re looking to screen needs to be on top with the leg straight. Take the ankle from underneath and hold the tibia to fix it in place. Then, take the other hand on to the fibula and move it anteriorly and posteriorly. A positive screen would produce pain or discomfort for your client or you would feel more of a range of movement compared to the other side.

As mentioned earlier in this post, it’s really important to have a medical practitioner rule out the possibility of fracture, contusion or compartment syndrome before performing these tests to bear that in mind should you suspect your client has a Syndesmosis Sprain.

All of these screens are really helpful when you need assess for dysfunction or sub-optimal movement patterns and pain or discomfort – But what we look at on our courses is then how you would help your client to effectively strengthen and rehab these areas using Pilates based exercise. Pilates is all about optimal movement so if we know which area of the body is preventing that and we can work on correcting and strengthening the weak link then the benefits can be huge for you and your clients!

We delve deeper into this on our Knee and Foot courses and we still have a few spaces free should you wish to join us and learn more! So if you’re interested, please feel free to visit our Courses page or why not drop us an email at

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