It sounds like the name of a house music act but anyone who has suffered the injury will not have their dancing shoes on any time soon. If osteitis pubis was the scourge of footballers in the 2000s, the “ankle syndesmosis” is now the injury du jour.
While it may not have the devastating consequences of an anterior cruciate ligament (ACL) tear, team supporters are still filled with dread by the mention of syndesmosis in connection with their own.
“When you see a knee injury, your nightmare is that it’s an ACL. When you see an ankle injury, your nightmare is it’s a syndesmosis rather than a standard ankle sprain,” says Dr Peter Brukner, who has worked with AFL teams Melbourne and Collingwood, the Australian Olympics squad, the Australian men’s cricket team and the Socceroos.
The roll-call of syndesmosis victims reads like a who’s who of the game: Patrick Dangerfield, Lachie Neale, Joel Selwood, Dion Prestia, Jake Stringer, Adam Treloar, Tim Taranto, Stephen Coniglio. More recently, it was the turn of Carlton’s great hope Sam Walsh, ruled out for at least the first month of the AFL season. There will be more.
Yet for those who can remember a time of 100-goal seasons, set positions and a 16-team competition, syndesmosis injuries were unheard of. So, why is there now, as one club doctor says, an “epidemic” of such injuries? Can the syndesmosis injury be eliminated or do we just have to live with it?
What’s a syndesmosis injury?
The ankle syndesmosis is a non-moveable fibrous joint to which the two bones in the lower leg – the tibia and fibular – are connected by strong membranes or ligaments. It’s at the top of the ankle rather than the side, which is why injuries to it are known as “high ankle sprains”.
Ankle syndesmosis injuries refer to damage to ligaments that connect the tibia and fibular and also to tears in the interosseous membrane, even though they are not in the joint.
Injury typically occurs when the foot is imposed and external forces, usually from a tackle, push the leg or shin forward, placing stress on the syndesmosis. Players often get their foot caught underneath their body as they are tackled.
Greater Western Sydney’s former head of athletic performance David Joyce did a deep dive into the issue after the Giants were struck down by a disproportionately high number of cases in 2017.
If you are squamish, this next part is not for you.
“If you stand up now, with your right foot, point your foot and touch the top of your toes to the ground,” Joyce says.
“You’ll feel a stretch at the top of your ankle. Imagine from there either someone falls straight on your heel, which will force the bone at the front to go right through the front, or the foot gets stuck, you’re pushed back and the shin goes backward. That’s a common traumatic way of doing it.”
Are there more cases now than before, and why?
The short answer is yes, but they are not as common as the anecdotal evidence cited by several experts suggests.
If you’re wondering why you didn’t hear anything about syndesmosis injuries before 2000, it’s not necessarily because they didn’t happen but more that they weren’t detected.
Three years ago, Deakin University released a study of AFL injuries between 1997 and 2016 by PhD candidate Daniel Hoffman.He found that shin, ankle and foot injuries in games rose from 22 missed matches per club in 1997 to 34 in 2016. This is disproportionate to the increased in missed matches per injury, which rose from 3.2 to 3.6 in the same period. “It’s quite significant,” says Hoffman, now a sports science analyst with St Kilda.
Gold Coast Suns doctor Barry Rigby calls the spate of syndesmosis cases an “epidemic”. Other respected sports medics, such as Brukner, have also noted a rise.
Yet surprisingly, the AFL’s most recent injury report, from 2020, found that the incidence per club, per season had dropped from 1.56 in 2018 to 0.89. If the decreased game time because of the pandemic that year is factored in, the figure of 0.89 rises marginally above the 1.1 recorded for 2019.
That is still a marked rise from the 1990s. The best supported theory focuses on the massive rise in football department spend, increased use of scans and the improvement in medical imaging technology, all of which allow for better detection.
“With the injury data survey we have we’re getting a bit more minutiae around the actual injury,” Rigby says.
“Once upon a time, it was an ankle injury which kept a player out for a set period of time, and we never honed in on exactly what that ankle injury was – medial, lateral, high. We’re a lot more detailed now in our assessments and data we produce.
“Previously, we might have suggested they were a bad ankle sprain and that was all there was to it.”
Or, as Joyce puts it, “They’ve always seen us, we’re now seeing them more.”
Changes in the way the game is played and the increased speed, strength and power of the contemporary footballer are also factors, say several medicos and sports scientists.
Even with the rule changes last year, football in 2021 bears little resemblance to 20 years ago. There are more players than ever around the ball, which results in more contests and tackles.
The role that tackling plays in syndesmosis injuries was put forward at a Laws of the Game Committee meeting last year as part of the argument for a stricter interpretation of the holding the ball rule.
According to a person who was privy to the discussions, one committee member claimed the extra time being given to the ball-carrier to dispose of the ball meant that tackles lasted longer. This then led to more twisting force being exacted to bring a player to ground.
The reduced leniency that umpires have been directed to give players this year as part of changes to the holding-the-ball rule interpretation should, in theory, reduce this as a factor in syndesmosis injuries.
Why do the big names get it?
Syndesmosis has become an injury for the (midfield) stars. Could that be because they get the ball more often, so they have an increased risk of being tackled?
Joyce is a subscriber to this theory. He was at the Giants in 2017 when the club was ravaged by the injury. Taranto, Jacob Hopper, Ryan Griffen and Coniglio (twice) all succumbed.
“Your inside bulls are visiting areas that they’re more likely to get their foot trapped under,” Joyce said. “It’s much more common for inside mids because they’re visiting those areas much more frequently. Coniglio, Hopper, Taranto, Walsh – that’s not a coincidence.”
When you add names such as Dangerfield, Neale, Prestia, Selwood and Stringer to the mix, the hypothesis is strengthened. “To a certain extent, I believe it’s an occupational hazard,” Joyce said.
How are syndesmosis injuries treated?
Not all ligament injuries require surgery to repair, but there has been a recent trend for players to go under the knife for syndesmosis, depending on the severity.
Because scans do not always tell the full picture, there has been a preference to open up the joint to take a better look at the damage. If a ligament is completely torn, the joint will become unstable and surgery is required to stabilize it, Brukner says.
The most common technique is “tightrope surgery” or “tightrope fixation technique”, which involves a plastic cord acting as the replacement ligament being drilled through the tibia and fibula and tightened into place.
As graphic as the procedure sounds, it means players no longer need medical screws to be inserted into the ankle, which can create complications and need to be removed later. Unlike ACL tears, which weaken the ligament, syndesmosis injuries do not tend to return unless the ankle is placed under great stress again.
“It’s commonly used now and seems to be a pretty effective operation,” Brukner says. “There don’t seem to be problems with the surgery or recurrences, which are the two things you’re concerned about.
“It’s a neat, good operation to have with minimal issues.”
Can syndesmosis injuries be prevented?
Osteitis pubis, referred to colloquially as a groin injury, stopped becoming a buzz injury in part due to a change in language around groin pain and better treatment and management. But even an ankle strengthened by exercises is still vulnerable to the brute force that causes syndesmosis injury. So long as tackling remains in the game, players will come a cropper.
“The syndesmosis injuries are more of an acute incident, either a contact, landing or tackle-related, as opposed to how much training and how many games someone is playing,” says Justin Crow, who worked with Essendon and Collingwood before becoming A- League club Melbourne Victory’s head of human performance.
There are mixed views on the effect of ankle strapping. Brownlow medallist and trained physiotherapist Gerard Healy was aghast last year when he saw footage of former West Coast defender Brad Sheppard without his ankle taped. Joyce is not convinced taping can prevent syndesmosis tears.
“There’s not a great deal of evidence but it’s a very difficult study to undertake,” Joyce said. “There’s an argument taping could increase the risk of syndesmosis because you don’t have the flexibility, so you have to pop out the front.
“We ended up taping everyone that had a syndesmosis and taping them medium- to long-term. It wasn’t to reduce the likelihood of a repeat syndesmosis, it was more that it just feels better and you get more confidence with it on.”
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