Physiotherapy plays a crucial role in the rehabilitation of distal tibiofibular syndesmosis injuries, aiming to restore stability, range of motion, strength, and function.

1. Manual Therapy

Manual therapy involves hands-on techniques to mobilize joints, modulate pain, reduce soft tissue restrictions, and improve circulation.

• Joint Mobilization/Manipulation: While no distal tibiofibular mobilizations are typically performed in the acute or early reparative phases due to the need for syndesmosis healing, mobilization of adjacent joints (e.g., talocrural, subtalar, midfoot, superior tibiofibular joints) can be crucial to restore normal arthrokinematics and improve overall ankle function. Specific mobilizations of the proximal tibiofibular joint may also be used to improve ankle dorsiflexion range of motion.
• Soft Tissue Mobilization: Gentle techniques to address muscle guarding and fascial restrictions around the ankle and lower leg.

2. Myofascial Release (MFR)

MFR is a specialized manual therapy technique that targets restrictions in the myofascial system, which is the web of connective tissue that surrounds muscles and other structures.

• Application: MFR can be used to release tension in muscles of the lower leg (e.g., gastrocnemius, soleus, tibialis anterior, tibialis posterior, peroneal muscles) that may be tight or guarded due to the injury or compensatory patterns. Releasing these restrictions can improve overall ankle mechanics and reduce stress on the healing syndesmosis.
• Technique: Sustained pressure and stretching are applied to the fascia until a release is felt.

3. Instrument-Assisted Soft Tissue Mobilization (IASTM)

IASTM uses specialized tools to effectively detect and treat soft tissue restrictions, adhesions, and scar tissue.

• Application: Once the acute inflammatory phase has subsided and the syndesmosis has begun to heal, IASTM can be used to address scar tissue formation and fascial restrictions in the surrounding muscles and ligaments of the lower leg and ankle. This can help improve tissue extensibility and promote optimal healing and remodeling.
• Technique: Tools are stroked over the affected area with varying pressure and direction, often causing some localized redness.

4. Active Release Technique (ART)

ART is a patented, non-invasive soft tissue treatment that addresses problems in muscles, tendons, ligaments, fascia, and nerves. It involves applying tension to the affected tissue while the patient actively moves the body part through a specific range of motion.

• Application: ART can be particularly effective in addressing specific adhesions or scar tissue that limit movement and contribute to pain around the ankle and lower leg. This might include addressing restrictions in the calf muscles, shin muscles, or even the small muscles of the foot that can be affected by changes in gait due to the injury.
• Technique: The therapist applies specific pressure to the affected tissue while the patient actively shortens and lengthens the muscle or moves the joint.

5. Muscle Energy Technique (MET)

MET utilizes a patient’s own muscle contractions to achieve therapeutic goals, such as increasing range of motion, reducing muscle hypertonicity, and mobilizing joints.

• Application: For syndesmosis injuries, MET can be used to:
  • Improve ankle dorsiflexion: By targeting the calf muscles.
  • Address fibular malposition: Although direct syndesmotic mobilization is avoided early on, MET can indirectly influence fibular position by addressing muscle imbalances and joint mechanics.
  • Restore muscle length and strength: In muscles surrounding the ankle that may have become tight or weak.
• Technique: The patient performs a gentle isometric contraction against the therapist’s resistance, followed by a stretch.

6. Dry Needling

Dry needling involves inserting thin needles into myofascial trigger points or taut bands of muscle to alleviate pain and muscle dysfunction.

• Application: Dry needling can be used to address trigger points in the surrounding musculature (e.g., gastrocnemius, soleus, tibialis anterior, peroneal muscles) that may be causing referred pain or contributing to muscle guarding and stiffness around the injured syndesmosis. It can help reduce pain, improve muscle activation, and increase range of motion.

7. Kinesiology Taping

Kinesiology taping involves applying elastic tape to the skin to provide support, reduce swelling, facilitate or inhibit muscle activity, and improve proprioception.

• Application: For syndesmosis injuries, kinesiology taping can be used to:
  • Provide support: To the ankle and syndesmosis, helping to limit excessive motion during daily activities or early rehabilitation exercises.
  • Reduce swelling and bruising: By creating a lifting effect on the skin, promoting lymphatic drainage.
  • Improve proprioception: By stimulating sensory receptors in the skin, which can enhance awareness of ankle position and movement.
  • Facilitate or inhibit muscle activity: Depending on the application technique, it can help activate weakened muscles or relax overactive ones.
• Technique: Specific taping patterns are applied by a trained professional based on the desired therapeutic effect.

General Rehabilitation Principles for Syndesmosis Injuries:

Beyond these advanced techniques, a comprehensive physiotherapy program for syndesmosis injuries will also include:-

• Protection and Immobilization: Initially, often with a brace or boot, and non-weight-bearing or partial weight-bearing to allow for ligament healing.
• Pain and Swelling Management: PRICE (Protection, Rest, Ice, Compression, Elevation) and modalities like cryotherapy, compression, and possibly electrical stimulation.
• Progressive Range of Motion Exercises: Starting with gentle, pain-free movements and gradually increasing the range.
• Strength Training: Initially isometric exercises, progressing to isotonic and eccentric exercises for the ankle and lower leg muscles.
• Proprioceptive and Balance Training: Crucial for regaining stability and preventing re-injury, starting with stable surfaces and progressing to unstable ones (e.g., wobble board, single-leg balance).
• Functional Exercises: Sport-specific drills and activities tailored to the individual’s return-to-sport or daily activity goals.
• Patient Education: On proper footwear, activity modification, and self-management strategies.