In this episode of The Sports Docs Podcast, Dr. Ashley Bassett and Dr. Catherine Logan sit down LIVE from the Arthrex Team Physician Controversies with foot and ankle expert Dr. Ned Amendola to discuss the modern management of ankle syndesmosis injuries (“high ankle sprains”) in athletes.

The conversation focuses on when surgery is indicated, the evolution from rigid screw fixation to dynamic stabilization with TightRope technology, surgical pearls, and accelerated return-to-sport strategies for high-demand athletes.

Highlights

When Does a Syndesmosis Injury Need Surgery?

Most isolated, stable syndesmosis injuries can be treated nonoperatively
Surgery is indicated when there is:

Mortise widening
Instability on stress imaging
Associated fibula fractures
Significant ligament disruption (AITFL, PITFL, interosseous membrane)

Key principle:
Instability—not just diagnosis—drives surgical decision-making

The Shift from Screws to Dynamic Fixation

Traditional screw fixation challenges:

Screw breakage and loosening
Frequent hardware removal surgeries
Restricted physiologic motion
Longer non-weight-bearing periods

Advantages of TightRope fixation:

Dynamic stabilization with physiologic micromotion
Lower risk of malreduction
Faster rehabilitation
No routine hardware removal

Key insight:
Dynamic fixation respects normal syndesmotic biomechanics

TightRope Surgical Technique

Critical first step:
Anatomic reduction of the fibula in the incisura

Technique highlights:

Confirm reduction on AP, mortise, and lateral imaging
Drill 2–4 cm above joint line, parallel to plafond
Pass TightRope across all four cortices
Carefully seat medial button
Tension laterally while maintaining reduction

Pearls:

Clamp carefully to avoid malreduction
Avoid posterior fibular translation
Ensure proper button seating without soft tissue interposition

One vs Two TightRopes

One construct may suffice for:

Lower-demand athletes
Isolated injuries without fracture

Two constructs favored for:

High-energy injuries
Athletes
Fibula fractures
Rotational instability or Maisonneuve injuries

Key principle:
Persistent rotational instability drives the need for additional fixation

Outcomes with Dynamic Fixation

Benefits seen clinically:

Lower reoperation rates
Less stiffness
Faster functional progression
Earlier return to sport

Athletes tolerate early motion and rehab particularly well with dynamic fixation

The TightRope PRO System

Improvements include:

Smaller drill tunnels
Lower-profile buttons
Less soft tissue irritation
Controlled self-tensioning handles

Key insight:
Modern implant design improves precision and preserves bone

Rehabilitation & Return to Sport

Isolated injuries:

Early ROM within 1–2 weeks
Progressive weight-bearing by 4 weeks
Running around 8–10 weeks
Cutting/pivoting at 10–12 weeks

Elite athletes may return as early as 6–8 weeks in select cases

Return-to-play criteria:

No syndesmotic tenderness
Symmetric dorsiflexion
Negative stress testing
Functional cutting/acceleration testing
Psychological confidence in the ankle

Key Takeaways

Surgical treatment is based on instability and biomechanics, not simply imaging findings
Dynamic fixation with TightRope technology has transformed syndesmosis management in athletes
Proper reduction technique remains the most important surgical factor
Modern fixation allows for earlier rehabilitation and faster return to play
Return-to-sport decisions should incorporate both functional and psychological readiness

Featured Guest

Dr. Ned Amendola – Duke University, President of the American Academy of Orthopaedic Surgeons, Head Team Physician and Chief Medical Officer for Duke Athletics

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Arthrex Team Physician Controversies 2026

Our Hosts:

Ashley Bassett, MD & Catherine Logan, MD, MBA / www.cosportsmedicine.com