The Maisonneuve injury, sometimes described as a Maisonneuve fracture in older medical literature, is a serious and often underdiagnosed injury that links the ankle joint with a proximal fibula fracture. While it begins with what looks like a simple ankle sprain, the injury can extend far beyond the ankle itself, affecting ligaments, the tibia, the fibula and even surrounding nerves and blood vessels. In this guide, we’ll unpack what a Maisonneuve injury is, how it occurs, how it is diagnosed, and how it is treated and rehabilitated. Whether you’re a patient seeking clarity or a clinician aiming to refresh knowledge, this article aims to be both practical and evidence-based.
What is a Maisonneuve Injury?
The term Maisonneuve injury refers to an injury pattern in which disruption of the ankle syndesmosis and often a proximal fibular fracture occur as part of a larger mechanism that begins with external rotation or eversion of the foot. The injury is named after the French surgeon Jules Maisonneuve, who first described this linked pattern. In clinical shorthand, many clinicians simply say “Maisonneuve injury” or “Maisonneuve fracture” to denote the combination of an ankle injury with a proximal fibular fracture, even though not every case includes a fracture of the fibula.
Important to note is that the injury is more than just a broken bone in the fibula. It involves injury to the syndesmosis — the syndesmotic ligaments that stabilise the tibia and fibula at the ankle. If the syndesmosis is unstable, the ankle mortise becomes widened, leading to instability that can jeopardise joint function if not recognised and treated properly. For many patients, the proximal fibula fracture is the visible sign of a more extensive injury inside the ankle, and missing it can lead to ongoing pain and instability.
The Anatomy Involved in a Maisonneuve Injury
Proximal Fibula
The proximal fibula is the upper end of the fibula, near the knee. In a Maisonneuve injury, a fracture often occurs here as part of the transfer of force from the ankle up the leg. This proximal fracture can be small or comminuted, and it may be radiographically subtle on initial views. The clinical significance lies in the fact that proximal fibular fractures can be associated with damage to structures that cross the knee and proximal leg, including nerves and vessels.
Distal Tibiofibular Syndesmosis
The syndesmosis is a fibrous joint between the distal tibia and fibula held together by ligaments, primarily the anterior inferior tibiofibular ligament, the posterior inferior tibiofibular ligament, and the interosseous ligament. In a Maisonneuve injury, this syndesmotic stability is often compromised, leading to ankle instability even if the visible ankle bone injuries seem minor.
Ankle Mortise and Malleoli
The ankle mortise is the socket formed by the tibia and fibula that houses the talus. Disruption of the syndesmosis can widen the mortise, creating instability and abnormal mechanics during walking and weight-bearing. The medial malleolus and other structures around the ankle may also be involved, depending on the force direction and the exact injury pattern.
How Does a Maisonneuve Injury Occur?
Most Maisonneuve injuries result from a twisting mechanism where the foot twists outward (eversion) while bearing weight. This mechanism places stress on the syndesmosis and can force the fibula to break proximally as the energy travels up the leg. Sometimes the injury begins with a high-energy impact, such as a sports collision or a fall, and other times it occurs in lower-energy activities but with poor alignment or underlying structural predispositions.
Common mechanisms include:
- External rotation of the foot with forced eversion, transmitting torque up the leg.
- Sudden dorsiflexion combined with rotation, which can strain the syndesmotic ligaments.
- Direct trauma to the leg that creates a proximal fibular fracture and disrupts ankle stability.
Recognising the Signs and Symptoms
One of the challenges of Maisonneuve injuries is their subtle presentation at first. Patients may report an ankle sprain with swelling, pain, and difficulty bearing weight, while the proximal fibular fracture is not immediately obvious on standard ankle X-rays. Awareness of the pattern is essential for timely diagnosis.
- Pain along the outer aspect of the lower leg that may radiate toward the knee (proximal fibula region).
- Tenderness around the proximal fibula that is not typical of a simple ankle sprain.
- Instability or a feeling of “looseness” at the ankle joint, especially during weight-bearing.
- Swelling, bruising, or warmth around the ankle, with focal tenderness around the distal tibiofibular region.
- Numbness or tingling if a nerve is affected, although this is less common.
Given that the fibular fracture is proximal, clinicians should consider evaluating the tibiofibular ligaments and syndesmosis when a patient presents with persistent ankle pain following an ankle sprain, especially if there is tenderness near the proximal fibula or if initial ankle radiographs are inconclusive.
Diagnosing a Maisonneuve Injury
Accurate diagnosis hinges on a thorough clinical assessment, targeted imaging, and an index of suspicion for the proximal fibula involvement. The diagnostic journey typically follows these steps:
Clinical Evaluation
A clinician will ask about the mechanism of injury, assess weight-bearing ability, inspect and palpate the ankle and proximal leg, and test for instability. Specific tests may be used to assess the syndesmosis and ankle ligaments, including gentle stress testing and evaluation of toe movement and Achilles function. A careful neurovascular examination is essential to identify any nerve or vascular compromise.
Imaging
Imaging is central to confirmation. Typical steps include:
- Plain radiographs (X-rays) of the ankle and leg: AP and oblique views of the ankle, plus a full-length tibia/fibula radiograph to assess the proximal fibula. Mortise view of the ankle can reveal syndesmotic widening.
- Long-leg radiographs may be necessary to evaluate alignment of the knee and tibia after a proximal fibular fracture is identified.
- Weight-bearing X-rays of the ankle can help reveal instability not seen on non-weight-bearing studies.
- MRI: Magnetic resonance imaging provides detailed assessment of ligaments, the syndesmosis, the proximal fibula, and potential associated injuries to the deltoid ligament, cartilage, or tendons. MRI is particularly helpful when X-rays are inconclusive or when there is suspicion of soft tissue injury beyond the visible fracture.
- CT: Computed tomography offers precise delineation of complex fractures and can be useful pre-operatively to plan fixation, especially in proximal fibular fractures with ankle involvement.
Radiologists and clinicians will often rely on a combination of findings: a proximal fibula fracture visible on X-ray, signs of syndesmotic injury on ankle radiographs, and clinical suspicion guided by mechanism and symptoms. In many cases, a Maisonneuve injury is diagnosed only after careful review or after obtaining MRI or CT scans following initial ankle X-rays that appear deceptively normal.
Treatment Options for a Maisonneuve Injury
Management strategies depend on the severity of the injury, the stability of the syndesmosis, the presence of proximal fibular fracture, and the patient’s overall health and activity demands. Early recognition is crucial to prevent long-term instability and degenerative change in the ankle.
Immediate (Acute) Care
- Immobilisation: The limb should be immobilised in a splint or boot to reduce pain and prevent further injury.
- Mode of transport: If there is significant instability or neurovascular concern, urgent referral to an emergency department is warranted.
- Elevation and ice: To help control swelling and pain in the initial 24-48 hours.
- Analgesia: Adequate pain relief, following local guidelines, to enable evaluation and subsequent treatment planning.
Non-Surgical Management
Some Maisonneuve injuries may be managed without surgery if the syndesmosis is stable and the proximal fibula fracture is nondisplaced, and if there is no significant ankle mortise widening. However, this approach requires careful monitoring and strict follow-up with repeat imaging to ensure stability as healing progresses. Non-operative management often includes:
- Immobilisation in a cast, boot, or brace with protected weight-bearing as advised by the clinician.
- Gradual progression of weight-bearing as healing permits, guided by radiographic findings and symptom resolution.
- Structured rehabilitation focusing on restoring range of motion, strength, and proprioception once stability is confirmed.
Surgical Management
Many Maisonneuve injuries require surgical intervention to restore ankle stability and prevent chronic instability. Surgery is typically considered when there is:
- Disruption of the distal tibiofibular syndesmosis with instability on imaging or persistent pain after a trial of non-operative care.
- Proximal fibular fracture with associated ankle involvement that risks malalignment or instability if not fixed.
- Deltoid ligament injury or significant mortise widening that cannot be adequately stabilised non-operatively.
Common surgical approaches include:
- Syndesmotic screw fixation or alternative dynamic fixation (such as suture-button devices) to stabilise the distal tibiofibular joint.
- Open reduction and internal fixation (ORIF) of the proximal fibula fracture if needed for alignment and healing considerations.
- Addressing any intra-articular injuries or peroneal tendon pathology that may contribute to ongoing symptoms.
Post-operative rehabilitation is critical and will typically involve immobilisation initially, followed by progressive weight-bearing and a structured physiotherapy programme. The pace and duration depend on the specifics of the injury and the fixation used, but full recovery can take several months for athletes and longer for more sedentary individuals.
Rehabilitation and Recovery: What to Expect
Rehabilitation after a Maisonneuve injury is a staged process designed to restore motion, strength and functional capacity while protecting healing structures. A well-structured programme can reduce stiffness and improve outcomes, particularly for those returning to sport or demanding activities.
- Protected weight-bearing with a boot or immobiliser as advised by the surgeon or physiotherapist.
- Gentle range-of-motion exercises for the ankle within pain-free limits.
- Maintenance exercises for the knee, hip, and core to support gait retraining.
Mid Phase (6-12 Weeks)
- Gradual increase in load bearing and functional activities, guided by imaging evidence of healing and symptom presentation.
- Progressive proprioceptive training and balance work to restore neuromuscular control.
- Targeted strengthening for the muscles around the ankle and lower leg, including peroneals, tibialis anterior and gastrocnemius-soleus complex.
Late Phase (3-6+ Months)
- Return-to-run or sport-specific drills if applicable, with a gradual ramp-up to full training.
- Continued conditioning to reduce recurrence risk, focusing on ankle stability, hip control and core endurance.
- Long-term strategies for management of symptoms and activity modification as needed.
Recovery timelines vary widely. Some individuals recover well within three to six months, particularly with diligent rehabilitation and appropriate surgical management when indicated. Others, especially those with high-energy injuries or significant syndesmotic disruption, may require longer rehabilitation and may benefit from ongoing physiotherapy beyond six months.
Potential Complications and Long-Term Outlook
As with any significant ankle injury, there are potential complications to be aware of after a Maisonneuve injury. These include:
- Persistent ankle instability or pain due to residual syndesmotic laxity or malalignment.
- Post-traumatic osteoarthritis, particularly if cartilage damage occurred or if malalignment persisted before treatment.
- Stiffness or reduced range of motion in the ankle and subtalar joints.
- Peroneal nerve irritation or injury in rare cases, which may require targeted management.
- A requirement for revision surgery if initial fixation fails to maintain stability or if new symptoms emerge.
With timely diagnosis, appropriate immobilisation, careful surgical planning when necessary, and a thorough rehabilitation programme, many patients regain substantial function and return to normal activities. The prognosis improves markedly when there is early recognition of the injury pattern, avoiding delays that can lead to irreversible instability.
Maisonneuve Injury vs Other Ankle Injuries: What Sets It Apart?
Compared with isolated ankle sprains or simple malleolar fractures, the Maisonneuve injury represents a more extensive injury pattern with a higher risk of missed diagnosis. The key differences include:
- The proximal fibular fracture as part of a link to the ankle injury, rather than being an isolated fracture.
- Potential for syndesmotic instability that may not be evident on initial X-rays of the ankle alone.
- Requirement for a broader assessment that includes the knee region and proximal leg to identify the full extent of injury.
Because of these factors, clinicians are urged to consider a full leg assessment when patients present with unusual ankle pain after an eversion mechanism, particularly if there is tenderness around the proximal fibula or if the patient cannot bear weight reliably with swelled ankle.
Preventing a Maisonneuve Injury: Practical Tips
While not all injuries are preventable, there are steps you can take to reduce your risk of a Maisonneuve injury, particularly in sports and activities with high sprain risk:
- Wear well-fitting, supportive footwear appropriate to the activity and terrain.
- Engage in proper warm-ups, including dynamic stretching and exercises that increase ankle mobility and proprioception.
- Incorporate balance and strength training for the ankle, calf, and leg muscles to enhance stabilisation and control during athletic movements.
- Use protective taping or bracing in sports with a high incidence of ankle sprains or where prior ankle injuries have occurred.
- Maintain good technique and surface awareness to minimise awkward torsion forces on the leg.
Living with a Maisonneuve Injury: Real-Life Guidance
For many patients, the most important questions relate to daily living and returning to activities. Here are some practical considerations:
- Follow medical advice precisely regarding immobilisation duration, weight-bearing restrictions and activity progression.
- Plan for a phased return to work, sports or hobbies, incorporating physiotherapy sessions and gradual load progression.
- Communicate honestly with your clinician about pain levels, swelling, and any numbness or tingling that may indicate nerve involvement.
- Consider a home exercise programme and set realistic milestones to stay motivated during rehabilitation.
- Recognise red flags requiring urgent assessment, such as increasing numbness, cold or pale toes, or rapid worsening swelling.
Frequently Asked Questions about the Maisonneuve Injury
Is the Maisonneuve injury the same as a high ankle sprain?
Both involve the syndesmosis, but a high ankle sprain refers more broadly to injuries of the distal tibiofibular syndesmosis which can occur without a proximal fibular fracture. The Maisonneuve injury is a specific pattern that includes a proximal fibula fracture and ankle involvement, often with syndesmotic injury.
Can a Maisonneuve injury heal without surgery?
Some cases may heal with non-operative management if the syndesmosis remains stable and there is no significant malalignment. However, many cases benefit from surgical stabilisation to ensure correct alignment and to reduce the risk of chronic instability or arthritis.
How long does recovery take?
Recovery varies, but many people can expect several months before returning to full activities. Athletes may need longer rehabilitation and careful clearance from medical professionals before resuming high-demand sports.
What tests are most useful for diagnosis?
While initial ankle X-rays are essential, MRI and CT can provide critical information about the proximal fibula, syndesmotic ligaments, and other soft tissue injuries that plain radiographs may miss. A clinician will tailor imaging based on exam findings and initial radiographs.
Bottom Line: Key Takeaways on the Maisonneuve Injury
The Maisonneuve injury is a complex, integrated injury pattern that starts at the ankle but may involve the proximal fibula and syndesmosis. Early recognition, accurate imaging, and a personalised treatment plan—whether surgical or non-surgical—are central to a favourable outcome. Rehabilitation and gradual reintroduction to activity underpin successful recovery and long-term function. If you suspect a Maisonneuve injury after an ankle twist, seek medical evaluation promptly to prevent missing a crucial component of this injury pattern.
