TightRope Surgery for High Ankle Sprain: Suture Button Results and Recovery

As of November 7, 2026, Miami wide receiver Malachi Toney hurt his ankle in practice on Wednesday, and ESPN reported a high ankle sprain that would need surgery, keeping him out of Saturday’s game at Notre Dame.^[3] On3 reported, as relayed by ClutchPoints, that he would have TightRope surgery on Thursday, with a typical recovery of four to six weeks.^[4] The College Football Playoff starts December 18.^[5] Georgia tight end Brock Bowers had TightRope surgery for a high ankle sprain in October 2023 and played again 26 days later.^[6,7] We have no connection with these athletes or their teams and have not examined them. The studies below describe other patients, not a forecast for anyone in the news.

What is the syndesmosis, and what is a high ankle sprain?

Your lower leg has two bones, the tibia (shin bone) and the fibula (the thin outer bone). Just above the ankle, strong ligaments called the syndesmosis bind them together. A high ankle sprain injures those ligaments, not the ones on the outside of the ankle that most sprains affect.^[8] It usually happens in collision sports when the foot twists outward.^[9] Many unstable syndesmosis injuries also come with a fracture.^[10] For how high and low sprains differ, see our parent practice’s guide to high versus low ankle sprains (external site).

Who needs TightRope surgery for high ankle sprain injuries?

The deciding question is stability. When the tibia and fibula spread apart (widening), the joint is unstable, and reviews agree that unstable injuries should be treated with surgery.^[11,12] Stable sprains without widening can heal without it.^[10]

Finding the instability takes care, because the first X-rays can look normal.^[9] The workup can include:

• An exam with tests that squeeze or rotate the leg.^[9]
• Weight-bearing or stress X-rays, which can show widening a resting X-ray misses, and MRI or CT when X-rays are inconclusive.^[11]
• Arthroscopy, a look inside the joint with a small camera. It remains the benchmark for diagnosis.^[9] See ankle arthroscopy.

Catching it matters. Syndesmosis injuries are often overlooked and can cause lasting pain, and untreated instability can lead to arthritis.^[12]

How does a suture button work, and how is it different from a screw?

“TightRope” is Arthrex’s brand name for one suture-button device.^[13] The surgeon drills a small tunnel through the fibula and tibia, passes the cord across, and tightens it so a button sits against each bone, holding the bones in their normal position.^[13,14,15]

The older method is a metal screw across the two bones. A screw holds them rigidly and may need a second operation to come out, while a suture button allows the small natural motion between the bones.^[16] The suture button was designed so routine removal would not be needed.^[17] For syndesmosis fixation during ankle fracture care, see fracture surgery.

Suture button vs. screw for the syndesmosis: what do the trials show?

Sources: the three reviews and the trial.^{[1,18,19,20,21]} The 2026 review concluded that suture buttons should be recommended for surgery on these injuries.^[1]

TightRope surgery recovery time: when can you walk and play?

Plans differ by surgeon and injury.

• Walking. In a 2026 randomized trial of ankle fractures with the syndesmosis held by a suture button, walking at 2 weeks worked as well as waiting 6 weeks, and gave better upward ankle bend at 1 year.^[22] In 32 patients with a pure syndesmosis injury, all walked early, none needed the implant removed, and ankle scores rose from 44 to 99 out of 100.^[23]
• College football. Seven college players returned to games an average of 39 days after suture-button fixation.^[2]
• Professional soccer. In 110 players operated on for severe, unstable injuries, on-field rehabilitation began at about 37 days, team training at about 72 days, and the first match at about 103 days.^[24]
• Across studies. In 18 studies of 1,133 syndesmosis sprains in athletes, 99% returned to play, and those treated with surgery took about 71 days.^[25] Surgery is reserved for the unstable, more severe injuries.^[10]

See recovery after foot and ankle surgery.

Why see a Foot and Ankle Surgeon early?

The trials above studied fresh injuries, fixed within 6 weeks.^[1] A Foot and Ankle Surgeon can check stability, order the right imaging and look for a fracture or cartilage damage. If your sprain is still sore weeks later, read why an ankle sprain may not be healing, or see ankle and foot fractures.

What are the limits?

Trial patients averaged 41 years old in one review, and the walking trial studied fractures, so evidence in young athletes comes from smaller studies. Walking at 2 weeks also hurt more at first.^[18,22] A 2026 review of trials with about 5 years of follow-up found no clear long-term difference in ankle scores and less pain with screws, though pain results varied widely between trials.^[16] Suture buttons sometimes come out: in 102 early cases, 8 were removed for infection, a painful bone reaction, failed stabilization or unexplained pain, and the knot can irritate the skin.^[14] Removal at about a year eased symptoms without loss of alignment.^[17] In a cadaver study, the cord pressed on the saphenous vein, which runs with a skin nerve on the inner ankle, at 11 of 30 drill sites.^[15] The common 2 mm cutoff used during arthroscopy may lead to overtreatment.^[26] Severe injuries, cartilage damage and older age meant a longer return to play.^[24]

Common questions

How long is TightRope surgery recovery time?

Return to play averaged about 6 weeks in college football players and about 15 weeks in professional soccer players with severe injuries.^[2,24]

Is a suture button better than a screw for the syndesmosis?

In 16 randomized trials, suture buttons had fewer complications and reoperations, with similar or slightly better function.^[1] One long-term review found no clear difference after 5 years.^[16]

Does a TightRope have to be removed?

Usually not. It was designed to avoid routine removal, though some are taken out later for irritation or pain.^[17,14]

Can a high ankle sprain heal without surgery?

Yes, if the joint is stable and has not widened. Unstable injuries are treated with surgery.^[10,11]

The bottom line

When a high ankle sprain leaves the tibia and fibula unstable, a suture button holds them in place with fewer complications than a screw, and athletes return to sport at high rates. Whether your ankle needs fixation, and which kind, is a decision Dr. Ozturk makes after examining it and reviewing your imaging. Dr. Ozturk is a double board certified Foot and Ankle Surgeon and podiatrist who sees patients in Lyndhurst, Paramus and Millburn. Our parent practice has a week-by-week sprain recovery guide (external site), or you can request an appointment.