Background:​ Grade III syndesmosis sprains are usually treated with internal fixation. Limited information is available on early weightbearing and early return to activity after operative treatment for grade III syndesmosis sprains.

Hypothesis:​ Treatment of grade III syndesmosis sprains in intercollegiate athletes with internal fixation, early range of motion, and early weightbearing can lead to rapid return to sport with minimal complications and no ankle problems in midterm follow-up.

Study Design:​ Case series;​ Level of evidence, 4.

Methods:​ We evaluated a consecutive series of intercollegiate athletes treated operatively with 4.5-mm cortical screw fixation for grade III syndesmosis sprains. At 1 week after surgery, patients were allowed to begin range of motion exercises, progressive weightbearing, and gradually return to full activity as tolerated. Outcome measures included time to return to full activity and, at final follow-up, the Sports Ankle Rating System scores.

Results:​ Six male intercollegiate college athletes met the inclusion criteria for this study. The average time for return to full activity was 41 days (range, 32–48 days). There were no intraoperative complications or complications when resuming in-season sport activities with the screw in place. One screw broke during removal. At an average follow-up of 34.3 months, using the Sports Ankle Rating System, the average clinical rating score was 96.2, the average quality-of-life measure was 96.7, and the average single assessment numeric evaluation was 95.3. Radiographs at final follow-up showed no mortise widening or lateral talar subluxation. Two patients had mild degenerative changes on lateral radiographs with anterior tibial osteophytes.

Conclusions:​ In selective cases, athletes can return to full activity as early as 6 weeks after internal fixation of grade III syndesmosis sprains.