Thirty-nine patients with rotational ankle fractures requiring syndesmotic fixation were randomized to receive early weight bearing at 2 weeks (n=16) or delayed weight bearing at 6 weeks (n=23). The primary outcome of interest was the maintenance of syndesmotic reduction at 1 year, assessed via postoperative and 1-year CT scans. Secondary outcomes included pain scores, surgical experience (SSQ-8), AAOS Foot and Ankle scores, range of motion, and complications. Outcomes were assessed at 2 weeks and 1 year. Overall, the results of the study revealed that early weight bearing led to significantly greater dorsiflexion at 1 year but was associated with higher pain scores at the 2-week visit. There were no significant differences in syndesmotic malreduction, loss of reduction, long-term pain scores, patient-reported outcomes, arthritis development, or complications. These findings suggest that early weight bearing is a safe option following syndesmotic fixation using suture buttons.