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Return-to-sport rate and time in elite athletes after ankle syndesmosis injuries: a systematic review and meta-analysis

Review written by Dr Chris Bleakley info

Key Points

  1. Return to sport (RTS) after syndesmosis injury is highly likely. Across 14 studies and 901 elite athletes, the pooled RTS rate was 96%.
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BACKGROUND & OBJECTIVE

Injuries to the ankle syndesmosis (high ankle sprains) account for up to 30% of all ankle sprains and they carry a high clinical burden, particularly in elite sport (1) They are especially prevalent in contact sports such as rugby, soccer, and American football. Recent kinematic research suggests a consistent injury mechanism characterized by either direct or indirect contact to the ankle, producing excessive external rotation and/or dorsiflexion of the foot (2). Management depends largely on injury severity.

Stable injuries are generally treated non-operatively with immobilization/bracing and structured rehabilitation, whereas unstable injuries with diastasis typically require operative fixation. In recent years, dynamic suture-button fixation has gained popularity as an alternative to rigid syndesmotic screw fixation, supported by evidence suggesting favourable clinical outcomes and potentially faster recovery (3,4). Despite this evolving management landscape, reported return-to-sport (RTS) rates and timelines remain variable across studies, creating uncertainty for clinicians, athletes, and coaching staff in elite sport.

This systematic review and meta-analysis by Li and colleagues aimed to synthesize current evidence on RTS outcomes following ankle syndesmosis injuries in elite athletes, focusing on RTS rates and time to return.

Injuries to the ankle syndesmosis (high ankle sprains) account for up to 30% of all ankle sprains and they carry a high clinical burden, particularly in elite sport.
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Clinicians should note that the average recovery trajectory to return to competitive match play is approximately eight weeks, typically longer than lateral ankle sprains.

METHODS

This review was prospectively registered and conducted in accordance with PRISMA guidelines. Five electronic databases were searched from inception to September 2025 without language restrictions. Eligible designs included randomized trials, prospective or retrospective cohort studies, and case series involving elite

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