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

Key points

1. 01Pooled return-to-sport rate was 96% (95% CI 93-98%) across 901 elite athletes in 14 studies.
2. 02Suture-button fixation and nonoperative management both yielded comparable RTS rates of approximately 98%.
3. 03Average time to return to sport was approximately 58 days (range 13-133 days across studies).
4. 04Higher-grade or surgically treated injuries, particularly in professional soccer, may take up to 15 weeks before match play.
5. 05Publication bias was detected, suggesting the true RTS rate may be slightly lower than the pooled estimate.

How it was conducted

Design

Systematic review and meta-analysis (PRISMA-compliant, PROSPERO-registered CRD420251149156)

Databases

PubMed, Embase, Web of Science, Cochrane Library searched from inception to September 2025

Participants

901 elite athletes (mean age 26.8 years) from 6 countries across 14 studies

Included study types

Prospective and retrospective cohort studies, RCTs, and case series reporting RTS outcomes in elite or professional athletes

Primary outcomes

Return-to-sport rate and time to return to sport

Statistical approach

Random-effects meta-analysis with logit transformation for proportions; heterogeneity assessed with I2 and tau2; subgroup, sensitivity, and meta-regression analyses performed

What they found

• Pooled RTS rate: 96% (95% CI 93-98%); I2 = 26.6%, tau2 = 0.3966, p = 0.169.
• Suture-button fixation subgroup RTS rate: 98% (95% CI 92-99%; I2 = 0%).
• Nonoperative management subgroup RTS rate: 98% (95% CI 94-99%; I2 = 0%).
• Studies with treatment not reported had a lower pooled RTS rate of 90% (95% CI 83-95%).
• Subgroup difference test was statistically significant (chi2 = 8.59, df = 2, p = 0.0136).
• Sensitivity analysis (leave-one-out): pooled RTS estimate remained stable at 0.95-0.97; excluding one large study (DeFroda) raised estimate to 0.98 (95% CI 0.95-0.99) and reduced I2 to 0%.
• Mean time to RTS across 13 studies: approximately 58 days (range 13-133 days).
• Publication bias confirmed by funnel plot asymmetry and Egger's test (z = 3.79, p = 0.0002).
• GRADE certainty of evidence: low for RTS rate; very low for time to RTS.

Limitations

• All included studies were observational and mostly retrospective, limiting causal inference and certainty of evidence.
• Time to RTS reporting was inconsistent with few dispersion measures, preventing formal pooled analysis; the 58-day estimate is a crude descriptive average only.
• Publication bias was detected, suggesting the pooled 96% RTS rate may be an overestimate.
• Incomplete reporting of injury grade, associated pathology, and sport type limited exploration of factors driving between-study heterogeneity.

Why it matters

For patients

Athletes who suffer a high ankle sprain can be reassured that a return to full competition is highly likely, usually within 2 months, with either surgery or conservative care for the appropriate injury grade.

For clinicians

Both suture-button fixation and structured conservative rehabilitation yield comparable high RTS rates; treatment selection should be guided by injury stability and grade, and return-to-play criteria should be objective and individualized.

For readers

This meta-analysis provides the most up-to-date pooled estimate for RTS after syndesmosis injuries in elite sport, but the low GRADE certainty and confirmed publication bias mean the 96% figure should be interpreted cautiously.