Abstract
BACKGROUND: Ankle syndesmosis injuries are a significant concern in elite athletes, often resulting in prolonged recovery and uncertainty regarding optimal management. Although most athletes eventually return to sport (RTS), reported RTS rates and timelines vary widely due to differences in treatment strategies. Given this heterogeneity and lack of consensus, this study systematically reviews RTS rates and time to RTS in elite athletes following syndesmotic ankle injuries. METHODS: A systematic search of five databases was performed through September 2025 to identify studies on RTS outcomes in elite athletes with ankle syndesmosis injuries. Pooled RTS proportions were calculated using a random-effects model with logit transformation, and time outcomes were synthesized using random-effects models or descriptive methods. Subgroup, sensitivity, and meta-regression analyses were conducted to assess heterogeneity. Study quality was evaluated using the Newcastle-Ottawa Scale, and publication bias was assessed with funnel plots and Egger's test. RESULTS: Fourteen studies comprising 901 elite athletes were included. The pooled RTS rate following ankle syndesmosis injuries was 96% (95% CI 93-98%), with low-to-moderate heterogeneity (I(2) = 27%). Subgroup analysis showed comparable RTS rates for suture-button fixation (98%) and nonoperative management (98%). Sensitivity analyses confirmed the robustness of the findings. Publication bias was suggested by funnel plot asymmetry and Egger's test (p = 0.0002). The average time to RTS across studies was approximately 58 days. CONCLUSION: Elite athletes sustaining ankle syndesmosis injuries demonstrate a high likelihood of returning to sport, with a pooled RTS rate of 96%. Comparable outcomes were observed following both suture-button fixation and nonoperative management, with most athletes resuming play within 2 months. Most athletes can anticipate favorable outcomes regardless of treatment strategy, though management should still be individualized based on injury severity and sport-specific demands.