Return to Play after High Ankle Sprains in Athletes: A Systematic Review and Meta-Analysis

Abstract

Category: Sports Introduction/Purpose: Syndesmotic ankle sprains, or high ankle sprains, are a challenging lower extremity injury, especially among high level athletes. The management of such injuries is still controversial, with a paucity of evidence on treatment protocols and unpredictability regarding the time lost to participate in sports following injury. Full recovery and return to play for syndesmotic injuries has been reported to require more than twice the time compared to standard, lateral ankle sprains The goal of this systematic review and meta-analysis was to provide orthopedic surgeons with the most updated evidence on high ankle sprains in athletes. Our primary objective was to report updated prevalence and time to return to play (RTP) after surgical or non-surgical management of syndesmotic injuries. Methods: A meta-analysis and systematic review of the literature was performed with adherence to the preferred reporting items for systematic reviews and meta analyses (PRISMA) guidelines. PubMed, Cochrane Library, and Google Scholar were queried in August 2021 for case series, cohorts, and randomized controlled trials that evaluated return to play time after ankle syndesmotic sprains. The primary outcome was the injury prevalence and time to RTP. Secondary outcomes were complications, functional outcomes, as well as recurrent injuries and reoperations after the initial management of an ankle syndesmotic sprain with no associated ankle fracture. To assess risk of bias, the Joanna Briggs institute critical appraisal tool was used for case series, the Newcastle Ottawa scale for comparetive studies and Rob2 for randomized clinical trials. Results: 18 articles were eligible for meta-analysis with a total of 1133 syndesmotic sprains. Four studies managed their patients with surgical intervention, nine articles reported non-surgical management, and three articles used both surgical and non-surgical methods. Two studies did not specify management method. The overall RTP was 99% (95% CI 0.96, 1.00), the overall mean RTP was 52.32 days (95% CI 39.01, 65.63). Pooled RTP for surgically treated patients was 70.94 days (95% CI 47.04, 94.85, while it was 39.33 days (95% CI 28.78, 49.88) for non-surgically treated cases. A low incidence of recurrence and complications were reported. Moreover platelet rich plasma injection was found to decrease the time needed to return to play in atheletes with high grade syndesmotic injuries. Conclusion: This systematic review and meta-analysis showed high rates of return to play after syndesmotic sprains in professional athletes regardless of surgical vs non-surgical treatment with surgically treated athletes needing more time to return to play compared to those treated non-surgically. Platelet rich plasma injections are safe and may improve time to RTP. Future comparative studies with larger sample size and subanalyis of grade of syndesmotic injury are required for better assessment of outcomes and complications.