Ankle injuries in elite athletes: A systematic review of epidemiology, biomechanics, diagnosis, treatment strategies, functional responses, and return to sport

Abstract

Background: Ankle injuries represent a significant burden in sports medicine, particularly among elite and high-performance athletes. Their high incidence, complex biomechanical implications, and potential for long-term disability necessitate an integrated understanding of injury mechanisms, diagnostic protocols, treatment strategies, and functional outcomes. Despite the abundance of isolated studies, a comprehensive synthesis focused specifically on this athletic population remains scarce. Objective: This systematic review aimed to examine and integrate current evidence regarding epidemiology, biomechanics, diagnosis, conservative and surgical treatments, functional responses, and return-to-sport outcomes associated with ankle injuries in elite athletes, using exclusively open-access, peer-reviewed literature. Methods: A total of 22 full-text, open-access articles were selected from peer-reviewed journals indexed in databases such as PubMed, ScienceDirect, and SpringerLink. Articles were included based on predefined eligibility criteria focusing on high-performance athletes and on themes directly related to ankle trauma. Data extraction and synthesis were conducted thematically across six categories, and the methodological quality of the included studies was assessed using the Modified Coleman Methodology Score (MCMS) and AMSTAR-2 tools. Results: Ankle sprains, particularly lateral ligament injuries involving the anterior talofibular ligament (ATFL), were identified as the most common injury type. Sports involving rapid deceleration, directional change, or repetitive landings showed the highest incidence rates. Biomechanical alterations such as limited dorsiflexion, altered peroneal activation, and asymmetrical ground reaction forces were closely associated with chronic ankle instability (CAI). Diagnostic precision improved significantly with the inclusion of arthroscopic techniques and biomechanical assessments. While conservative management remains the first-line approach, approximately 30% of elite athletes require surgical intervention due to functional or structural deficits. Functional responses extended beyond structural damage to include proprioceptive dysfunction, central motor adaptation, and psychological barriers. Return-to-sport decisions were optimized when based on objective functional criteria and sport-specific performance benchmarks. Conclusion: Ankle injuries in elite athletes are multifactorial, involving complex biomechanical and neuromuscular dimensions. Early diagnosis, tailored rehabilitation, and criteria-based return-to-sport protocols are essential for minimizing recurrence and optimizing athletic performance. This systematic review underscores the need for interdisciplinary management strategies grounded in evidence-based practice.