Published 3/4/2026
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Leah Lawrence
Fractures and soft tissue injuries are a major concern for athletes. Appropriate management should include comprehensive diagnostic evaluations, considerations of surgical and non-surgical treatment options, and tailored rehabilitation programs.
Tuesday’s Instructional Course Lecture, “Foot and Ankle Injuries in Athletes: Getting to the Finish Line,” presented in partnership with the American Orthopaedic Foot & Ankle Society, addressed how to thoroughly evaluate and treat three difficult foot and ankle injuries that commonly occur in athletes.
Syndesmotic injury
Arianna L. Gianakos, DO, assistant professor of orthopaedic surgery at Yale School of Medicine, opened the course with a discussion of syndesmotic injuries.
“Syndesmotic injuries are getting more attention in the news as a lot of high-level athletes are starting to experience this high ankle sprain,” Dr. Gianakos said.
During her talk, Dr. Gianakos focused on the lower-level ligaments, the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), and the interosseous (IO) ligament.
Why are these important? Studies demonstrate that the AITFL contributes to 35% of overall tib-fib stability and the PITFL contributes to 9% of stability. Additionally, studies have shown if you transect the AITFL it can increase talar translation up to 7.3 mm.
“These are things you absolutely cannot miss in elite athletes,” Dr. Gianakos said. “They make up 12% of all ankle sprains and anywhere from 25-75% of ankle sprains in collision.”
The most common mechanism of this injury is an external rotation of the foot with simultaneous internal rotation of the leg. Diagnosis should include a weight-bearing radiograph, which can show some medial clear space widening or tip space widening, and an MRI, if there is suspicion of ligament rupture.
Treatment can be broken into two categories, purely ligamentous injuries and fractures with syndesmotic instability. If the injury is purely ligamentous, conservative intervention can be attempted.
“Oftentimes, we label these as grade 1 or grade 2 sprains,” Dr. Gianakos said. “Typically, you can allow them to be immobilized for a couple of days, if needed, and then convert them to weight bearing as tolerated, and start early range of motion physical therapy.”
Grade 3 injuries, those that are overtly unstable, are typically treated with surgery. There are several intraoperative considerations, Dr. Gianakos said, including testing for synaptic instability via a radiograph or arthroscopy. Studies have demonstrated that arthroscopy correlates with subtle syndesmotic injury.
Finally, Dr. Gianakos discussed some of the pros and cons of use of a more rigid screw fixation or more flexible suture button fixation for syndesmosis injuries.
“The majority of evidence is overall positive, utilizing either method,” Dr. Gianakos said. “One study looking at five randomized clinical trials found that suture button actually had better outcome scores, with a lower rate of broken implants, a lower rate of implant removal, and lower rate of malreduction.”
Recommendations on return to sport for these patients are variable in the literature.
“That’s why the current consensus group will be focusing on these syndesmotic injuries in May at ESSKA Congress 2026,” Dr. Gianakos said, referring to the European Society of Sports Traumatology, Knee Surgery and Arthroscopy scheduled for May in Prague. “We will be looking at what global foot and ankle surgeons who take care of elite athletes are recommending.”
Fifth metatarsal fractures
Next, Gregory Richard Waryasz, MD, CSCS, FAAOS, director of foot and ankle sports medicine in the department of orthopaedic surgery at Mass General Hospital, discussed fifth metatarsal fractures, which have an 18% annual incidence — about one per 2,500 people. The majority of these fractures are considered zone 1 — an avulsion fracture; about 18% will be zone 2 (Jones fracture) or zone 3 (mid-shaft fracture).
“The vascular anatomy dictates a lot of healing patterns in these injuries,” Dr. Waryasz said. “The proximal fifth metatarsal is supplied by the metaphyseal arteries and the metadiaphyseal junction, a watershed region, which can contribute to difficulty in healing.”
The fifth metatarsal base also features key insertions, including the peroneus tertius, the peroneal brevis, and the plantar aponeurosis.
Zone 1 fractures have good healing potential, Dr. Waryasz said. Even asymptomatic non-unions are usually treated with observation. For zone 2, there is a longer return to sport with surgery (15 vs. 30 weeks).
“But the majority of non-displaced ones heal fine,” Dr. Waryasz said. “If you have an athlete trying to get back mid-season, you might fix it, but for the general population, it might not be worth fixing them.”
For non-operative zone 3 injuries, historical data showed refracture rates of up to 50% and delayed union rates of 25-67%. However, Dr. Waryasz detailed a case of successful non-operative zone 3 management that he said taught him a lot about non-operative management.
For surgical cases, Dr. Waryasz described different available approaches, discussing use of axial screws, cannulated versus noncannulated screws, plating, and adjuncts.
Achilles tendon injury
Finally, course moderator James Turner Vosseller, MD, FAOA, FAAOS, attending surgeon, Jacksonville Orthopaedic Institute, Jacksonville, Florida, covered Achilles rupture.
“These are catastrophic injuries for athletes,” Dr. Vosseller said, “and certainly a pain in the butt for anybody else.” These ruptures occur as a byproduct of a tendinotic tendon that undergoes an uncontrolled eccentric contracture. Often, there are no symptoms beforehand.
Given their catastrophic nature, it would be beneficial to have methods to identify people at risk for rupture and provide effective interventions. Unfortunately, Dr. Vosseller said, although research has been conducted in this area, it has been somewhat inconclusive.
When these ruptures do occur, they require a long length of recovery. One study looking at professional soccer players’ return to play after operative repair showed that players had decreased play time and performance at one year, but that had normalized somewhat by the second year.
With operative treatment, the goal is restoration of appropriate tension and a minimization of the risk of doing so, Dr. Vosseller said. He noted how his surgical approach has evolved. In 2026, he performs a more traditional, minimally invasive repair using a vertical incision and no augmentation. Rehabilitation includes three weeks of non-weight bearing and heel lift out to six months to block the risk of elongation.
There have also been advances in non-operative treatment, including the introduction of more aggressive rehabilitation protocols.
Leah Lawrence is a freelance medical writer for AAOS Now.
References
- Ogilvie-Harris DJ, Reed SC, Hedman TP, et al. Disruption of the ankle syndesmosis: biomechanical study of the ligamentous restraints. Arthroscopy. 1994;10(5):558-60.
- Xenos JS, Hopkinson WJ, Mulligan ME, et al. The tibiofibular syndesmosis. Evaluation of the ligamentous structures, methods of fixation, and radiographic assessment. J Bone Joint Surg Am. 1995;77(6):847-856.
- Shimozono Y, Hurley ET, Myerson CL, et al. Suture button versus syndesmotic screw for syndesmosis injuries: A meta-analysis of randomized controlled trials. Am J Sports Med. 2019;47(11):2764-2771.
- Petrisor BA, Ekrol I, Court-Brown C. The epidemiology of metatarsal fractures. Foot Ankle Int. 2006;27(3):172-174.
- Coleman MM, Guton GP. Jones fracture in the nonathletic population. Foot Ankle Clin. 2020;25(4):737-751.
- Trofa DP, Noback PC, Caldwell J-ME, et al. Professional soccer players' return to play and performance after operative repair of Achilles tendon rupture. Orthop J Sports Med. 2018 Nov 28;6(11):2325967118810772.