Weightbearing CT in the Evaluation of Athletic Foot and Ankle Injuries

Subtle foot and ankle injuries in athletes, including syndesmotic sprains, ligamentous Lisfranc injuries, osteochondral lesions of the talus, and proximal fifth metatarsal stress fractures, may be underestimated or misclassified on conventional imaging. This review summarizes the current role of weightbearing CT (WBCT) in their evaluation, focusing on quantitative parameters, recent technical advances, and their potential influence on clinical decision-making.

Recent evidence has shifted WBCT from qualitative assessment toward reproducible three-dimensional quantification. Volumetric assessment and distance mapping improve characterization of syndesmotic instability, while external-rotation stress can reveal abnormalities not evident during neutral standing. In the midfoot, triplanar realignment and side-to-side comparison improve the reliability of Lisfranc measurements and support detection of subtle instability. Distance mapping permits reproducible quantification of osteochondral lesion surface area, depth, and volume and may improve consistency in surgical planning. WBCT has also characterized sport-specific alignment patterns and a morphologic and bone-density phenotype associated with proximal fifth metatarsal stress fractures. Semiautomated segmentation and deep-learning methods may further reduce observer dependence and analysis time. WBCT provides three-dimensional measurements under physiologic load that complement clinical examination and conventional imaging in selected athletic foot and ankle conditions. Its greatest current value lies in characterizing subtle instability, malalignment, and osseous morphology when these findings may alter treatment planning. However, most available evidence is retrospective and derived from symptomatic or injured cohorts. Prospective studies are needed to validate diagnostic thresholds, determine whether WBCT-derived parameters predict injury or outcomes, and define their role in routine athletic screening and return-to-sport decision-making.