Return to Sport After Foot and Ankle Surgery Is Inconsistently Defined and Assessed: A Systematic Review

To conduct a systematic review of return-to-sport (RTS) definitions in the orthopaedic literature, addressing common operative athletic foot and ankle pathologies including ankle instability, Achilles tendon ruptures or tendinopathy, and fifth metatarsal fractures.

A systematic review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Cochrane, Embase, Medline, and CINAHL databases were searched for studies published through March 2024. Inclusion criteria were studies in which subjects were involved in some level of sports and received surgery for 1 of 3 common sports-related injuries: ankle instability, Achilles tendinopathy, and fifth metatarsal fracture. The primary outcome was each study's definition of RTS.

There were 145 articles that met all inclusion criteria. Of these, 73 articles investigated ankle instability, 56 investigated Achilles tendinopathy, and 16 investigated fifth metatarsal fracture. Seventy-nine articles (54.5%) had an unclear definition of RTS with 66 articles (45.5%) reporting a precise definition. Sixty-four articles (44.1%) provided an isolated binary metric reporting whether a patient returned to sport or failed to provide a method for determining the timepoint for RTS. Thirty-eight (26.2%) of the articles used an objective start criterion (e.g., resumption of competition), followed by custom (n = 27, 18.6%) and standardized patient-reported questionnaire use (n = 21, 14.5%).

Most articles included in this systematic review did not provide an explicit definition of RTS or a clearly defined assessment methodology. When specified, RTS was assessed using objective events, custom questionnaires, or standardized patient-reported outcome measures, highlighting substantial heterogeneity in both RTS definitions and assessment approaches across foot and ankle literature.

Level IV, systematic review of Level I to IV studies.