Chronic syndesmosis MRI findings compared to arthroscopy findings

Injuries to the distal tibiofibular syndesmosis are less common than lateral ankle sprains but are frequently associated with persistent pain and functional impairment when not accurately diagnosed. Magnetic resonance imaging (MRI) is commonly used to evaluate suspected syndesmotic injury; however, its diagnostic accuracy in the setting of chronic pathology remains uncertain. A retrospective review was performed of patients who underwent both preoperative MRI and ankle arthroscopy between August 2022 and December 2024. MRI findings from official radiology reports were compared with intraoperative arthroscopic findings, which served as the reference standard. Fifty patients met inclusion criteria. MRI demonstrated a sensitivity of 100% and specificity of 28.57% for detecting syndesmotic tearing. For syndesmotic fibrosis or synovitis, MRI sensitivity was 100% with a specificity of 15.38%. All positive MRI findings correlated with intraoperative pathology; however, a substantial number of syndesmotic abnormalities identified during arthroscopy were not detected on preoperative MRI. These findings indicate that MRI demonstrates excellent sensitivity but limited specificity; while positive MRI findings reliably correlated with intraoperative pathology, negative MRI findings did not reliably exclude clinically significant syndesmotic injury. Integration of clinical examination and adjunctive diagnostic modalities may be necessary to accurately evaluate patients with persistent syndesmotic symptoms.