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MRI showed high sensitivity, specificity, and accuracy under the criteria we proposed, and we recommend it as the main diagnostic tool for diagnosing a chronic syndesmosis injury. These findings might suggest that pain is mainly caused by hypertrophy and impingement of the soft tissue in the distal tibiofibular joint. Arthroscopic debridement alone can be recommended if the distal tibiofibular chronic syndesmosis injury is not combined with medial ankle instability and lateral displacement of the talus.

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