Diagnostic Value of Ultrasound in Ankle Sprain

Published:August 20, 2021DOI:


      The present study aimed to evaluate the sensitivity and specificity of clinical tests and ultrasonography in detecting ankle ligament injuries. In this cross-sectional study, 105 patients with a history of ankle sprain were included. Ankle ligaments, including syndesmosis of ankle, as well as deltoid, calcaneofibular, anterior talofibular, and posterior talofibular ligaments were evaluated by clinical tests, ultrasonography, and magnetic resonance imaging. The sensitivity and specificity of ultrasound and clinical tests were assessed in normal, sprain, partial tear, and complete tear groups. The inter-observer reliability (Cohen's Kappa score) of the evaluated techniques with magnetic resonance imaging was assessed. Anterior drawer test showed a sensitivity and specificity of 81 and 80% in the detection of anterior talofibular ligament injuries, respectively. Ultrasonography showed 100% sensitivity and specificity in distinguishing normal anterior talofibular ligament from the torn or sprained ligament with a kappa value of 1. The sensitivity of ultrasonography in detecting normal calcaneofibular ligament and deltoid ligament was 93% and 90%, respectively. Ultrasonography was highly specific in detecting calcaneofibular ligament tear but it was not sensitive in this regard. Ultrasonography was proved reliable in determining the normal anterior talofibular ligament and calcaneofibular ligament from the torn or sprained ligament. Ultrasonography is an effective complementary tool for primary evaluation of ankle injuries, which leads to early diagnosis and efficient quality of care. Clinical tests are not reliable to rule out the ankle ligaments injury and the results should be interpreted with caution.

      Level of Clinical Evidence


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Foot and Ankle Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Doherty C
        • Delahunt E
        • Caulfield B
        • Hertel J
        • Ryan J
        • Bleakley C
        The incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis of prospective epidemiological studies.
        Sports Med. 2014; 44: 123-140
        • Croy T
        • Koppenhaver S
        • Saliba S
        • Hertel J
        Anterior talocrural joint laxity: diagnostic accuracy of the anterior drawer test of the ankle.
        J Orthop Sports Phys Ther. 2013; 43: 911-919
        • Tan DW
        • Teh DJW
        • Chee YH
        Accuracy of magnetic resonance imaging in diagnosing lateral ankle ligament injuries: a comparative study with surgical findings and timings of scans.
        Asia Pac J Sports Med Arthrosc Rehabil Technol. 2017; 7: 15-20
        • Azni KK
        • Saini SM
        • Nasir N
        • Bahari N
        Correlation of clinical examination, magnetic resonance imaging and surgical findings in diagnosing ankle joint ligament injuries.
        Eur J Mol Clin Med. 2020; 7: 1474-1484
        • El-Liethy N
        • Kamal H
        High resolution ultrasonography and magnetic resonance imaging in the evaluation of tendino-ligamentous injuries around ankle joint.
        Egypt J Radiol Nuclear Med. 2016; 47: 543-555
        • Cheng Y
        • Cai Y
        • Wang Y
        Value of ultrasonography for detecting chronic injury of the lateral ligaments of the ankle joint compared with ultrasonography findings.
        Br J Radiol. 2014; 8720130406
        • Seok H
        • Lee SH
        • Yun SJ
        Diagnostic performance of ankle ultrasound for diagnosing anterior talofibular and calcaneofibular ligament injuries: a meta-analysis.
        Acta Radiol. 2020; 61: 651-661
        • Shalaby MH
        • Sharara SM
        • Abdelbary MH
        High resolution ultrasonography in ankle joint pain: where does it stand?.
        Egypt J Radiol Nuclear Med. 2017; 48: 645-652
        • Margetić P
        • Pavić R
        Comparative assessment of the acute ankle injury by ultrasound and magnetic resonance.
        Coll Antropol. 2012; 36: 605-610
        • Hayes R
        • Callaghan M
        BET 2: Diagnostic value of ultrasound in determining lateral ligament injury of the ankle.
        Emergency Med J. 2019; 36: 56-57
        • Beighton P
        • Solomon L
        • Soskolne C
        Articular mobility in an African population.
        Ann Rheum Dis. 1973; 32: 413
        • Martinoli C
        Musculoskeletal ultrasound: technical guidelines.
        Insights Imaging. 2010; 1: 99-141
        • Sconfienza LM
        • Albano D
        • Allen G
        • Bazzocchi A
        • Bignotti B
        • Chianca V
        • de Castro FF
        • Drakonaki EE
        • Gallardo E
        • Gielen J
        Clinical indications for musculoskeletal ultrasound updated in 2017 by European Society of Musculoskeletal Radiology (ESSR) consensus.
        Eur Radiol. 2018; 28: 5338-5351
        • Mokbel MA-MI
        • Shawky KM
        • Hamed MAE-G
        • Al-Kenawy HA
        The diagnostic value of high-resolution ultrasound in evaluation of ankle sports injuries: a comparative study with MRI.
        Egypt J Hosp Med. 2020; 81: 1209-1216
        • Alvarez CAD
        • Hattori S
        • Kato Y
        • Takazawa S
        • Adachi T
        • Yamada S
        • Ohuchi H
        Dynamic high-resolution ultrasound in the diagnosis of calcaneofibular ligament injury in chronic lateral ankle injury: a comparison with three-dimensional magnetic resonance imaging.
        J Med Ultrason (2001). 2020; 47: 313-317
        • Fujii T
        • Luo Z-P
        • Kitaoka HB
        • An K-N
        The manual stress test may not be sufficient to differentiate ankle ligament injuries.
        Clin Biomech (Bristol, Avon). 2000; 15: 619-623
        • Margetic P
        • Salaj M
        • Lubina IZ
        The value of ultrasound in acute ankle injury: comparison with MR.
        Eur J Trauma Emerg Surg. 2009; 35: 141-146
        • Sconfienza LM
        • Orlandi D
        • Lacelli F
        • Serafini G
        • Silvestri E
        Dynamic high-resolution US of ankle and midfoot ligaments: normal anatomic structure and imaging technique.
        Radiographics. 2015; 35: 164-178
        • Friedrich JM
        • Schnarkowski P
        • Rübenacker S
        • Wallner B
        Ultrasonography of capsular morphology in normal and traumatic ankle joints.
        J Clin Ultrasound. 1993; 21: 179-187
        • Gün C
        • Unlüer EE
        • Vandenberk N
        • Karagöz A
        • Sentürk GO
        • Oyar O
        Bedside ultrasonography by emergency physicians for anterior talofibular ligament injury.
        J Emerg Trauma Shock. 2013; 6: 195-198
        • Hua Y
        • Yang Y
        • Chen S
        • Cai Y
        Ultrasound examination for the diagnosis of chronic anterior talofibular ligament injury.
        Acta Radiol. 2012; 53: 1142-1145
        • Jones S
        • Colaco K
        • Fischer J
        • Stimec J
        • Kwan C
        • Boutis K
        Accuracy of point-of-care ultrasonography for pediatric ankle sprain injuries.
        Pediatr Emerg Care. 2018; 34: 842-847
        • Lee SH
        • Yun SJ
        The feasibility of point-of-care ankle ultrasound examination in patients with recurrent ankle sprain and chronic ankle instability: comparison with magnetic resonance imaging.
        Injury. 2017; 48: 2323-2328
        • Milz P
        • Milz S
        • Steinborn M
        • Mittlmeier T
        • Putz R
        • Reiser M
        Lateral ankle ligaments and tibiofibular syndesmosis. 13-MHz high-frequency sonography and MRI compared in 20 patients.
        Acta Orthop Scand. 1998; 69: 51-55
        • McCarthy CL
        • Wilson DJ
        • Coltman TP
        Anterolateral ankle impingement: findings and diagnostic accuracy with ultrasound imaging.
        Skelet Radiol. 2008; 37: 209-216
        • Rosa I
        • Rodeia J
        • Fernandes PX
        • Teixeira R
        • Saldanha T
        • Consciência JG
        Ultrasonographic assessment of deltoid ligament integrity in ankle fractures.
        Foot Ankle Int. 2020; 41: 147-153
        • Henari S
        • Banks LN
        • Radiovanovic I
        • Queally J
        • Morris S
        Ultrasonography as a diagnostic tool in assessing deltoid ligament injury in supination external rotation fractures of the ankle.
        Orthopedics. 2011; 34: e639-e643
        • Hertel J
        • Denegar CR
        • Monroe MM
        • Stokes WL
        Talocrural and subtalar joint instability after lateral ankle sprain.
        Med Sci Sports Exerc. 1999; 31: 1501-1508
        • Raatikainen T
        • Putkonen M
        • Puranen J
        Arthrography, clinical examination, and stress radiograph in the diagnosis of acute injury to the lateral ligaments of the ankle.
        Am J Sports Med. 1992; 20: 2-6
        • Crim JR
        • Beals TC
        • Nickisch F
        • Schannen A
        • Saltzman CL
        Deltoid ligament abnormalities in chronic lateral ankle instability.
        Foot Ankle Int. 2011; 32: 873-878
        • Alves T
        • Dong Q
        • Jacobson J
        • Yablon C
        • Gandikota G
        Normal and injured ankle ligaments on ultrasonography with magnetic resonance imaging correlation.
        J Ultrasound Med. 2019; 38: 513-528
        • Scorza A
        • Conforto S
        • D'Anna C
        • Sciuto SA
        A comparative study on the influence of probe placement on quality assurance measurements in B-mode ultrasound by means of ultrasound phantoms.
        Open Biomed Eng J. 2015; 9: 164-178
        • Gaebler C
        • Kukla C
        • Breitenseher MJ
        • Nellas ZJ
        • Mittlboeck M
        • Trattnig S
        • Vécsei V
        Diagnosis of lateral ankle ligament injuries: comparison between talar tilt, MRI and operative findings in 112 athletes.
        Acta Orthop Scand. 1997; 68: 286-290
        • Rosen A
        • Ko J
        • Brown C
        Diagnostic accuracy of instrumented and manual talar tilt tests in chronic ankle instability populations.
        Scand J Med Sci Sports. 2015; 25: e214-e221