Diagnostic performance of ankle ultrasound for diagnosing anterior talofibular and calcaneofibular ligament injuries: a meta-analysis

EURO-MUSCULUS/USPRM Dynamic Ultrasound Protocols for Ankle/Foot

ABSTRACT

In this dynamic scanning protocol, ultrasound examination of the ankle is described using various maneuvers to assess different conditions. Real-time patient examination and scanning videos are used for better simulation of daily clinical practice. The protocol is prepared by several/international experts in the field of musculoskeletal ultrasound and within the umbrella of European Musculoskeletal Ultrasound Study Group in Physical and Rehabilitation Medicine/Ultrasound Study Group of the International Society of Physical and Rehabilitation Medicine.

Effects of Peroneus Brevis versus Peroneus Longus Muscle Training on Muscle Function in Chronic Ankle Instability: A Randomized Controlled Trial

Chronic ankle instability (CAI) is a common injury that can occur in daily life or sporting events. Injuries to the anterior talofibular, posterior talofibular, and calcaneofibular ligaments are common, and the core of rehabilitation training involves strengthening the peroneus muscle. Many studies on rehabilitation training have focused on strengthening the peroneus brevis muscle, and few studies have focused on specific training to strengthen the peroneus longus muscle. Therefore, this study aims to investigate changes in the symptoms and functions of patients by applying training to strengthen the peroneus longus and peroneus brevis muscles. Home-based training and mobile monitoring were utilized for 12 weeks, divided into peroneus brevis training (PBT) and peroneus longus training (PLT), in 52 adult males with CAI. Participation was voluntary, with enrollment done through a bulletin board, and intervention training allocation was randomly assigned and conducted in a double-blind manner. This study was registered as a trial protocol (KCT 0008478). Foot and ankle outcome scores (FAOS), isokinetic ankle strength tests, and Y-balance tests were performed before and after the intervention. Both PLT and PBT significantly improved in FAOS, inversion, and eversion at angular velocities of 30°/s and 120°/s and in the anterior and posterolateral directions of the Y-balance test (p < 0.05). Interaction effects by time and group were not significant for the FAOS (p > 0.05). However, PLT improved eversion muscle strength and muscle power to a greater degree, compared with PBT, in the anterior and posterolateral directions of the Y-balance test (p < 0.05). In conclusion, both PLT and PBT were effective for CAI patients; in addition, PLT had greater potential for improving strength and balance.

The Role of Ultrasound in the Management of Ankle Sprains and a Clinically Relevant Geisinger Ankle Sprain Sports Ultrasound Protocol

ABSTRACT

Ankle sprains are the most common lower extremity injury in physically active individuals. These injuries are classified as lateral, medial, and/or syndesmotic. Treatment may include functional rehabilitation, bracing, weight-bearing restriction, medications, injections, and surgery. While most sprains heal rapidly, permanent disability and pain may arise. Diagnostic ultrasound has been demonstrated to be accurate in diagnosing ligamentous injuries, but it is often excluded from management algorithms that rely on physical examination alone to diagnose significant injuries. This article proposes a comprehensive, evidence-based diagnostic ankle ultrasound protocol to implement in conjunction with thorough history and physical examination. We also review the current literature to describe where this protocol most improves diagnostic accuracy compared with physical examination alone.

Conservative Functional Treatment of Acute Fibular Ligament Rupture of the Ankle

BACKGROUND

Acute rupture of the fibular ligament complex is one of the commonest injuries in sports. Prospective randomized trials in the 1980s led to a paradigm shift from primary surgical repair to conservative functional treatment.

METHODS

This review is based on publications retrieved by a selective search in PubMed, Embase, and the Cochrane Library for randomized controlled trials (RCTs) and meta-analyses on surgical versus conservative treatment from the years 1983 to 2023.

RESULTS

10 of 11 prospective randomized trials of surgical versus conservative treatment conducted between 1984 and 2017 did not reveal any significant difference in the overall outcome. These findings were confirmed in two meta-analyses and two systematic reviews that were published between 2007 and 2019. Isolated benefits in the surgical group were outweighed by a variety of postoperative complications. The anterior fibulotalar ligament (AFTL) was ruptured in 58% to 100% of cases, followed by the fibulocalcaneal ligament combined with the LFTA in 58% to 85%, and the posterior fibulotalar ligament (mostly incomplete ruptures) in 1.9% to 3%.

CONCLUSION

Conservative functional treatment is now the standard treatment in acute fibular ligament rupture of the ankle because it is low-risk, low-cost, and safe. Primary surgery is indicated in only 0.5% to 4% of cases. Physical examination for tenderness to palpation and for stability, as well as stress ultrasonography, can be used to differentiate sprains from ligamentous tears. MRI is superior only for the detection of additional injuries. Stable sprains can be successfully treated with an elastic ankle support for a few days, and unstable ligamentous ruptures with an orthosis for 5 to 6 weeks. Subsequent physiotherapy with proprioceptive exercises is the best way to prevent recurrent injury.

Advanced Imaging in the Chronic Lateral Ankle Instability: An Algorithmic Approach

Imaging examinations are a fundamental part of assessing chronic lateral ankle instability (CLAI). Plain radiographs are used in the initial examination, whereas stress radiographs can be requested to actively search for instability. Ultrasonography (US) and Magnetic Resonance Imaging (MRI) allow direct visualization of ligamentous structures, with the advantage of dynamic evaluation for US, and assessment of associated lesions and intra-articular abnormalities for MRI, which plays an essential role in surgical planning. This article reviews imaging methods to diagnose and follow up on CLAI, along with illustrative cases and an algorithmic approach.

Imaging diagnosis for anterior talofibular ligament injury: a systemic review with meta-analysis

A definite diagnosis of ankle ligament injury is crucial, and many imaging examinations can be used. This review systematically analyzed the effectiveness of various examination methods in the diagnosis of anterior talofibular ligament (ATFL) injuries. Three English databases (PubMed, Embase, and Cochrane Library) and three Chinese databases (CNKI, VIP Database, and Wanfang Database) were searched and relevant studies were summarized. A total of 25 randomized controlled trials met the selection criteria, including six, 16, and three studies recruiting patients with acute, chronic, and both acute and chronic ATFL injuries, respectively. A total of 1409 participants were included. The pooled sensitivity rates of acute ATFL injuries were 82.1% (77.1%-86.5%) by magnetic resonance imaging (MRI) and 88.6% (82.0%-93.5%) by ultrasonography (US). The pooled sensitivity rates of chronic ATFL injuries were 86.3% (82.5%-89.5%) by MRI, 98.7% (95.3%-99.8%) by US, 74.4% (63.6%-83.4%) by stress radiography, and 100% (87.7%-100.0%) for MR arthrography. The pooled specificity rates of acute ATFL injuries were 37.8% (29.1%-47.2%) by MRI and 90.3% (80.1%-96.4%) by US. The pooled specificity rates of chronic ATFL injuries were 86.8% (81.3%-91.2%) by MRI, 94.0% (85.4%-98.3%) for US, 89.4% (76.9%- 96.5%) by stress radiography and 100% (54.1%-100.0%) by MR arthrography. In conclusion, US may be a valuable imaging technique with high sensitivity for diagnosing chronic lateral ankle ligament injuries.

The anterior talofibular ligament ratio was greater in young men with generalized joint laxity than in those without generalized joint laxity

PURPOSE

This study aimed to evaluate the relationship between generalized joint laxity (GJL) and stress ultrasonographic (US) findings of the anterior talofibular ligament (ATFL) of healthy young men.

METHODS

The ATFL lengths of healthy young men were consecutively measured in the stress and nonstress positions. The ATFL ratio was calculated as an indicator of lateral ankle laxity. GJL was evaluated using the Beighton score (BS), and a BS of ≥ 5 was considered GJL. The manual anterior drawer test (ADT) was also performed. The results of stress US and ADT were compared between subjects with and without GJL, and the correlation between GJL and US findings was examined.

RESULTS

A total of 13 subjects with GJL and 95 without GJL were included in the study. The mean BSs in the GJL and no-GJL groups were 5.9 ± 0.9 and 1.1 ± 1.3, respectively (p < 0.0001). The GJL group showed a higher grade of ADT than the no-GJL group (p < 0.0001). Significant differences were found in the stress ATFL length (23.6 ± 1.8 mm vs. 21.7 ± 1.8 mm, p = 0.002) and ATFL ratio (1.15 ± 0.06 vs. 1.07 ± 0.03, p < 0.0001) between the GJL and no-GJL groups. Spearman's correlation coefficients showed a moderate correlation between the BS and ATFL ratio (r = 0.45, p < 0.0001).

CONCLUSION

The present study showed significant differences in the ATFL ratio and stress ATFL length between young men with and without GJL. The BS was moderately correlated with the lateral ankle laxity in this population.

LEVEL OF EVIDENCE

Level IV.

Diagnostic Value of Ultrasound in Ankle Sprain

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.

Chronic ankle instability has no correlation with the number of ruptured ligaments in severe anterolateral sprain: a systematic review and meta-analysis

PURPOSE

Despite being a significant public health problem, ankle sprains' prognostic factors are largely unknown. This review aimed to systematically analyze the literature on acute ankle sprains to compare the prognosis of a combined anterior talofibular (ATFL) and calcaneofibular (CFL) ligaments rupture with an isolated ATFL rupture in terms of progression to chronic ankle instability and other clinical outcomes.

METHODS

The databases for Pubmed, CENTRAL and Web of Science were searched. Clinical studies reporting the prognostic effect of combined ATFL-CFL rupture versus an isolated ATFL rupture in conservatively treated ankle sprains, with a minimum follow-up of 12 months, were eligible for inclusion. Only studies with a reliable diagnostic method for anterolateral ankle ligaments evaluation, namely ultrasonography, magnetic resonance imaging, arthrography or stress tenography, were included. The relative risk (RR), along with the 95% confidence interval (CI), was used to quantitatively analyze the main outcomes.

RESULTS

Nine papers were selected for inclusion, of which five were suitable for quantitative analysis. None of them found a statistically significant correlation between ligament injury severity and progression to chronic instability. Concerning other clinical outcomes, three studies found a statistically significant correlation between a combined ligament injury and a worse clinical prognosis. From the quantitative analysis, the relative risk (RR) of chronic ankle instability in a single versus a combined ligament rupture showed no significant difference.

CONCLUSION

A significant statistical correlation between a combined ATFL-CFL rupture and chronic ankle instability, compared to an isolated ATFL rupture, was not found. There is, however, fair evidence showing a worse clinical outcome score in the combined ruptures, as well as a decreased return to full sports activities. The use of reliable and accessible diagnostic methods to determine the number of ruptured ligaments might have a role in managing severe ankle sprains.

LEVEL OF EVIDENCE

Level III.

Can virtual touch tissue imaging quantification be a reliable method to detect anterior talofibular ligament type I injury at the acute, subacute, and chronic stages?

Background

Anterior talofibular ligament (ATFL) injury affects ankle joint stability. To date, very few studies have examined tissue stiffness changes inside injured ligaments. Virtual touch tissue imaging quantification (VTIQ) allows for the non-invasive quantitative measurement of tissue stiffness. The present study aimed to examine the efficacy of VTIQ as a method for detecting ligament injury.

Methods

A total of 206 patients diagnosed with unilateral ATFL type I injury (81 acute cases, 69 subacute cases, and 56 chronic cases) were reviewed retrospectively. Shear wave velocity (SWV) values were collected from both the injured and non-affected sides of the ATFL using a virtual touch tissue imaging quantification technique (ACUSON Oxana 2, Siemens Medical Solutions USA, Inc.).

Results

The average SWV of injured ATFL was 4.09±1.15 m/s in the acute group, 5.60±1.39 m/s in the subacute group, and 7.74±1.44 m/s in the chronic group (P<0.001). The SWV values of the ATFL on the non-affected side were almost identical (acute 7.50±1.12 m/s, subacute 7.53±1.06 m/s, and chronic 7.61±1.30 m/s; P>0.05). The injured ATFL had a significantly lower SWV value than the non-affected ATFL in the acute and subacute groups (P<0.001); however, there was no significant difference in the chronic group (P>0.05). Concerning the validity of SWV as a predictor of acute and subacute ATFL injury, the receiver operator characteristics curve analysis showed that the best cut-off point for SWV was 6.165 m/s, with 84.3% sensitivity, 88.5% specificity, and an area under the curve of 0.93 (95% CI, 0.90-0.95).

Conclusions

VTIQ is a reliable sonographic method for detecting acute and subacute ATFL type I injury.

Sensitivity and specificity of ultrasound in the diagnosis of traumatic ankle injury

Background:

This study was performed to determine the sensitivity and specificity of ultrasound in the diagnosis of traumatic ankle injury in comparison with magnetic resonance imaging (MRI).

Materials and Methods:

This cross-sectional study was performed on 31 patients with soft-tissue injury or fracture, referring to the MRI imaging center of Alzahra and Kashani Hospitals in Isfahan from October 2018 to March 2019. After an MRI, an ultrasound of the affected ankle was performed for all patients. Sonography and MRI were performed by two radiologists who were blinded to the results of each other's reports. The sensitivity, specificity, positive predictive value, and negative predictive value of sonography were determined.

Results:

In this study, 31 patients with ankle trauma were studied. The mean age of the patients was 30.73 ± 10.15 years; 32.3% were male and 67.7% were female. The sensitivity of ultrasound relative to MRI to detect damage to the anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL), and calcaneofibular ligament (CFL) was 66.67%, 50%, and 100%, respectively, and the corresponding specificity was 92.86%, 93.10%, and 93.10%, respectively. According to Kappa test, the agreement between ultrasound and MRI methods for detecting injury to ATFL (κ = 0.51), PTFL (κ = 0.35), and CFL (κ= 0.63) was statistically significant (P < 0.05).

Conclusion:

Ultrasound is an appropriate modality for the diagnosis of injuries to CFL and ATFL and has shown acceptable results for PTFL. It could be used as an alternative in cases where access to MRI is not available.

Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021

This revised clinical practice guideline (CPG) addresses the distinct but related lower extremity impairments of those with a first-time lateral ankle sprain (LAS) and those with chronic ankle instability (CAI). Depending on many factors, impairments may continue following injury. While most individuals experience resolution of symptoms, complaints of instability may continue and are defined as CAI. The aims of the revision were to provide a concise summary of the contemporary evidence since publication of the original guideline and to develop new recommendations or revise previously published recommendations to support evidence-based practice. J Orthop Sports Phys Ther 2021;51(4):CPG1-CPG80. doi:10.2519/jospt.2021.0302.