Diagnostic Accuracy of Clinical Tests Assessing Ligamentous Injury of the Talocrural and Subtalar Joints: A Systematic Review With Meta-Analysis

Fredh Netterström-Wedin F,, Mark Matthews, C M Bleakley

Research output: Contribution to journalReview articlepeer-review

17 Citations (Scopus)
340 Downloads (Pure)


Context:: Ankle sprains are the most common acute musculoskeletal injury. Clinical tests represent the first opportunity to assess the sprain’s severity, but no systematic review has compared these tests to contemporary reference standards. Objective:: To determine the diagnostic accuracy of clinical tests assessing the talocrural and subtalar joint ligaments after ankle sprain. Data Sources:: CINAHL, EMBASE, MEDLINE, hand-searching, and PubMed-related article searches (inception to November 18, 2020). Study Selection:: Eligible diagnostic studies compared clinical examination (palpation, joint laxity) against imaging or surgery. Studies at a high risk of bias or with high concerns regarding applicability on Quality Assessment of Diagnostic Accuracy Studies-2 were excluded from the meta-analysis. Study Design:: Systematic review and meta-analysis. Level of Evidence:: Level 3a. Data Extraction:: True-positive, false-negative, false-positive, and true-negative findings were extracted to calculate sensitivity, specificity, and likelihood ratios. If ordinal data were reported, these were extracted to calculate Cohen’s kappa. Results:: A total of 14 studies met the inclusion criteria (6302 observations; 9 clinical tests). No test had both sensitivity and specificity exceeding 90%. Palpation of the anterior talofibular ligament is highly sensitive (sensitivity 95%-100%; specificity 0%-32%; min-max; n = 6) but less so for the calcaneofibular ligament (sensitivity 49%-100%; specificity 26%-79%; min-max; n = 6). Pooled data from 6 studies (885 observations) found a low sensitivity (54%; 95% CI 35%-71%) but high specificity (87%; 95% CI 63%-96%) for the anterior drawer test. Conclusion:: The anterior talofibular ligament is best assessed using a cluster of palpation (rule out), and anterior drawer testing (rule in). The talar tilt test can rule in injury to the calcaneofibular ligament, but a sensitive clinical test for the ligament is lacking. It is unclear if ligamentous injury grading can be done beyond the binary (injured vs uninjured), and clinical tests of the subtalar joint ligaments are not well researched. The generalizability of our findings is limited by insufficient reporting on blinding and poor study quality. Registration:: Prospero ID: CRD42020187848. Data Availability:: Data are available in a public, open access repository on publication, including our RevMan file and the CSV file used for meta-analysis: http://doi.org/10.5281/zenodo.4917138
Original languageEnglish
Pages (from-to)336-347
Number of pages12
JournalSports Health
Issue number3
Early online date21 Jul 2021
Publication statusPublished (in print/issue) - 1 May 2022

Bibliographical note

Publisher Copyright:
© 2021 The Author(s).


  • diagnosis
  • ankle
  • examination
  • ligament
  • meta-analysis
  • Focus Topic: Foot/Ankle


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