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

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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.
Original languageEnglish
JournalSports Health
Early online date21 Jul 2021
Publication statusE-pub ahead of print - 21 Jul 2021


  • diagnosis
  • ankle
  • examination
  • ligament
  • meta-analysis


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