Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 24, Issue 4, pp 1022–1028 | Cite as

Value of stress ultrasound for the diagnosis of chronic ankle instability compared to manual anterior drawer test, stress radiography, magnetic resonance imaging, and arthroscopy

  • Jae Ho Cho
  • Doo Hyung Lee
  • Hyung Keun Song
  • Joon Young Bang
  • Kyung Tai Lee
  • Young Uk ParkEmail author



Clinicians frequently diagnose chronic ankle instability using the manual anterior drawer test and stress radiography. However, both examinations can yield incorrect results and do not reveal the extent of ankle instability. Stress ultrasound has been reported to be a new diagnostic tool for the diagnosis of chronic ankle instability. The purpose of this study was to assess the diagnostic value of stress ultrasound for chronic ankle instability compared to the manual anterior drawer test, stress radiography, magnetic resonance imaging (MRI), and arthroscopy.


Twenty-eight consecutive patients who underwent ankle arthroscopy and subsequent modified Broström repair for treatment of chronic ankle instability were included. The arthroscopic findings were used as the reference standard. A standardized physical examination (manual anterior drawer test), stress radiography, MRI, and stress ultrasound were performed to assess the anterior talofibular ligament (ATFL) prior to operation. Ultrasound images were taken in the resting position and the maximal anterior drawer position.


Grade 3 lateral instability was verified arthroscopically in all 28 cases with a clinical diagnosis (100 %). Twenty-two cases showed grade III instability on the manual anterior drawer test (78.6 %). Twenty-four cases displayed anterior translation exceeding 5 mm on stress radiography (86 %), and talar tilt angle exceeded 15° in three cases (11 %). Nineteen cases displayed a partial chronic tear (change in thickness or signal intensity), and nine cases displayed complete tear on MRI (100 %). Lax and wavy ATFL was evident on stress ultrasound in all cases (100 %). The mean value of the ATFL length was 2.8 ± 0.3 cm for the stressed condition and 2.1 ± 0.2 cm for the resting condition (p < 0.001).


Stress ultrasound may be useful for the diagnosis of chronic ankle instability in addition to the manual anterior drawer test and stress radiography.

Level of evidence



Anterior talofibular ligament Chronic ankle instability Stress ultrasound 

Supplementary material

Supplementary material 1 (WMV 1813 kb)


  1. 1.
    Alparslan L, Chiodo CP (2008) Lateral ankle instability: MR imaging of associated injuries and surgical treatment procedures. Semin Musculoskelet Radiol 12:346–358CrossRefPubMedGoogle Scholar
  2. 2.
    Aradi AJ, Wong J, Walsh M (1988) The dimple sign of a ruptured lateral ligament of the ankle: brief report. J Bone Joint Surg Br 70:327–328PubMedGoogle Scholar
  3. 3.
    Balduini FC, Vegso JJ, Torg JS, Torg E (1987) Management and rehabilitation of ligamentous injuries to the ankle. Sports Med 4:364–380CrossRefPubMedGoogle Scholar
  4. 4.
    Brooks SC, Potter BT, Rainey JB (1981) Treatment for partial tears of the lateral ligament of the ankle: a prospective trial. Br Med J (Clin Res Ed) 282:606–607CrossRefGoogle Scholar
  5. 5.
    Campbell DG, Menz A, Isaacs J (1994) Dynamic ankle ultrasonography. A new imaging technique for acute ankle ligament injuries. Am J Sports Med 22:855–858CrossRefPubMedGoogle Scholar
  6. 6.
    Chandnani VP, Harper MT, Ficke JR, Gagliardi JA, Rolling L, Christensen KP, Hansen MF (1994) Chronic ankle instability: evaluation with MR arthrography, MR imaging, and stress radiography. Radiology 192:189–194CrossRefPubMedGoogle Scholar
  7. 7.
    Croy T, Saliba SA, Saliba E, Anderson MW, Hertel J (2012) Differences in lateral ankle laxity measured via stress ultrasonography in individuals with chronic ankle instability, ankle sprain copers, and healthy individuals. J Orthop Sports Phys Ther 42:593–600CrossRefPubMedGoogle Scholar
  8. 8.
    De Maeseneer M, Marcelis S, Jager T, Shahabpour M, Van Roy P, Weaver J, Jacobson JA (2009) Sonography of the normal ankle: a target approach using skeletal reference points. AJR Am J Roentgenol 192:487–495CrossRefPubMedGoogle Scholar
  9. 9.
    Dimmick S, Kennedy D, Daunt N (2008) Evaluation of thickness and appearance of anterior talofibular and calcaneofibular ligaments in normal versus abnormal ankles with MRI. J Med Imaging Radiat Oncol 52:559–563CrossRefPubMedGoogle Scholar
  10. 10.
    Evans GA, Hardcastle P, Frenyo AD (1984) Acute rupture of the lateral ligament of the ankle. To suture or not to suture? J Bone Joint Surg Br 66:209–212PubMedGoogle Scholar
  11. 11.
    Fujii T, Luo ZP, Kitaoka HB, An KN (2000) The manual stress test may not be sufficient to differentiate ankle ligament injuries. Clin Biomech (Bristol, Avon) 15:619–623CrossRefGoogle Scholar
  12. 12.
    Glaser F, Friedl W, Welk E (1989) The value of ultrasound in the diagnosis of capsule ligament injuries of the upper ankle joint. Unfallchirurg 92:540–546PubMedGoogle Scholar
  13. 13.
    Glasgow M, Jackson A, Jamieson AM (1980) Instability of the ankle after injury to the lateral ligament. J Bone Joint Surg Br 62-B:196–200PubMedGoogle Scholar
  14. 14.
    Guillodo Y, Varache S, Saraux A (2010) Value of ultrasonography for detecting ligament damage in athletes with chronic ankle instability compared to computed arthrotomography. Foot Ankle Spec 3:331–334CrossRefPubMedGoogle Scholar
  15. 15.
    Hintermann B, Boss A, Schafer D (2002) Arthroscopic findings in patients with chronic ankle instability. Am J Sports Med 30:402–409PubMedGoogle Scholar
  16. 16.
    Kannus P, Renstrom P (1991) Treatment for acute tears of the lateral ligaments of the ankle. Operation, cast, or early controlled mobilization. J Bone Joint Surg Am 73:305–312PubMedGoogle Scholar
  17. 17.
    Lee KT, Park YU, Jegal H, Park JW, Choi JP, Kim JS (2014) New method of diagnosis for chronic ankle instability: comparison of manual anterior drawer test, stress radiography and stress ultrasound. Knee Surg Sports Traumatol Arthrosc 22:1701–1707CrossRefPubMedGoogle Scholar
  18. 18.
    Lee KT, Park YU, Kim JS, Kim JB, Kim KC, Kang SK (2011) Long-term results after modified Brostrom procedure without calcaneofibular ligament reconstruction. Foot Ankle Int 32:153–157CrossRefPubMedGoogle Scholar
  19. 19.
    Oae K, Takao M, Uchio Y, Ochi M (2010) Evaluation of anterior talofibular ligament injury with stress radiography, ultrasonography and MR imaging. Skelet Radiol 39:41–47CrossRefGoogle Scholar
  20. 20.
    Pijnenburg AC, Bogaard K, Krips R, Marti RK, Bossuyt PM, van Dijk CN (2003) Operative and functional treatment of rupture of the lateral ligament of the ankle. A randomised, prospective trial. J Bone Joint Surg Br 85:525–530CrossRefPubMedGoogle Scholar
  21. 21.
    Rijke AM (1995) MR imaging versus stress radiography in the evaluation of chronic ankle instability. Radiology 196:580–581CrossRefPubMedGoogle Scholar
  22. 22.
    Schneck CD, Mesgarzadeh M, Bonakdarpour A (1992) MR imaging of the most commonly injured ankle ligaments. Part II. Ligament injuries. Radiology 184:507–512CrossRefPubMedGoogle Scholar
  23. 23.
    Seligson D, Gassman J, Pope M (1980) Ankle instability: evaluation of the lateral ligaments. Am J Sports Med 8:39–42CrossRefPubMedGoogle Scholar
  24. 24.
    Sheehan FT, Seisler AR, Siegel KL (2007) In vivo talocrural and subtalar kinematics: a non-invasive 3D dynamic MRI study. Foot Ankle Int 28:323–335CrossRefPubMedGoogle Scholar
  25. 25.
    Sisson L, Croy T, Saliba S, Hertel J (2011) Comparison of ankle arthrometry to stress ultrasound imaging in the assessment of ankle laxity in healthy adults. Int J Sports Phys Ther 6:297–305PubMedPubMedCentralGoogle Scholar
  26. 26.
    Tohyama H, Yasuda K, Ohkoshi Y, Beynnon BD, Renstrom PA (2003) Anterior drawer test for acute anterior talofibular ligament injuries of the ankle. How much load should be applied during the test? Am J Sports Med 31:226–232PubMedGoogle Scholar
  27. 27.
    Valderrabano V, Hintermann B, Horisberger M, Fung TS (2006) Ligamentous posttraumatic ankle osteoarthritis. Am J Sports Med 34:612–620CrossRefPubMedGoogle Scholar
  28. 28.
    van Dijk CN, Mol BW, Lim LS, Marti RK, Bossuyt PM (1996) Diagnosis of ligament rupture of the ankle joint. Physical examination, arthrography, stress radiography and sonography compared in 160 patients after inversion trauma. Acta Orthop Scand 67:566–570CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2015

Authors and Affiliations

  • Jae Ho Cho
    • 1
  • Doo Hyung Lee
    • 1
  • Hyung Keun Song
    • 1
  • Joon Young Bang
    • 1
  • Kyung Tai Lee
    • 2
  • Young Uk Park
    • 1
    Email author
  1. 1.Department of Orthopedic SurgeryAjou University Hospital, Ajou University School of MedicineSuwonRepublic of Korea
  2. 2.Foot and Ankle ServiceKT Lee’s Orthopedic HospitalSeoulRepublic of Korea

Personalised recommendations