MRI of ankle sprain: the association between joint effusion and structural injury severity in a large cohort of athletes

  • Michel D. CremaEmail author
  • Branislav Krivokapic
  • Ali Guermazi
  • Predrag Gravilovic
  • Nebojsa Popovic
  • Pieter D’Hooghe
  • Frank W. Roemer



To test the hypothesis if presence and amount of effusion in the tibiotalar and talocalcaneal joints are associated with an increased risk for severe structural injury in ankle sprains.


A total of 261 athletes sustaining acute ankle sprains were assessed on MRI for the presence and the amount of joint effusion in the tibiotalar and talocalcaneal joints, as well as for ligamentous and osteochondral injury. Specific patterns of injury severity were defined based on lateral collateral ligament, syndesmotic, and talar osteochondral involvement. The presence and the amount effusion (grades 1 and 2) were considered as risk factors for severe injury, while physiological amount of fluid (grade 0) was considered as the referent. Conditional logistic regression was used to assess the risk for associated severe injuries (syndesmotic ligament rupture and talar osteochondral lesions) based on the presence and amount of tibiotalar and talocalcaneal effusions.


For ankles exhibiting large (grade 2) effusion in the tibiotalar joint (without concomitant grade 2 effusion in the talocalcaneal joint), the risk for partial or complete syndesmotic ligament rupture was increased more than eightfold (adjusted odds ratio 8.7 (95% confidence intervals 3.7–20.7); p < 0.001). The presence of any degree of effusion in any of the joints was associated with an increased risk for severe talar osteochondral involvement (several odds ratio values reported; p < 0.001), including large subchondral contusions and any acute osteochondral lesion.


The presence of tibiotalar and talocalcaneal effusions is associated with an increased risk for severe concomitant structural injury in acute ankle sprains.

Key Points

• For ankles exhibiting severe (grade 2) effusion in the tibiotalar joint after sprain, the risk for partial or complete syndesmotic ligament rupture increases more than eightfold.

• The presence of effusion in both tibiotalar and talocalcaneal joints is associated with an increased risk for severe ligament injury such as complete ATFL rupture as well as partial or complete syndesmotic ligament rupture.

• The presence of effusion in the tibiotalar or talocalcaneal joints after sprain is associated with an increased risk for severe talar osteochondral involvement.


Magnetic resonance imaging Ankle injuries Sprains and strains 



Anterior talofibular ligament


Calcaneofibular ligament


Field of view


Magnetic resonance imaging


National Sports Medicine Program of the State of Qatar


Posterior talofibular ligament


Echo time


Repetition time



We thank very much the staff from Aspetar Orthopaedic and Sports Medicine Hospital for their help.


The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Michel D. Crema, MD.

Conflict of interest

Authors MDC, AG, and FWR are shareholders of Boston Imaging Core Lab (BICL), LLC. Author AG is a consultant with AstraZeneca, Genzyme, and Merck Serono. None of the other authors declare any conflict of interest.

Statistics and biometry

Branislav Krivokapic (University of Belgrade) provided statistical advice for this manuscript.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.


• Retrospective

• Cross-sectional study

• Performed at one institution

Supplementary material

330_2019_6156_MOESM1_ESM.docx (19 kb)
ESM 1 (DOCX 18 kb)


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Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  1. 1.Department of Radiology, Hôpital Saint-AntoineSorbonne UniversityParisFrance
  2. 2.Institute of Sports ImagingFrench National Institute of Sports (INSEP)ParisFrance
  3. 3.Department of Radiology, Quantitative Imaging CenterBoston University School of MedicineBostonUSA
  4. 4.Medical SchoolUniversity of BelgradeBelgradeSerbia
  5. 5.Institute for Orthopedic Surgery “Banjica”BelgradeSerbia
  6. 6.Center for Medical InformaticsBelgradeSerbia
  7. 7.Aspetar Orthopaedic and Sports Medicine HospitalDohaQatar
  8. 8.Department of RadiologyUniversity of ErlangenErlangenGermany

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