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Diagnostic validity of alternative manual stress radiographic technique detecting subtalar instability with concomitant ankle instability

  • Ankle
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope



To incorporate a diagnostic technique for measuring subtalar motion, namely “talar rotation”, into the manual supination-anterior drawer stress radiographs for evaluation of the severity of rotational instability, and to determine its clinical relevance.


Sixty-six patients with combined injuries of the anterior talofibular (ATFL) and calcaneofibular ligament (CFL) underwent three bilateral manual stress radiographs, and mean increments of anterior talar translation (mm), talar tilt (°), and talar rotation (%) in the injured ankle compared to the normal opposite side were measured with the technique. Intraobserver and interobserver reliability of each measure was assessed, and the difference in the degree of increments was compared according to the presence of additional cervical ligament insufficiency.


Ankle stress radiographic intraobserver and interobserver agreement was ICC = 0.91 and 0.82 for talar rotation (%), ICC = 0.64 and 0.51 for anterior talar translation, and ICC = 0.78 and 0.71 for talar tilt angle, respectively. In group 2 including patients with combined injuries of the ATFL and CFL along with additional cervical ligament insufficiency, a significantly higher increment of talar rotation, mean 6.4 % (SD 3.4 %), was observed compared to that of talar rotation, mean 4.1 % (SD 2.7 %), in the other group (group 1) with an intact cervical ligament (p < 0.001).


A new comprehensive stress radiographic technique for diagnosis of chronic lateral ankle instability presented in this study might be a reliable and representable measurement tool to assess additional injury or instability of the subtalar joint.

Level of evidence

Prospective cohort study, Level II.

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  1. Baumhauer JF, O’Brien T (2002) Surgical considerations in the treatment of ankle instability. J Athl Train 37:458–462

    PubMed  PubMed Central  Google Scholar 

  2. Beltran J, Munchow AM, Khabiri H, Magee DG, McGhee RB, Grossman SB (1990) Ligaments of the lateral aspect of the ankle and sinus tarsi: an MR imaging study. Radiology 177:455–458

    Article  CAS  PubMed  Google Scholar 

  3. Breitenseher MJ, Trattnig S, Kukla C, Gaebler C, Kaider A, Baldt MM, Haller J, Imhof H (1997) MRI versus lateral stress radiography in acute lateral ankle ligament injuries. J Comput Assist Tomogr 21:280–285

    Article  CAS  PubMed  Google Scholar 

  4. Chan KW, Ding BC, Mroczek KJ (2011) Acute and chronic lateral ankle instability in the athlete. Bull NYU Hosp Jt Dis 69:17–26

    PubMed  Google Scholar 

  5. 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 192:189–194

    Article  CAS  PubMed  Google Scholar 

  6. Chien AJ, Jacobson JA, Jamadar DA, Brigido MK, Femino JE, Hayes CW (2004) Imaging appearances of lateral ankle ligament reconstruction. Radiographics 24:999–1008

    Article  PubMed  Google Scholar 

  7. Clanton TO (1989) Instability of the subtalar joint. Orthop Clin North Am 20:583–592

    CAS  PubMed  Google Scholar 

  8. Fallat L, Grimm DJ, Saracco JA (1998) Sprained ankle syndrome: prevalence and analysis of 639 acute injuries. J Foot Ankle Surg 37:280–285

    Article  CAS  PubMed  Google Scholar 

  9. Ferran NA, Maffulli N (2006) Epidemiology of sprains of the lateral ankle ligament complex. Foot Ankle Clin 11:659–662

    Article  PubMed  Google Scholar 

  10. 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) 15:619–623

    Article  CAS  Google Scholar 

  11. Fuller EA (1999) Center of pressure and its theoretical relationship to foot pathology. J Am Podiatr Med Assoc 89:278–291

    Article  CAS  PubMed  Google Scholar 

  12. Greiner M, Pfeiffer D, Smith RD (2000) Principles and practical application of the receiver-operating characteristic analysis for diagnostic tests. Prev Vet Med 45:23–41

    Article  CAS  PubMed  Google Scholar 

  13. Harper MC (1992) Stress radiographs in the diagnosis of lateral instability of the ankle and hindfoot. Foot Ankle 13:435–438

    Article  CAS  PubMed  Google Scholar 

  14. Heilman AE, Braly WG, Bishop JO, Noble PC, Tullos HS (1990) An anatomic study of subtalar instability. Foot Ankle 10:224–228

    Article  CAS  PubMed  Google Scholar 

  15. Hertel J (2002) Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train 37:364–375

    PubMed  PubMed Central  Google Scholar 

  16. Ishii T, Miyagawa S, Fukubayashi T, Hayashi K (1996) Subtalar stress radiography using forced dorsiflexion and supination. J Bone Joint Surg Br 78:56–60

    CAS  PubMed  Google Scholar 

  17. Joshy S, Abdulkadir U, Chaganti S, Sullivan B, Hariharan K (2010) Accuracy of MRI scan in the diagnosis of ligamentous and chondral pathology in the ankle. Foot Ankle Surg 16:78–80

    Article  PubMed  Google Scholar 

  18. Jung HG, Park JT, Shin MH, Lee SH, Eom JS, Lee DO (2015) Outcome of subtalar instability reconstruction using the semitendinosus allograft tendon and biotenodesis screws. Knee Surg Sports Traumatol Arthrosc 23:2376–2383

    Article  PubMed  Google Scholar 

  19. Karlsson J, Eriksson BI, Renstrom P (1998) Subtalar instability of the foot. A review and results after surgical treatment. Scand J Med Sci Sports 8:191–197

    Article  CAS  PubMed  Google Scholar 

  20. Kato T (1995) The diagnosis and treatment of instability of the subtalar joint. J Bone Joint Surg Br 77:400–406

    CAS  PubMed  Google Scholar 

  21. Kier R, McCarthy S, Dietz MJ, Rudicel S (1991) MR appearance of painful conditions of the ankle. Radiographics 11:401–414

    Article  CAS  PubMed  Google Scholar 

  22. Klein MA (1994) MR imaging of the ankle: normal and abnormal findings in the medial collateral ligament. AJR Am J Roentgenol 162:377–383

    Article  CAS  PubMed  Google Scholar 

  23. Kobayashi T, No Y, Yoneta K, Sadakiyo M, Gamada K (2013) In vivo kinematics of the talocrural and subtalar joints with functional ankle instability during weight-bearing ankle internal rotation: a pilot study. Foot Ankle Spec 6:178–184

    Article  PubMed  Google Scholar 

  24. 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 22:1701–1707

    Article  PubMed  Google Scholar 

  25. Mabit C, Boncoeur-Martel MP, Chaudruc JM, Valleix D, Descottes B, Caix M (1997) Anatomic and MRI study of the subtalar ligamentous support. Surg Radiol Anat 19:111–117

    Article  CAS  PubMed  Google Scholar 

  26. Martin LP, Wayne JS, Monahan TJ, Adelaar RS (1998) Elongation behavior of calcaneofibular and cervical ligaments during inversion loads applied in an open kinetic chain. Foot Ankle Int 19:232–239

    Article  CAS  PubMed  Google Scholar 

  27. McCaskie AW, Gale DW, Finlay D, Allen MJ (1995) Chronic ankle instability: the value of talar tilt under general anaesthesia. Br J Sports Med 29:103–104

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Merl T, Scholz M, Gerhardt P, Langer M, Laubenberger J, Weiss HD, Gehl HB, Wolf KJ, Ohnesorge I (1999) Results of a prospective multicenter study for evaluation of the diagnostic quality of an open whole-body low-field MRI unit. A comparison with high-field MRI measured by the applicable gold standard. Eur J Radiol 30:43–53

    Article  CAS  PubMed  Google Scholar 

  29. Metz CE (1989) Some practical issues of experimental design and data analysis in radiological ROC studies. Invest Radiol 24:234–245

    Article  CAS  PubMed  Google Scholar 

  30. Meyer JM, Garcia J, Hoffmeyer P, Fritschy D (1988) The subtalar sprain. A roentgenographic study. Clin Orthop Relat Res 226:169–173

    PubMed  Google Scholar 

  31. Nakasa T, Fukuhara K, Adachi N, Ochi M (2006) Evaluation of anterior talofibular ligament lesion using 3-dimensional computed tomography. J Comput Assist Tomogr 30:543–547

    Article  PubMed  Google Scholar 

  32. Oae K, Takao M, Uchio Y, Ochi M (2010) Evaluation of anterior talofibular ligament injury with stress radiography, ultrasonography and MR imaging. Skeletal Radiol 39:41–47

    Article  PubMed  Google Scholar 

  33. Park HJ, Cha SD, Kim SS, Rho MH, Kwag HJ, Park NH, Lee SY (2012) Accuracy of MRI findings in chronic lateral ankle ligament injury: comparison with surgical findings. Clin Radiol 67:313–318

    Article  PubMed  Google Scholar 

  34. Ringleb SI, Dhakal A, Anderson CD, Bawab S, Paranjape R (2011) Effects of lateral ligament sectioning on the stability of the ankle and subtalar joint. J Orthop Res 29:1459–1464

    Article  PubMed  Google Scholar 

  35. Rosenberg ZS, Beltran J, Bencardino JT (2000) From the RSNA refresher courses. Radiological Society of North America. MR imaging of the ankle and foot. Radiographics 20 Spec No: S153-179

  36. Saltzman CL, Brandser EA, Berbaum KS, DeGnore L, Holmes JR, Katcherian DA, Teasdall RD, Alexander IJ (1994) Reliability of standard foot radiographic measurements. Foot Ankle Int 15:661–665

    Article  CAS  PubMed  Google Scholar 

  37. Schneck CD, Mesgarzadeh M, Bonakdarpour A (1992) MR imaging of the most commonly injured ankle ligaments, Part II. Ligament injuries. Radiology 184:507–512

    Article  CAS  PubMed  Google Scholar 

  38. Sijbrandij ES, van Gils AP, van Hellemondt FJ, Louwerens JW, de Lange EE (2001) Assessing the subtalar joint: the Broden view revisited. Foot Ankle Int 22:329–334

    CAS  PubMed  Google Scholar 

  39. Snow NJ, Peters S, Borich MR, Shirzad N, Auriat AM, Hayward KS, Boyd LA (2016) A reliability assessment of constrained spherical deconvolution-based diffusion-weighted magnetic resonance imaging in individuals with chronic stroke. J Neurosci Methods 257:109–120

    Article  PubMed  Google Scholar 

  40. Stephens MM, Sammarco GJ (1992) The stabilizing role of the lateral ligament complex around the ankle and subtalar joints. Foot Ankle 13:130–136

    Article  CAS  PubMed  Google Scholar 

  41. Sugimoto K, Samoto N, Takaoka T, Takakura Y, Tamai S (1998) Subtalar arthrography in acute injuries of the calcaneofibular ligament. J Bone Joint Surg Br 80:785–790

    Article  CAS  PubMed  Google Scholar 

  42. Tourne Y, Besse JL, Mabit C (2010) Chronic ankle instability. Which tests to assess the lesions? Which therapeutic options? Orthop Traumatol Surg Res 96:433–446

    Article  CAS  PubMed  Google Scholar 

  43. Trc T, Handl M, Havlas V (2010) The anterior talo-fibular ligament reconstruction in surgical treatment of chronic lateral ankle instability. Int Orthop 34:991–996

    Article  PubMed  PubMed Central  Google Scholar 

  44. Viladot A, Lorenzo JC, Salazar J, Rodriguez A (1984) The subtalar joint: embryology and morphology. Foot Ankle 5:54–66

    Article  CAS  PubMed  Google Scholar 

  45. Youden WJ (1950) Index for rating diagnostic tests. Cancer 3:32–35

    Article  CAS  PubMed  Google Scholar 

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We thank Jung-Min Shin for her effort in providing medical writing in this study.

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Correspondence to Gab Lae Kim.

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Lee, B.H., Choi, KH., Seo, D.Y. et al. Diagnostic validity of alternative manual stress radiographic technique detecting subtalar instability with concomitant ankle instability. Knee Surg Sports Traumatol Arthrosc 24, 1029–1039 (2016).

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