Skip to main content

Advertisement

SpringerLink
Log in

Chronic ankle instability has no correlation with the number of ruptured ligaments in severe anterolateral sprain: a systematic review and meta-analysis

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

Abstract

Purpose

Despite being a significant public health problem, ankle sprains’ prognostic factors are largely unknown. This review aimed to systematically analyze the literature on acute ankle sprains to compare the prognosis of a combined anterior talofibular (ATFL) and calcaneofibular (CFL) ligaments rupture with an isolated ATFL rupture in terms of progression to chronic ankle instability and other clinical outcomes.

Methods

The databases for Pubmed, CENTRAL and Web of Science were searched. Clinical studies reporting the prognostic effect of combined ATFL-CFL rupture versus an isolated ATFL rupture in conservatively treated ankle sprains, with a minimum follow-up of 12 months, were eligible for inclusion. Only studies with a reliable diagnostic method for anterolateral ankle ligaments evaluation, namely ultrasonography, magnetic resonance imaging, arthrography or stress tenography, were included. The relative risk (RR), along with the 95% confidence interval (CI), was used to quantitatively analyze the main outcomes.

Results

Nine papers were selected for inclusion, of which five were suitable for quantitative analysis. None of them found a statistically significant correlation between ligament injury severity and progression to chronic instability. Concerning other clinical outcomes, three studies found a statistically significant correlation between a combined ligament injury and a worse clinical prognosis. From the quantitative analysis, the relative risk (RR) of chronic ankle instability in a single versus a combined ligament rupture showed no significant difference.

Conclusion

A significant statistical correlation between a combined ATFL-CFL rupture and chronic ankle instability, compared to an isolated ATFL rupture, was not found. There is, however, fair evidence showing a worse clinical outcome score in the combined ruptures, as well as a decreased return to full sports activities. The use of reliable and accessible diagnostic methods to determine the number of ruptured ligaments might have a role in managing severe ankle sprains.

Level of evidence

Level III.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Ahn BH, Cho BK (2021) Persistent pain after operative treatment for chronic lateral ankle instability. Orthop Res Rev 13:47–56

    PubMed  PubMed Central  Google Scholar 

  2. Aicale R, Maffulli N (2020) Chronic lateral ankle instability: topical review. Foot Ankle Int 41(12):1571–1581

    Article  PubMed  Google Scholar 

  3. Bleichrodt RP, Kingma LM, Binnendijk B, Klein JP (1989) Injuries of the lateral ankle ligaments: classification with tenography and arthrography. Radiology 173(2):347–349

    Article  CAS  PubMed  Google Scholar 

  4. Broström L (1965) Sprained ankles. III. Clinical observations in recent ligament ruptures. Acta Chir Scand 130(6):560–569

    PubMed  Google Scholar 

  5. Broström L (1966) Sprained ankles. V. Treatment and prognosis in recent ligament ruptures. Acta Chir Scand 132(5):537–550

    PubMed  Google Scholar 

  6. Broström L, Liljedahl SO, Lindvall N (1965) Sprained Ankles. II. Arthrographic diagnosis of recent ligament ruptures. Acta Chir Scand 129:485–499

    Google Scholar 

  7. Choi WS, Cho JH, Lee DH, Chung JY, Lim SM, Park YU (2020) Prognostic factors of acute ankle sprain: need for ultrasonography to predict prognosis. J Orthop Sci 25(2):303–309

    Article  PubMed  Google Scholar 

  8. Clay FJ, Newstead SV, McClure RJ (2010) A systematic review of early prognostic factors for return to work following acute orthopaedic trauma. Injury 41(8):787–803

    Article  PubMed  Google Scholar 

  9. Crema MD, Krivokapic B, Guermazi A, Gravilovic P, Popovic N, D’Hooghe P, Roemer FW (2019) MRI of ankle sprain: the association between joint effusion and structural injury severity in a large cohort of athletes. Eur Radiol 29(11):6336–6344

    Article  PubMed  Google Scholar 

  10. Dettori JR, Basmania CJ (1994) Early ankle mobilization, part II: a one-year follow-up of acute, lateral ankle sprains (a randomized clinical trial). Mil Med 159(1):20–24

    Article  CAS  PubMed  Google Scholar 

  11. D’Hooghe P, Cruz F, Alkhelaifi K (2020) Return to play after a lateral ligament ankle sprain. Curr Rev Musculoskelet Med 13(3):281–288

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Evans GA, Frenyo SD (1979) The stress-tenogram in the diagnosis of ruptures of the lateral ligament of the ankle. J Bone Joint Surg Br 61-B(3):347–351

    Article  CAS  PubMed  Google Scholar 

  13. 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(2):209–212

    Article  CAS  PubMed  Google Scholar 

  14. Fong DT, Chan YY, Mok KM, Yung PS, Chan KM (2019) Understanding acute ankle ligamentous sprain injury in sports. Sports Med Arthrosc Rehabil Ther Technol 30:1–14

    Google Scholar 

  15. Fagerland MW (2015) Evidence-based medicine and systematic reviews. Res Med Biol Sci 431–461

  16. Ferreira JN, Vide J, Mendes D, Protásio J, Viegas R, Sousa MR (2020) Prognostic factors in ankle sprains: a review. EFORT Open Rev 5(6):334–338

    Article  PubMed  PubMed Central  Google Scholar 

  17. Frost SC, Amendola A (1999) Is stress radiography necessary in the diagnosis of acute or chronic ankle instability? Clin J Sport Med 9(1):40–45

    Article  CAS  PubMed  Google Scholar 

  18. George J, Jaafar Z, Hairi IR, Hussein KH (2020) The correlation between clinical and ultrasound evaluation of anterior talofibular ligament and calcaneofibular ligament tears in athletes. J Sports Med Phys Fitness 60(5):749–757

    Article  PubMed  Google Scholar 

  19. Gremeaux V, Coudreuse JM, Collado H, Cohen M, Bensoussan L, Fondarai J, Champsaur P, Viton JM, Delarque A (2009) Comparative study of clinical and ultrasonographic evaluation of lateral collateral ligament sprains of the ankle. J Sports Med Phys Fitness 49(3):285–291

    CAS  PubMed  Google Scholar 

  20. Gribble PA, Bleakley CM, Caulfield BM, Docherty CL, Fourchet F, Fong DT, Hertel J, Hiller CE, Kaminski TW, McKeon PO, Refshauge KM, Verhagen EA, Vicenzino BT, Wikstrom EA, Delahunt E (2016) Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains. Br J Sports Med 50(24):1496–1505

    Article  PubMed  Google Scholar 

  21. Gribble PA, Delahunt E, Bleakley C, Caulfield B, Docherty C, Fourchet F, Fong DT, Hertel J, Hiller C, Kaminski T, McKeon P, Refshauge K, van der Wees P, Vincenzino B, Wikstrom E (2014) Selection criteria for patients with chronic ankle instability in controlled research: a position statement of the International Ankle Consortium. Br J Sports Med 48(13):1014–1018

    Article  PubMed  Google Scholar 

  22. Grønmark T, Johnsen O, Kogstad O (1980) Rupture of the lateral ligaments of the ankle: a controlled clinical trial. Injury 11(3):215–218

    Article  PubMed  Google Scholar 

  23. Guerra-Pinto F, Côrte-Real N, Consciência JAG (2016) Entorse lateral do tornozelo: capacidade diagnóstica do exame objectivo e exames imagiológicos. Revista Portuguesa Ortopedia Traumatologia 24(1):37–50

    Google Scholar 

  24. Hackenbruch W, Noesberger B, Debrunner HU (1979) Differential diagnosis of ruptures of the lateral ligaments of the ankle joint. Arch Orthop Trauma Surg 93(4):293–301

    Article  CAS  PubMed  Google Scholar 

  25. Halabchi F, Hassabi M (2020) Acute ankle sprain in athletes: clinical aspects and algorithmic approach. World J Orthop 11(12):534–558

    Article  PubMed  PubMed Central  Google Scholar 

  26. Herzog MM, Kerr ZY, Marshall SW, Wikstrom EA (2019) Epidemiology of ankle sprains and chronic ankle instability. J Athl Train 54(6):603–610

    Article  PubMed  PubMed Central  Google Scholar 

  27. Higgins JP, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21(11):1539–1558

    Article  Google Scholar 

  28. Hunt KJ, Pereira H, Kelley J, Anderson N, Fuld R, Baldini T, Kumparatana P, D’Hooghe P (2019) The role of calcaneofibular ligament injury in ankle instability: implications for surgical management. Am J Sports Med 47(2):431–437

    Article  PubMed  Google Scholar 

  29. Kannus P, Renström P (1991) Treatment for acute tears of the lateral ligaments of the ankle. Operation, cast, or early controlled mobilization [published correction appears in J Bone Joint Surg Am. 2015 97(23):e76]. J Bone Joint Surg Am 73(2):305–312

    Article  CAS  PubMed  Google Scholar 

  30. Klein J, Schreckenberger C, Röddecker K, Tiling T (1988) Operative oder konservative Behandlung der frischen Aussenbandruptur am oberen Sprunggelenk. Randomisierte klinische Studie [Surgical or conservative treatment of recent rupture of the lateral ligament of the upper ankle joint. Randomized clinical study]. Unfallchirurg 91(4):154–160

    CAS  PubMed  Google Scholar 

  31. Korkala O, Rusanen M, Jokipii P, Kytömaa J, Avikainen V (1987) A prospective study of the treatment of severe tears of the lateral ligament of the ankle. Int Orthop 11(1):13–17

    Article  CAS  PubMed  Google Scholar 

  32. Kreitner KF, Ferber A, Grebe P, Runkel M, Berger S, Thelen M (1999) Injuries of the lateral collateral ligaments of the ankle: assessment with MR imaging. Eur Radiol 9(3):519–524

    Article  CAS  PubMed  Google Scholar 

  33. Langner I, Frank M, Kuehn JP, Hinz P, Ekkernkamp A, Hosten N, Langner S (2011) Acute inversion injury of the ankle without radiological abnormalities: assessment with high-field MR imaging and correlation of findings with clinical outcome. Skeletal Radiol 40(4):423–430

    Article  PubMed  Google Scholar 

  34. Martin RL, Davenport TE, Fraser JJ, Sawdon-Bea J, Carcia CR, Carroll LA, Kivlan BR, Carreira D (2021) Ankle stability and movement coordination impairments: lateral ankle ligament sprains revision. J Orthop Sports Phys Ther 51(4):CPG1–CPG80

    Article  PubMed  Google Scholar 

  35. Marx RG, Wilson SM, Swiontkowski MF (2015) Updating the assignment of levels of evidence. J Bone Joint Surg Am 97(1):1–2

    Article  PubMed  Google Scholar 

  36. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6(7):1000097. https://doi.org/10.1371/journal.pmed.1000097

    Article  Google Scholar 

  37. Møller-larsen R, Wethelund JO, Jurik AG, Carvalho A, Lucht U (1988) Comparison of three different treatments for ruptured lateral ankle ligaments. Acta Orthop Scand 59(5):564–566

    Article  PubMed  Google Scholar 

  38. Niedermann B, Andersen A, Andersen SB, Funder V, Jørgensen JP, Lindholmer E, Vuust M (1981) Rupture of the lateral ligaments of the ankle: operation or plaster cast? A propective study. Acta Orthop Scand 52(5):579–587

    Article  CAS  PubMed  Google Scholar 

  39. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A (2016) Rayyan-a web and mobile app for systematic reviews. Syst Ver 5(1):210. https://doi.org/10.1186/s13643-016-0384-4

    Article  Google Scholar 

  40. Park HJ, Lee SY, Park NH, Kim E, Chung EC, Kook SH, Lee JW (2015) Usefulness of the oblique coronal plane in ankle MRI of the calcaneofibular ligament. Clin Radiol 70(4):416–423

    Article  CAS  PubMed  Google Scholar 

  41. Percy EC, Hill RO, Callaghan JE (1969) The “sprained” ankle. J Trauma 9(12):972–986

    Article  CAS  PubMed  Google Scholar 

  42. Pijnenburg ACM (2006) Thesis: acute ankle injuries: diagnostic and therapeutic strategies on evidence-based grounds. University of Amsterdam, The Netherlands

    Google Scholar 

  43. Pourkazemi F, Hiller CE, Raymond J, Nightingale EJ, Refshauge KM (2014) Predictors of chronic ankle instability after an index lateral ankle sprain: a systematic review. J Sci Med Sport 17(6):568–573

    Article  PubMed  Google Scholar 

  44. Prins JG (1978) Diagnosis and treatment of injury to the lateral ligament of the ankle. A comparative clinical study. Acta Chir Scand Suppl 486:3–149

    CAS  PubMed  Google Scholar 

  45. Raatikainen T, Puranen J (1993) Arthrography for the diagnosis of acute lateral ligament injuries of the ankle. Am J Sports Med 21(3):343–347

    Article  CAS  PubMed  Google Scholar 

  46. Raatikainen T, Putkonen M, Puranen J (1992) Arthrography, clinical examination, and stress radiograph in the diagnosis of acute injury to the lateral ligaments of the ankle. Am J Sports Med 20(1):2–6

    Article  CAS  PubMed  Google Scholar 

  47. Radwan A, Bakowski J, Dew S, Greenwald B, Hyde E, Webber N (2016) Effectiveness of ultrasonography in diagnosing chronic lateral ankle instability: a systematic review. Int J Sports Phys Ther 11(2):164–174

    PubMed  PubMed Central  Google Scholar 

  48. Riley RD, Moons KGM, Snell KIE, Ensor J, Hooft L, Altman DG, Hayden J, Collins GS, Debray TPA (2019) A guide to systematic review and meta-analysis of prognostic factor studies. BMJ 364:4597

    Article  Google Scholar 

  49. Samoto N, Sugimoto K, Takaoka T, Fujita T, Kitada C, Takakura Y (2007) Comparative results of conservative treatments for isolated anterior talofibular ligament (ATFL) injury and injury to both the ATFL and calcaneofibular ligament of the ankle as assessed by subtalar arthrography. J Orthop Sci 12(1):49–54

    Article  PubMed  Google Scholar 

  50. Schaap GR, de Keizer G, Marti K (1989) Inversion trauma of the ankle. Arch Orthop Trauma Surg 108(5):273–275

    Article  CAS  PubMed  Google Scholar 

  51. Seok H, Lee SH, Yun SJ (2020) Diagnostic performance of ankle ultrasound for diagnosing anterior talofibular and calcaneofibular ligament injuries: a meta-analysis. Acta Radiol 61(5):651–661

    Article  PubMed  Google Scholar 

  52. Song K, Pietrosimone B, Tennant JN, Nissman DB, Dederer KM, Paranjape C, Wikstrom EA (2021) Talar and subtalar T1ρ relaxation times in limbs with and without chronic ankle instability. Cartilage. https://doi.org/10.1177/1947603521994626

    Article  PubMed  Google Scholar 

  53. Tan DW, Teh DJW, Chee YH (2016) Accuracy of magnetic resonance imaging in diagnosing lateral ankle ligament injuries: a comparative study with surgical findings and timings of scans. Asia Pac J Sports Med Arthrosc Rehabil Technol 7:15–20

    PubMed  PubMed Central  Google Scholar 

  54. Thompson JY, Byrne C, Williams MA, Keene DJ, Schlussel MM, Lamb SE (2017) Prognostic factors for recovery following acute lateral ankle ligament sprain: a systematic review. BMC Musculoskelet Disord 18(1):421

    Article  PubMed  PubMed Central  Google Scholar 

  55. van Dijk CN, Lim LS, Bossuyt PM, Marti RK (1996) Physical examination is sufficient for the diagnosis of sprained ankles. J Bone Joint Surg Br 78(6):958–962

    Article  PubMed  Google Scholar 

  56. van Dijk CN, Vuurberg G (2017) There is no such thing as a simple ankle sprain: clinical commentary on the 2016 International Ankle Consortium position statement. Br J Sports Med 51:485–486

    Article  PubMed  Google Scholar 

  57. van Moppes FI, van den Hoogenband CR (1982) Diagnostic and therapeutic aspects of inversion trauma of the ankle joint. Rijksuniversiteit Limburg, Maastricht

    Google Scholar 

  58. van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, Bierma-Zeinstra SM (2008) What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med 121(4):324-331.e6

    Article  PubMed  Google Scholar 

  59. Vuurberg G, Hoorntje A, Wink LM, van der Doelen BFW, van den Bekerom MP, Dekker R, van Dijk CN, Krips R, Loogman MCM, Ridderikhof ML, Smithuis FF, Stufkens SAS, Verhagen EALM, de Bie RA, Kerkhoffs GMMJ (2018) Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med 52(15):956

    Article  PubMed  Google Scholar 

Download references

Funding

No external fundings were received by any of the authors for this study.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Hospital de Sant’Ana, Rua de Benguela, 501, 2775-028, Cascais, Portugal

    Jácome Pacheco, Francisco Guerra-Pinto, Luis Araújo, Miguel Flora, Teresa Rocha & Pedro Diniz

  2. Department of Orthopaedic Surgery, Hospital da Cruz Vermelha, Lisbon, Portugal

    Francisco Guerra-Pinto & Miguel Flora

  3. Department d’Anatomia i Embriologia Humana, Universitat de Barcelona, Barcelona, Spain

    Francisco Guerra-Pinto

  4. NOVA Medical School, Lisbon, Portugal

    Francisco Guerra-Pinto & José Guimarães Consciência

  5. Department of Orthopaedic Surgery, Hospital de Cascais, Cascais, Portugal

    Rita Alçada

  6. Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal

    Pedro Diniz

  7. Fisiogaspar, Lisbon, Portugal

    Pedro Diniz

  8. Department of Orthopaedic Surgery, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal

    José Guimarães Consciência

Authors
  1. Jácome Pacheco
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Francisco Guerra-Pinto
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Luis Araújo
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Miguel Flora
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Rita Alçada
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Teresa Rocha
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Pedro Diniz
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. José Guimarães Consciência
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jácome Pacheco.

Ethics declarations

Conflict of interest

The authors declare that they have no competing interests.

Ethical approval

This study was approved by the Research and Ethical Committees of our Institution. This article does not contain any studies with human participants or animals performed by any of the authors.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 21 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Pacheco, J., Guerra-Pinto, F., Araújo, L. et al. Chronic ankle instability has no correlation with the number of ruptured ligaments in severe anterolateral sprain: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 29, 3512–3524 (2021). https://doi.org/10.1007/s00167-021-06610-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-021-06610-y

Keywords

Search

Navigation