Clinical vs MRI Assessment of Lateral Ankle Sprains Are We Seeing the Same Injuries?

IntroductionLateral ankle sprain (LAS) is the most common orthopaedic injury, yet initial diagnosis often lacks precision, leading to suboptimal management and persistent symptoms. This study aimed to compare findings from routine clinical tests with magnetic resonance imaging (MRI) results following LAS.MethodsPatients presenting with LAS were re-evaluated 7 to 10 days post-injury using standardized clinical tests. Ligaments assessed included the anterior talo-fibular (ATFL), calcaneo-fibular (CFL), antero-inferior tibiofibular (AITFL), interosseous talo-calcaneal (ITCL), and superficial and deep deltoid ligaments (sDL, dDL). Specific tests included Anterior Drawer Test (ADT) for ATFL; Varus Talar Tilt Test (VTTT) for CFL; palpation pain for ATFL, CFL, ITCL, and DL; VTTT in dorsiflexion and sinus tarsi pain for ITCL; medial malleolus and deltoid pain for DL; Squeeze Test, External Rotation Test, and syndesmosis pain for AITFL. The MRI performed within 3 weeks served as the reference standard. Sensitivity (Se) and specificity (Sp) were calculated for each individual and combined test per ligament. Results. Isolated ATFL ± CFL injuries were found in 50% of cases. Combined tests showed the highest sensitivity. "Pain on palpation" was the most reliable test for ATFL, CFL, and ITCL (Se/Sp: 100%/33.3%, 70.8%/56.2%, 70.8%/56.2%). Dynamic tests like ADT, VTTT, and VTTT in dorsiflexion showed limited diagnostic value (Se/Sp: 58.8%/66.7%, 29.2%/68.8%, 29.2%/68.8%). For sDL and dDL, "pain on deltoid" had low sensitivity but high specificity (0%/84.2 and 44.4%/93.5%). Squeeze and External Rotation Tests were poor for general AITFL injuries (0%/84.2%) but highly accurate for unstable syndesmosis (100%/91.9%).ConclusionLateral ankle sprains often involve more than just the lateral ligament complex. Clinical tests alone lack accuracy, particularly for deltoid and AITFL injuries. Combining tests improves sensitivity. Suspicion of syndesmosis, subtalar, or medial injury should prompt further imaging due to the low sensitivity of clinical evaluation.