Acute clinical evaluation for the diagnosis of lateral ankle ligament injuries is useful: A comparison between the acute and delayed settings

Purpose: To determine the diagnostic value of seven injury history variables, nine clinical tests (including the combination thereof) and overall clinical suspicion for complete discontinuity of the lateral ankle ligaments in the acute (0–2 days post-injury) and delayed setting (5–8 days post-injury). Methods: All acute ankle injuries in adult athletes (≥18 years) presenting up to 2 days post-injury were assessed for eligibility. Athletes were excluded if imaging studies demonstrated a frank fracture or 3 T MRI could not be acquired within 10 days post-injury. Using standardized history variables and clinical tests, acute clinical evaluation was performed within 2 days post-injury. Delayed clinical evaluation was performed 5–8 days post-injury. Overall, clinical suspicion was recorded after clinical evaluation. MRI was used as the reference standard. Results: Between February 2018 and February 2020, a total of 117 acute ankle injuries were screened for eligibility, of which 43 were included in this study. Complete discontinuity of lateral ankle ligaments was observed in 23 (53%) acute ankle injuries. In the acute setting, lateral swelling had 100% (95% confidence interval [CI]: 82–100) sensitivity, haematoma had 85% (95% CI: 61–96) specificity and the anterior drawer test had 100% (95% CI: 77–100) specificity. In the delayed setting, sensitivity for the presence of haematoma improved from 43% (95% CI: 24–65) to 91% (95% CI: 70–98; p < 0.01) and the sensitivity of the anterior drawer test improved from 21% (95% CI: 7–46) to 61% (95% CI: 39–80; p = 0.02). Clinical suspicion had a positive likelihood ratio (LR) of 4.35 (95% CI: 0.55–34.17) in the acute setting and a positive LR of 6.09 (95% CI: 1.57–23.60) in the delayed setting. Conclusions: In the acute setting, clinical evaluation can exclude complete discontinuity (e.g., absent lateral swelling) and identify athletes with a high probability of complete discontinuity (e.g., positive anterior drawer test) of the lateral ankle ligaments. In the delayed setting, the sensitivity of common clinical findings increases resulting in an improved diagnostic accuracy. In clinical practice, this study underlines the importance of meticulous clinical evaluation in the acute setting. Level of Evidence: Level III.