Rethinking Ankle Injury Evaluation: Why Ultrasound Is Changing the Game

Based on the 2025 narrative review by Hattori et al. in Diagnostics

When it comes to ankle injuries—especially in athletes—we’ve traditionally relied on manual exams, X-rays, and MRIs. But growing research is challenging this standard.

A comprehensive narrative review published in Diagnostics (2025) by Hattori and colleagues at the University of Pittsburgh is making a strong case: musculoskeletal ultrasound (MSK US) isn’t just a helpful tool—it’s often the best first-line option for ligament injury assessment around the ankle.

What the Research Found

This peer-reviewed paper analyzed over 99 studies, covering diagnostic accuracy for ultrasound across key ankle ligaments:

• Anterior talofibular ligament (ATFL)

• Calcaneofibular ligament (CFL)

• Syndesmosis (including AiTFL)

• Deltoid ligament (DL)

Key takeaways from the review:

• Ultrasound matches or outperforms MRI in many chronic and sub-acute ligament injuries

• Dynamic stress ultrasound enhances detection of instability, especially for ATFL and syndesmotic injuries

• Cost-effective, portable, radiation-free—ideal for sideline, clinic, and real-time assessments

• Particularly effective for medial and lateral ankle ligament injuries in fracture scenarios
  

Numbers Clinicians Should Know

Ligament	Sensitivity (Range)	Specificity (Range)	Notes
ATFL	84–100% (chronic); 57–97% (acute)	91–100% (chronic); 64–100% (acute)	Dynamic US boosts accuracy in chronic cases
CFL	90–100% (chronic); 49–100% (acute)	Consistently 90%+	Visualization harder in acute due to swelling, tendon overlap
AiTFL	66–100%	75–100%	Stress US most useful in sub-acute stage
Deltoid Ligament (DL)	94–100%	90–100%	Highly accurate in assessing tears in fracture cases

Reference: Hattori, S. et al. (2025). Role of Ultrasound in Evaluating Ligament Injuries Around the Ankle: A Narrative Review. Diagnostics, 15(392). https://doi.org/10.3390/diagnostics15030392

Figure 4A -- 4D.TRANSDUCER PLACEMENT AND NORMAL ANATOMY FOR THE SUPERFICIAL POSTERIOR TIBIOTALAR LIGAMENT (SPTL) AND THE POSTERIOR FIBERS OF THE DEEP POSTERIOR TIBIOTALAR LIGAMENT (pDPTL)

Why This Matters for Sports Medicine Teams

If you’re working with athletes or active individuals, the implications are clear:

• Sideline assessments can be faster and more accurate.

• Chronic instability can be monitored with dynamic stress imaging.

• Return-to-play decisions can be based on real structural insight.

• Surgical planning especially in ankle fractures becomes more targeted.

Yet, despite the evidence, MSK ultrasound remains underutilized, largely due to lack of hands-on training and confidence.

The Bottom Line

Diagnostic ultrasound is no longer the future it’s the present. And if your clinic, team, or facility isn’t using it confidently for ankle injuries, it’s time to bridge that gap.

We’re here to help. At Pura Health, we offer tailored ultrasound training sessions focused on:

• Lateral and medial ankle ligaments

• Dynamic stress scanning protocols

• Real-world case practice for clinicians and sports medicine providers

Interested in hosting or attending a training session? Contact us today to bring evidence-based imaging into your hands.