From the Guidelines
For left ankle pain over the anterior talofibular ligament (ATFL) without injury history and normal ultrasound and X-ray findings, I strongly recommend an MRI as the next diagnostic step to evaluate ligamentous integrity and identify potential causes of pain, given its high diagnostic accuracy of 97% for MRI compared with arthroscopic findings 1. The patient's symptoms of pain radiating up the fibula and the absence of abnormalities on routine radiography suggest the need for advanced imaging to assess for ligamentous injuries, tenosynovitis, tendon injury, or osteochondral lesions. Key considerations in the diagnostic workup include:
- Evaluating for injuries associated with or mimicking lateral instability, such as tenosynovitis, tendon injury, and osteochondral lesions, which can be identified by MRI 1.
- Assessing the integrity of the anterior talofibular ligament, calcaneofibular ligament, and deep deltoid ligament, for which MRI has demonstrated high accuracy 1.
- Considering the potential for interosseous membrane tears, which can be diagnosed with high sensitivity and specificity using MRI or US 1. Initial management should focus on conservative measures, including rest, ice, compression, and elevation, as well as physical therapy to improve ankle strength, proprioception, and range of motion. If symptoms persist despite conservative treatment, referral to a foot and ankle specialist is warranted for further evaluation and management.
From the Research
Diagnostic Workup for Left Ankle Pain
- The patient presents with left ankle pain over the anterior talofibular ligament (ATFL) with no history of injury, and the pain radiates up the fibula to the lateral malleolus.
- Initial diagnostic tests, including ultrasound and X-ray, have shown no abnormalities.
Further Diagnostic Considerations
- Given the normal ultrasound and X-ray results, further imaging studies may be necessary to evaluate the ATFL and rule out other potential causes of ankle pain 2, 3.
- Magnetic resonance imaging (MRI) has been shown to have high accuracy in diagnosing ATFL injuries, with a sensitivity of 97% and specificity of 91% in one study 2.
- Stress radiography and MR arthrography may also be useful in evaluating the ATFL and assessing for any ligamentous laxity or instability 3.
Clinical Evaluation and Management
- A thorough clinical evaluation, including a physical examination and review of the patient's medical history, is essential in diagnosing and managing ATFL injuries 4.
- Non-surgical treatment, including rest, ice, compression, and elevation (RICE), as well as physical therapy and bracing, may be effective in managing acute ATFL injuries 4.
- In cases of chronic ankle instability, surgical intervention, such as arthroscopic Broström procedure or anatomical reconstruction, may be necessary to restore stability and function to the ankle joint 5.
Emerging Diagnostic Techniques
- Stress ultrasonography has been shown to be a safe and repeatable method for measuring the talofibular interval and assessing for talocrural laxity and ATFL injury 6.
- This technique may be useful in evaluating patients with acute ankle injuries and monitoring their progress over time.