Abstract
Context:Ankle sprains are the most common acute musculoskeletal injury. Clinical tests represent the first opportunity to assess the sprain’s severity, but no systematic review has compared these tests to contemporary reference standards.Objective:To determine the diagnostic accuracy of clinical tests assessing the talocrural and subtalar joint ligaments after ankle sprain.Data Sources:CINAHL, EMBASE, MEDLINE, hand-searching, and PubMed-related article searches (inception to November 18, 2020).Study Selection:Eligible diagnostic studies compared clinical examination (palpation, joint laxity) against imaging or surgery. Studies at a high risk of bias or with high concerns regarding applicability on Quality Assessment of Diagnostic Accuracy Studies-2 were excluded from the meta-analysis.Study Design:Systematic review and meta-analysis.Level of Evidence:Level 3a.Data Extraction:True-positive, false-negative, false-positive, and true-negative findings were extracted to calculate sensitivity, specificity, and likelihood ratios. If ordinal data were reported, these were extracted to calculate Cohen’s kappa.Results:A total of 14 studies met the inclusion criteria (6302 observations; 9 clinical tests). No test had both sensitivity and specificity exceeding 90%. Palpation of the anterior talofibular ligament is highly sensitive (sensitivity 95%-100%; specificity 0%-32%; min-max; n = 6) but less so for the calcaneofibular ligament (sensitivity 49%-100%; specificity 26%-79%; min-max; n = 6). Pooled data from 6 studies (885 observations) found a low sensitivity (54%; 95% CI 35%-71%) but high specificity (87%; 95% CI 63%-96%) for the anterior drawer test.Conclusion:The anterior talofibular ligament is best assessed using a cluster of palpation (rule out), and anterior drawer testing (rule in). The talar tilt test can rule in injury to the calcaneofibular ligament, but a sensitive clinical test for the ligament is lacking. It is unclear if ligamentous injury grading can be done beyond the binary (injured vs uninjured), and clinical tests of the subtalar joint ligaments are not well researched. The generalizability of our findings is limited by insufficient reporting on blinding and poor study quality.Registration:Prospero ID: CRD42020187848.Data Availability:Data are available in a public, open access repository on publication, including our RevMan file and the CSV file used for meta-analysis: http://doi.org/10.5281/zenodo.4917138
Highlights
Context: Ankle sprains are the most common acute musculoskeletal injury
The anterior talofibular ligament is best assessed using a cluster of palpation, and anterior drawer testing
The talar tilt test can rule in injury to the calcaneofibular ligament, but a sensitive clinical test for the ligament is lacking
Summary
Protocol and RegistrationWe used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis of Diagnostic Test Accuracy Studies (PRISMADTA)[45] for our review.We prospectively drafted our study protocol to PROSPERO on May 20 2020, registration ID: CRD42020187848.Eligibility CriteriaWe assessed original research for eligibility using the criteria presented in Table 1, with no restrictions on the language of the article nor the publication year. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis of Diagnostic Test Accuracy Studies (PRISMADTA)[45] for our review. We prospectively drafted our study protocol to PROSPERO on May 20 2020, registration ID: CRD42020187848. We assessed original research for eligibility using the criteria presented, with no restrictions on the language of the article nor the publication year. Most criteria were decided on a priori, as part of the PROSPERO protocol. Arthroscopy as an inclusion criterion was extended to include other surgical techniques as well, and avulsion fractures as an exclusion criterion were omitted to broaden the eligibility criteria.
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