Accuracy of ultrasound in diagnosing anterior talofibular ligament injury: a meta-analysis

Abstract

The anterior talofibular ligament (ATFL) is the most frequently injured structure of the ankle joint. This meta-analysis evaluates the diagnostic accuracy of ultrasound for anterior talofibular ligament injury. We systematically searched for PubMed, Embase, Web of Science, Scopus, and Cochrane Library databases, with a search deadline of November 28,2025, and extract data related to diagnostic performance. A bivariate model was used to summarize the estimated values and construct a summary receiver operating characteristic (SROC) curve. Heterogeneity was evaluated using I² statistic, clinical applicability was assessed using Fagan’s nomogram and likelihood ratio scatter plot, and potential publication bias was employing Deeks funnel plot asymmetry test. A total of 21 studies were included, evaluating 1248 patients. The meta-analysis results indicate that the pooled sensitivity of ultrasound examination is 0.93 (95% CI: 0.89–0.96), specificity is 0.86 (95% CI: 0.78–0.91), area under the SROC curve (AUC) is 0.95, diagnostic odds ratio (DOR) is 100.74 (40.08-253.19), positive likelihood ratio (PLR) is 5.86 (95% CI: 3.65–9.43), and negative likelihood ratio (NLR) is 0.09 (95% CI: 0.05–0.15). Subgroup analyses showed that specificity was higher when MRI was used as the reference standard (0.88) and in prospective studies (0.85), with particularly favorable performance observed in investigations of chronic injury. Ultrasound shows promise as a first-line screening modality with high sensitivity and specificity. Whether routine ultrasound triage translates into reduced MRI referrals and overall cost savings warrants prospective health-economic evaluation.