Why ultrasound is the missing piece of the puzzle in the imaging and management pathway of acute ankle injuries.

This review explores the utility of diagnostic ultrasound in acute ankle injuries, a prevalent condition affecting approximately 1 in 10,000 people daily in Western countries. Up to 70 % of patients with such injuries may develop chronic ankle instability, leading to persistent dysfunction, reduced quality of life, and increased healthcare burden. Diagnostic errors, particularly missed fractures or complex soft tissue injuries, contribute significantly to patient dissatisfaction and are a common cause of medico-legal claims. Limited access to advanced imaging modalities like CT or MRI, especially in resource limited settings, hampers early and accurate diagnosis. In this context, ultrasound presents a compelling alternative. It is inexpensive, non-invasive, non-ionising, portable, and widely accessible. With appropriate training, ultrasound can reliably detect clinically significant and occult injuries. When used alongside clinical examination, ultrasound may reduce unnecessary Xrays, especially in Ottawa-positive but radiograph-negative patients. It shows high accuracy in identifying ligament, tendon, and nerve injuries and offers the added benefit of dynamic, real-time, and multi-planar assessment. Despite these advantages, ultrasound remains underutilised in clinical practice for acute ankle injuries. Broader adoption could improve diagnostic accuracy, tailor treatment strategies, reduce imaging delays, and enhance patient outcomes. This review highlights the need for integrating ultrasound more effectively into the imaging pathways for ankle trauma.