Talar Tilt Test

The Talar Tilt Test is used to assess ankle stability and detect injuries to the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL). It is particularly valuable for identifying mechanical ankle instability following acute sprains, and is often combined with the Anterior Drawer Test for a more comprehensive evaluation.

Technique

Patient position:The patient sits with the foot and ankle unsupported. The foot is placed in 10–20° of plantarflexion.

Execution:

• The examiner stabilizes the distal leg just above the malleoli with one hand.

• With the other hand, the heel is inverted.

• The lateral aspect of the talus is palpated to assess tilting.

• Laxity or increased motion is compared with the contralateral side¹ ².

Interpretation:

• Normal: Minimal or no difference between sides.

• Positive test: Increased talar tilt relative to the uninjured ankle, suggesting injury to the ATFL and/or CFL.

Evidence

Complementary use with the Anterior Drawer Test

A prospective study of 244 patients with ankle injuries concluded³:

• Ligament injuries not detected by the talar tilt test may be identified with the anterior drawer test.

• The two tests are complementary and should be used together.

• Neither test alone can differentiate isolated ATFL injuries from combined ATFL+CFL lesions.

Radiological and MRI findings

In a study of 112 athletes, the reliability of the radiographic talar tilt test was compared with MRI⁴:

• MRI proved reliable for diagnosing lateral ligament injuries.

• A talar tilt ≥15° compared to the healthy side indicated complete rupture of both ATFL and CFL.

Diagnostic accuracy:

Parameter	Value
Sensitivity	67 %
Specificity	75 %
Positive LR	2.7
Negative LR	0.44

Clinical use

A recent cross-sectional study confirmed the talar tilt test’s value in identifying mechanical ankle instability, especially in chronic cases⁵.

Clinical relevance

The talar tilt test has high specificity, meaning that a positive test strongly suggests lateral ligament injury. However, its moderate sensitivity implies that a negative test does not rule out pathology.

• Best used in combination with other clinical tests (e.g., Anterior Drawer Test).

• Provides insight into the degree of mechanical instability and can guide further treatment, rehabilitation, or imaging.

• Particularly important in both acute ankle sprains and the evaluation of chronic instability in athletes.

Sources:

1. Cook CE and Hegedus EJ. Orthopedic Physical Examination Tests: An Evidence-Based Approach. Prentice Hall. New Jersey. 2007.

2. Wheeless Online Textbook of Orthopaedics. Talar Tilt: Physical Exam. http://www.wheelessonline.com/ortho/talar_tilt_physical_exam

3. Johannsen, A. 1978. Acta Orthopaedica. Radiological diagnosis of lateral ligament lesion of the ankle: a comparison between talar tilt and anterior drawer sign.

4. Hertel et al. Extracted from Orthopedic Physical Examination Tests: An Evidence-Based Approach: "Medial Talar Tilt Stress Test."

5. Wenning M, Gehring D, Lange T, Fuerst-Meroth D, Streicher P, Schmal H, Gollhofer A. Clinical evaluation of manual stress testing, stress ultrasound and 3D stress MRI in chronic mechanical ankle instability. BMC Musculoskeletal Disorders. 2021 Dec;22(1):1-3.