Scanning the calcaneofibular ligament: placing the patient’s ankle in dorsiflexion or plantar flexion?

Musculoskeletal ultrasound (MSKUS) of the ankle, which is a non-invasive and radiation-free modality, demonstrates high diagnostic performance in the diagnosis of calcaneofibular ligament (CFL) injuries. Seok et al. (2019) recommend that MSKUS should be performed by musculoskeletal radiologists as a first-line diagnostic tool to more accurately diagnose CFL injuries.

But how to position the patients’ ankle when scanning the CFL? There is some controversy about it. The study of Hattori et al. (2019) revealed that the whole length of the CFL, including the fibular attachment of the CFL, is more likely to be visualized with MSKUS in dorsiflexion than in plantar flexion. Funk (2011) also described in a very informative flowchart to scan the CFL in dorsiflexion combined with inversion. The European Society of MusculoSkeletal Radiology also describes scanning the CFL in dorsiflexion. On the other hand, a few articles, and some sonographers, strongly state that the CFL should be scanned in plantar flexion.

QUESTION: How do you scan the CFL? In dorsiflexion or plantar flexion?
URL’s to PubMed:
1) http://bit.ly/30Gb9ed
2) http://bit.ly/2v0YOWf
3) http://bit.ly/2RcZj8t