Objectives-To determine the diagnostic performance of ultrasonography (US) for evaluation of the ankle joint osteoarthritic (OA) changes. Cone-beam computed tomography (CT) was used as the gold standard and US performance was compared with conventional radiography (CR). As a secondary aim, associations between the imaging findings and ankle symptoms were assessed.Methods-US was performed to 51 patients with ankle OA. Every patient had prior ankle CR and underwent cone-beam CT during the same day as US examination. On US, effusion/synovitis, osteophytes, talar cartilage damage, and tenosynovitis were evaluated. Comparison to respective imaging findings on CR and cone-beam CT was then performed. Single radiologist blinded to other modalities assessed all the imaging studies. Symptoms questionnaire, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), was available for 48 patients.Results-US detected effusion/synovitis of the talocrural joint with 45% sensitivity and 90% specificity. For the detection of anterior talocrural osteophytes, US sensitivity was 78% and specificity 79%. For the medial talocrural osteophytes, they were 39 and 83%, and for the lateral talocrural osteophytes 54 and 100%, respectively. Considering cartilage damage of the talus, US yielded a low sensitivity of 18% and high specificity of 97%. Overall, the performance of US was only moderate and comparable to CR. The imaging findings showed only weak associations with ankle symptoms.Conclusions-The ability of US to detect ankle OA is only moderate. Interestingly, performance of CR also remained moderate. The associations between imaging findings and WOMAC score seem to be weak in ankle OA.