Anterior talofibular ligament
Ankle is mainly stabilized by 2 groups of ligaments. Primary ligaments of ankle include medial and lateral groups.
Medial group consists of
- Deltoid ligament
- Calcaneofibular ligament – which is also known as Spring Ligament
Lateral group consists of
- Syndesmosis – which includes
- Anterior-inferior tibiofibular ligament (AITFL)
- Posterior-inferior tibiofibular ligament (PITFL) – deep portion of this ligament sometimes referred to as the inferior transverse ligament
- Transverse tibiofibular ligament(TTFL)
- Interosseous ligament (IOL)
- Anterior talofibular ligament (ATFL)
- Posterior talofibular ligament (PTFL)
- Calcaneal fibular ligament (CFL)
- Lateral talocalcaneal ligament (LTCL)
Ligamentous injuries around the ankle are most commonly seen among athletes. Inversion type of injuries around the ankle account for at least 40% of all sports injuries. Among the lateral group of ligaments around ankle, anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) are sequentially the most commonly injured ligaments when a plantar-flexed foot is forcefully inverted. Approximately 35% of ankle injuries tend to be isolated injuries to the anterior talofibular ligament (ATFL) as it is the weakest ligament in the lateral collateral complex of the ankle. Avulsion injuries are more common at the fibular than at the talar end of the ligament. The posterior talofibular ligament (PTFL) is rarely involved and particularly seen in association with a complete dislocation of the talus.
Personal feeling of‘rolling over’ in the injured ankle joint is generally the situation that the patient describes about the mechanism of injury. Acute pain, not able to walk and acute swelling may also be seen.
The Ottawa ankle rules have been demonstrated to be accurate in predicting which patients with ankle injuries require X-rays to exclude fractures in both adult and children older than five years.
The Ottawa ankle rules suggest ankle radiographs should be obtained in the setting of pain in the malleolar region and any of the following:
Tenderness over the posterior edge of the distal 6 cm or tip of the lateral malleolus
Tenderness over the posterior edge of the distal 6 cm or tip of the medial malleolus
Inability to bear weight immediately after the injury and for four steps at the time of evaluation.
A foot series is indicated in patients with midfoot pain and any of the following:
Tenderness of the base of the fifth metatarsal
Tenderness over the navicular bone
Inability to bear weight immediately after the injury and for four steps at the time of evaluation
A typical ankle X-ray series would include anteroposterior, lateral, and mortise views. Standard views with a foot series include anteroposterior, lateral, and oblique views.
Treatment / Management
Initial management of ankle sprains includes the PRICE protocol (protection, rest, ice, compression, and elevation). Resting the injured ankle for the first 72 hours followed by gradual resumption of activity as tolerated is a reasonable approach. Initially, crutches can be used, if needed for comfort. When compared with immobilization, early weight-bearing with support (elastic compression wrap or a walking boot, aircast, or walking cast) has been found to improve return to sports, return to work, persistent swelling, the range of motion, and patient satisfaction.
Compression can be achieved with an elastic bandage, any lace-up ankle support, or a semi-rigid or inflatable brace. Elevation of the injured ankle above the level of the heart as frequently as possible for the first 24 to 48 hours may lessen the swelling associated with the injury. The range of motion exercises can be initiated when pain and edema resolve. Nonsteroidal anti-inflammatory drugs or acetaminophen can be used for analgesia.
Early functional rehabiilitation programs should begin with a focus on restoring range of motion, following by proprioception and neuromuscular training, and strength training (especially the peroneal muscles) to help combat recurrent injuries. The strengthening phase should begin once swelling and pain has decreased and the patient demonstrates full range of motion (active and passive). The functional braces should be utilized early on in the strengthening phases and when the patient initially returns to activity.
Mild to moderate ankle sprains typically have a full recovery in 7 to 15 days. Symptoms persisting beyond this period should prompt reevaluation. All symptoms should be resolved before return to sports. For highly competitive athletes, reevaluation by a sports medicine physician for all but mild sprains is reasonable before returning to play to ensure full recovery to avoid recurrent injury and ankle instability.
Recurrent Instability Patients
Patients with evidence of ligamentous laxity should be immobilized, given crutches to allow ambulation without weight-bearing of the injured ankle, and referred to a sports medicine specialist or orthopedic surgeon. The referral is critical given that higher energy injuries are often associated with osteochondral defects of the talus, peroneal tendon injuries, intra-articular loose bodies, and fractures.
Patients suspected of having syndesmotic complex injuries should also be referred given that these injuries are often associated with a prolonged recovery and may require surgical intervention. Acute syndesmotic injuries demonstrating diastasis and ankle instability on exam and stress radiographs will require screw versus tightrope fixation methods. Chronic, recurrent ankle instability should also be referred for ligamentous reconstruction by a variety of accepted surgical techniques.