eMedicine Specialties > Sports Medicine > Foot and Ankle

Calcaneofibular Ligament Injury

Bryan L Reuss, MD, Orthopedic Surgeon, Orlando Orthopedic Center
Michael C Wadman, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, University of Nebraska College of Medicine; Randy Schwartzberg, MD, Director of Sports Medicine Education, Department of Orthopedic Surgery, Orlando Regional Healthcare System
Contributor Information and Disclosures

Updated: Jan 2, 2008

Introduction

Background

Ankle injuries are among the most common injuries that present to physician offices and emergency departments (EDs) because the ankle is the most frequently injured joint in the body.1, 2, 3, 4, 5, 6, 7, 8 Ankle injuries are a major cause of time loss from work or other daily activities and constitute up to 25% of all time-loss injuries from running and jumping sports.9, 10 Sprains account for 85% of ankle injuries and, of these sprains, 85% are caused by inversion injuries. An inversion sprain results in an injury to the lateral ligaments, one of which is the calcaneofibular ligament (CFL).

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center and Sprains and Strains Center. Also, see eMedicine's patient education articles Ankle Sprain and Sprains and Strains.

See also the following on eMedicine:
Ankle Injury, Soft Tissue
Ankle Sprain [in the Physical Medicine and Rehabilitation section]
Ankle Sprain [in the Sports Medicine section]

See also the following on Medscape:
Interventions for Preventing Ankle Ligament Injuries
Different Functional Treatment Strategies for Acute Lateral Ankle Ligament Injuries in Adults
Surgical Versus Conservative Treatment for Acute Injuries of the Lateral Ligament Complex of the Ankle in Adults
Therapeutic Ultrasound for Acute  Ankle Sprains 

Frequency

United States

An estimated 1 ankle inversion injury occurs per 10,000 people per day, or 23,000 ankle inversion injuries per day. Of these ankle inversion injuries, the CFL is the second most common ligament injured after the anterior talofibular ligament (ATFL).
 
See also the following on eMedicine:
Talofibular Ligament Injury

Functional Anatomy

The CFL courses from the distal fibula to the calcaneus by extending from the distal anterior margin of the lateral malleolus to insert onto the posterior lateral tubercle of the lateral wall of the calcaneus.8, 11, 12 The CFL lies deep to the peroneal tendons, is cylindrical in shape, and, because it crosses 2 joints, it acts as a subtalar joint stabilizer.

Sport-Specific Biomechanics

The CFL is 20-30 mm long, 3-5 mm thick, and 4-8 mm wide, and the angle of the CFL from the fibula to the calcaneus is 10 º -45 º posterior to the axis of the fibula. Except in the extremes of inversion, the CFL is in a lax position. With an inverted ankle, strain on the CFL is highest in dorsiflexion; thus, when the ankle is dorsiflexed or in a neutral position, the CFL is the lateral ligament that is most often injured in inversion sprains. Although isolated CFL tears are uncommon, CFL tears in combination with ATFL tears are the second most common injury pattern (20% of injuries). Midsubstance rupture of the CFL remains the most common injury pattern, although a number of fibula or calcaneus avulsion-type injury patterns exist.13

Clinical

History

The patient's history may include the following:

  • Ankle inversion at the time of injury or, more specifically, ankle inversion with the foot in the neutral position
  • Running on an uneven surface or landing on an uneven surface after a jump (eg, another player's foot during a basketball game)
  • Previous ankle inversion injury

The injury history can include the following signs and/or symptoms:

  • Pain is primarily located on the lateral side of the ankle joint
  • Presence of edema (increases with the severity of a sprain)
  • Presence of ecchymosis (increases with the severity of a sprain)
  • Presence of joint instability (increases with the severity of a sprain)
  • Audible pop or crack heard at the time of the injury
  • Possible inability to bear weight on the affected ankle
  • Other signs and symptoms may include the following:
    • Nausea and vomiting
    • Joint deformity
    • Cold or pale foot on the affected side
    • Impaired sensation of the affected foot

Physical

The physical examination should include the following:

  • Examine the ankle and its areas of tenderness as soon as possible after the injury has occurred because pain, ecchymosis, and edema all decrease the sensitivity of the physical examination.
  • Evaluate the neurovascular status of the sites distal and proximal to the injury site.
  • Examine for point tenderness. Start at distant sites (eg, fifth metatarsal base, distal fibula) to eliminate other causes of the patient's symptoms.
  • Evaluate the passive range of motion (ROM) of the ankle, and compare the findings to the contralateral ankle. Pain and swelling may limit findings.
  • Evaluate ankle stability.
    • The anterior drawer test is the first test performed and the most useful test to rule out or diagnose an ATFL injury.
      • With the ankle in neutral to slight plantar flexion, hold the lower leg in position with one hand while the other hand attempts to pull the hindfoot anteriorly (by grasping the heel and pulling anteriorly).
      • A soft endpoint or anterior displacement of the talus indicates an ATFL injury/tear.
    • After the anterior drawer test is performed, the examination can focus on the CFL. The best test to assess CFL stability is the talar tilt test.
      • Often, this test is more revealing after infiltration of the area with local anesthetic or by performing the test under general anesthesia.
      • Medially support the tibia on the affected side with one hand, and forcibly invert the lateral aspect of the heel with the other hand.
      • A soft endpoint, increase in talar tilt compared with the other ankle, or lateral dimpling indicates damage/tear to the CFL.
    • If the anterior drawer test is positive and the talar tilt test is negative, most likely an isolated ATFL injury has occurred, which accounts for 60-70% of all inversion injuries.
    • If both the anterior drawer test and talar tilt test are positive, a combination ATFL/CFL injury has probably occurred, which accounts for 20% of inversion injuries.
    • An isolated CFL injury with a negative anterior drawer test and positive talar tilt test is very rare.
    • Consider all aspects of the patient history and physical examination when trying to make a diagnosis, because certain parts of the physical examination may be inconclusive due to patient pain, edema, or spasticity.

Causes

Causes of injury to the lateral ankle include the following:

  • Walking, running, or jumping on uneven surfaces increases the risk of an inversion sprain and subsequent injuries to the CFL.
  • Proprioceptive deficit, peroneal muscle weakness, and subtalar instability increase the risk of an inversion injury.
  • Previous injury to the ankle is a risk factor: athletes have a 2.3-fold greater risk of recurrence after a previous ankle injury.

Contents

Overview: Calcaneofibular Ligament Injury
Differential Diagnoses & Workup: Calcaneofibular Ligament Injury
Treatment & Medication: Calcaneofibular Ligament Injury
Follow-up: Calcaneofibular Ligament Injury
Multimedia: Calcaneofibular Ligament Injury
[ CLOSE WINDOW ]

References

  1. Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle. 7th ed. St. Louis, Mo: Mosby; 1999:114-30.

  2. Rosen P, Barkin RM, Hayden SR, Schaider JJ, Wolfe R. The 5 Minute Emergency Medicine Consult. Philidelphia, Pa: Lippincott Williams & Wilkins; 1999:70-1.

  3. Mellion MB, Walsh WM, Shelton GL, eds. The Team Physician's Handbook. St. Louis, Mo: Mosby; 1997:584.

  4. Skinner HB. Current Diagnosis and Treatment in Orthopedics. Stamford, Conn: Appleton & Lange; 1995.

  5. Lutter LD, Mizel MS, Pfeffer GB, eds. Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1994:241-51.

  6. Mayeda DV. Ankle and foot. In: Rosen P, Barkin RM, Danzl DF, et al, eds. Emergency Medicine Concepts and Clinical Practice. 3rd ed. St. Louis, Mo: Mosby Year-Book; 1992:745-57.

  7. Gerbert J, Burns A. Acute soft tissue trauma of the ankle. In: Scurran BL, ed. Foot and Ankle Trauma. New York, NY: Churchill Livingstone; 1989:571-8.

  8. Hutton PAN. Ankle lesions. In: Jenkins DHR, ed. Ligament Injuries and Their Treatment. Rockville, Md: Aspen Publication; 1985:95-111.

  9. Kerkhoffs GM, Rowe BH, Assendelft WJ, et al. Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev. 2002;3:CD003762. [Medline].

  10. Wexler RK. The injured ankle. Am Fam Physician. Feb 1 1998;57(3):474-80. [Medline]. [Full Text].

  11. Taser F, Shafiq Q, Ebraheim NA. Anatomy of lateral ankle ligaments and their relationship to bony landmarks. Surg Radiol Anat. Aug 2006;28(4):391-7. [Medline].

  12. Birrer RB. Ankle injuries and the family physician. J Am Board Fam Pract. Oct-Dec 1988;1(4):274-81. [Medline].

  13. Haraguchi N, Toga H, Shiba N, Kato F. Avulsion fracture of the lateral ankle ligament complex in severe inversion injury: incidence and clinical outcome. Am J Sports Med. Jul 2007;35(7):1144-52. [Medline].

  14. Reuss BL. Managing ankle injuries: follow the rules?. J Musculoskelet Med. 2004;21(3):155-64.

  15. Chou MC, Yeh LR, Chen CK, et al. Comparison of plain MRI and MR arthrography in the evaluation of lateral ligamentous injury of the ankle joint. J Chin Med Assoc. Jan 2006;69(1):26-31. [Medline].

  16. Duc SR, Mengiardi B, Pfirrmann CW, Hodler J, Zanetti M. Improved visualization of collateral ligaments of the ankle: multiplanar reconstructions based on standard 2D turbo spin-echo MR images. Eur Radiol. May 2007;17(5):1162-71. [Medline].

  17. McDowell LD, Seymour SF. Diagnosis and treatment of ankle sprains. Nurse Pract. Mar 1994;19(3):36-9, 43. [Medline].

  18. Cukiernik VA, Lim R, Warren D, et al. Naproxen versus acetaminophen for therapy of soft tissue injuries to the ankle in children. Ann Pharmacother. Sep 2007;41(9):1368-74. [Medline].

  19. Evans GA, Hardcastle P, Frenyo AD. Acute rupture of the lateral ligament of the ankle. To suture or not to suture?. J Bone Joint Surg Br. Mar 1984;66(2):209-12. [Medline]. [Full Text].

  20. Samoto N, Sugimoto K, Takaoka T, et al. Comparative results of conservative treatments for isolated anterior talofibular ligament (ATFL) injury and injury to both the ATFL and calcaneofibular ligament of the ankle as assessed by subtalar arthrography. J Orthop Sci. Jan 2007;12(1):49-54. [Medline].

  21. Kerkhoffs GM, Struijs PA, Marti RK, et al. Different functional treatment strategies for acute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev. 2002;3:CD002938. [Medline].

  22. Kaikkonen A, Kannus P, Järvinen M. Surgery versus functional treatment in ankle ligament tears. A prospective study. Clin Orthop Relat Res. May 1996;326:194-202. [Medline].

  23. Broström L. Sprained ankles. V. Treatment and prognosis in recent ligament ruptures. Acta Chir Scand. Nov 1966;132(5):537-50. [Medline].

  24. Caprio A, Oliva F, Treia F, Maffulli N. Reconstruction of the lateral ankle ligaments with allograft in patients with chronic ankle instability. Foot Ankle Clin. Sep 2006;11(3):597-605. [Medline].

  25. Eiff MP, Smith AT, Smith GE. Early mobilization versus immobilization in the treatment of lateral ankle sprains. Am J Sports Med. Jan-Feb 1994;22(1):83-8. [Medline].

  26. Ferkel RD, Chams RN. Chronic lateral instability: arthroscopic findings and long-term results. Foot Ankle Int. Jan 2007;28(1):24-31. [Medline].

  27. Freeman MA. Instability of the foot after injuries to the lateral ligament of the ankle. J Bone Joint Surg Br. Nov 1965;47(4):669-77. [Medline]. [Full Text].

  28. Fujii T, Kitaoka HB, Watanabe K, Luo ZP, An KN. Comparison of modified Broström and Evans procedures in simulated lateral ankle injury. Med Sci Sports Exerc. Jun 2006;38(6):1025-31. [Medline].

  29. Grønmark T, Johnsen O, Kogstad O. Rupture of the lateral ligaments of the ankle: a controlled clinical trial. Injury. Feb 1980;11(3):215-8. [Medline].

  30. Haller J, Bernt R, Seeger T, et al. MR-imaging of anterior tibiotalar impingement syndrome: agreement, sensitivity and specificity of MR-imaging and indirect MR-arthrography. Eur J Radiol. Jun 2006;58(3):450-60. [Medline].

  31. Jones AP, Sidhom S, Sefton G. A minimally invasive surgical technique for augmented reconstruction of the lateral ankle ligaments with woven polyester tape. J Foot Ankle Surg. Nov-Dec 2007;46(6):416-23. [Medline].

  32. Klein J, Schreckenberger C, Röddecker K, Tiling T. [Surgical or conservative treatment of recent rupture of the lateral ligament of the upper ankle joint. Randomized clinical study] [German]. Unfallchirurg. Apr 1988;91(4):154-60. [Medline].

  33. Korkala O, Rusanen M, Jokipii P, Kytömaa J, Avikainen V. A prospective study of the treatment of severe tears of the lateral ligament of the ankle. Int Orthop. 1987;11(1):13-7. [Medline].

  34. Lui TH. Endoscopic lateral calcaneal ostectomy for calcaneofibular impingement. Arch Orthop Trauma Surg. May 2007;127(4):265-7. [Medline].

  35. Møller-Larsen F, Wethelund JO, Jurik AG, de Carvalho A, Lucht U. Comparison of three different treatments for ruptured lateral ankle ligaments. Acta Orthop Scand. Oct 1988;59(5):564-6. [Medline].

  36. Niedermann B, Andersen A, Andersen SB, et al. Rupture of the lateral ligaments of the ankle: operation or plaster cast? A prospective study. Acta Orthop Scand. Oct 1981;52(5):579-87. [Medline].

  37. Prins JG. Diagnosis and treatment of injury to the lateral ligament of the ankle. A comparative clinical study. Acta Chir Scand Suppl. 1978;486:3-149. [Medline].

  38. Tokuda O, Awaya H, Taguchi K, Matsunga N. Kinematic MRI of the normal ankle ligaments using a specially designed passive positioning device. Foot Ankle Int. Nov 2006;27(11):935-42. [Medline].

  39. Trevino SG, Davis P, Hecht PJ. Management of acute and chronic lateral ligament injuries of the ankle. Orthop Clin North Am. Jan 1994;25(1):1-16. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

ankle ligament injury, ankle injury, ligament injury, lateral ankle injury, sprain, ankle sprain, lateral ankle sprain, CFL injury

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Bryan L Reuss, MD, Orthopedic Surgeon, Orlando Orthopedic Center
Disclosure: Nothing to disclose

Coauthor

Michael C Wadman, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, University of Nebraska College of Medicine
Michael C Wadman, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose

Randy Schwartzberg, MD, Director of Sports Medicine Education, Department of Orthopedic Surgery, Orlando Regional Healthcare System
Randy Schwartzberg, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Florida Medical Association, Southern Medical Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose

Medical Editor

Janos P Ertl, MD, Clinical Assistant Professor, Department of Orthopedic Surgery, University of California at Davis; Director of Amputee Clinic, Chief of Orthopedic Trauma, Kaiser Hospital
Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Hungarian Medical Association of America, Orthopaedic Trauma Association, and Sierra Sacramento Valley Medical Society
Disclosure: Nothing to disclose

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.