eMedicine Specialties > Sports Medicine > Foot and Ankle
Talofibular Ligament Injury
Updated: Aug 19, 2008
Introduction
Background
Ligamentous injuries of the ankle are common among athletes. Inversion injuries of the ankle account for 40% of all athletic injuries. The anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) are sequentially the most commonly injured ligaments when a plantar-flexed foot is forcefully inverted. The posterior talofibular ligament (PTFL) is rarely injured, except in association with a complete dislocation of the talus.
Ligamentous injuries of the ankle are classified into the following 3 categories, depending on the extent of damage to the ligaments:
- Grade I is an injury without macroscopic tears. No mechanical instability is noted. Pain and tenderness is minimal.
- Grade II is a partial tear. Moderate pain and tenderness is present. Mild to moderate joint instability may be present.
- Grade III is a complete tear. Severe pain and tenderness, inability to bear weight, and significant joint instability are noted.
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.
Related eMedicine topics:
Ankle Impingement Syndrome
Ankle Injury, Soft Tissue
Ankle Sprain
Ankle Taping and Bracing
Related Medscape topics
Resource Center Exercise and Sports Medicine
Resource Center Joint Disorders
Specialty Site Orthopaedics
Frequency
United States
Approximately 3600 cases of talofibular ligament injury per 100,000 people are reported per year.
Functional Anatomy
The lateral articular capsule of the ankle can be divided into anterior and posterior segments. The anterior segment attaches proximally to the anterior portion of the distal tibia superior to the articular surface and to the border of the articular surface of the medial malleolus. The posterior segment attaches distally to the talus just posterior to its superior articular facet and attaches laterally to the depression in the medial surface of the lateral malleolus.
The ATFL is intracapsular and attaches anteriorly to the anterior border of the distal fibula and laterally to the neck of the talus. The PTFL attaches posteriorly to the digital fossa of the fibula and laterally to the lateral tubercle on the posterior portion of the talus.
Sport-Specific Biomechanics
The talofibular ligaments along with the CFL are components of the lateral ligament complex. This complex becomes stressed when the ankle is inverted and plantar flexed. Supination of the foot in neutral flexion usually results in injury of the CFL. Supination and adduction injuries tear both the ATFL and the CFL.
The PTFL is the strongest of the lateral ligaments, and extreme inversion with plantar flexion is required to place the PTFL under stress; as a result, the PTFL is less commonly injured. Transient subluxation or dislocation of the talus from the tibial mortise usually results in injury of all 3 lateral ligaments. Prevention of anterior displacement of the talus is primarily a function of the ATFL. Little additional motion occurs when the CFL also is damaged. Instability to inversion is greater when both the CFL and the ATFL are injured than when either ligament is injured alone.
Clinical
History
The history portion of the examination for a suspected talofibular ligament injury should include the following:
- Mechanism of injury
- Time of injury
- Concurrent injuries
- Position of the body at the time of injury
- Rotational component to injury
- Ability or inability to bear weight immediately after the injury
- Time of onset of pain and swelling (immediate or delayed)
- Whether the patient heard or felt a popping sound or sensation at the time of the injury
- Information regarding any previous ankle injuries
Physical
The physical examination for a suspected talofibular injury should include the following:
- Inspect the ankles.
- Both ankles should be completely uncovered so the injured side can be compared with the uninjured side.
- Note any swelling, ecchymosis, lacerations, abrasions, or deformities.
- Palpate the injured ankle, noting any tenderness or crepitus.
- Test the range of motion. Patients with ligamentous injuries, especially to the ATFL, will have limited and painful inversion of their ankle.
- Perform a neurovascular examination of the foot distal to the injury. Document the findings.
- Assess the stability of the ankle joint.
- The anterior drawer test assesses the stability of the lateral ligaments.
- To perform this test, the foot is placed in slight inversion and 20° of plantar flexion. The heel is grasped firmly and drawn forward by the examiner, while the tibia is stabilized by the examiner's other hand.
- A positive sign occurs when the talus moves forward on the tibia.
- The injured side should also be tested for maximal inversion compared with the uninjured side.
- If the ATFL is torn, forward motion is detected on performing the anterior drawer test.
- If the ATFL and the CFL are torn, abnormal inversion is elicited.
- Talar tilt test: Assess the stability of the calcaneofibular ligament.
- Grade I sprains are partial tears of the ligaments and are stable to stress testing.
- Grade II sprains have a mildly increased anterior drawer test and are stable to inversion.
- Grade III sprains are unstable to both the anterior drawer test and the talar tilt test. Instability with these tests indicates a complete tear of the ATFL and at least a partial tear of the CFL.
- The anterior drawer test assesses the stability of the lateral ligaments.
- Perform a neurologic exam.
- This should include testing the patient's balance. Have them stand on their uninjured foot, initially with their eyes open; then, have them close their eyes. Then have the patient do this with the injured foot and compare. Ankle injuries will often disrupt the nerves, causing the patient to have poor balance.
Related Medscape topics:
Resource Center Trauma
Resource Center Vascular Surgery
Specialty Site Neurology & Neurosurgery
Specialty Site Orthopaedics
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Further Reading
Keywords
talofibular ligament injury, ankle sprain, inversion ankle injury, lateral ligament ankle sprain, anterior talofibular ligament injury, ATFL sprain, posterior talofibular ligament injury, PTFL sprain, recurrent ankle sprain
