AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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.
• 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

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Other Problems to be Considered

Ankle dislocation (see also eMedicine's Joint Reduction, Ankle Dislocation [in the Clinical Procedures section])
Calcaneus bone injuries
Midfoot injuries

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Lab Studies

• Laboratory studies are not indicated in the workup of ligamentous injuries of the ankle.

Related Medscape topic:
Resource Center Pathology & Lab Medicine

Imaging Studies

• Indications for imaging studies in cases of suspected talofibular ligament injuries include the following:
• • Bony tenderness or deformity
  • Suspicion of a fracture or syndesmotic injury
  • Severe pain or swelling that makes the physical examination unreliable
  • Inability to walk
• Initial radiologic studies of the ankle should include the following:
• • An anteroposterior (AP) view with the ankle in slight adduction
  • A true lateral view
  • A mortise view (45° oblique view with the ankle in dorsiflexion)
  • Consider stress views of the ankle.
  • If a syndesmotic injury is suspected, then AP and lateral views of the tibia and fibula should also be obtained to rule out associated fibular fractures.
• Magnetic resonance imaging (MRI) may be useful in evaluating the soft-tissue anatomy of the ankle, such as ligaments and tendons. This imaging modality is not typically an initial test performed, but MRI may be useful in the patient who is not healing, in whom a stress fracture is suspected, or in chronic ankle pain and instability.

Related Medscape topics:
Resource Center Joint Disorders
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
Specialty Site Radiology

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Acute Phase

Rehabilitation Program

Physical Therapy

Initial treatment of all grades of lateral ankle sprains consists of rest, ice, compression, and elevation (RICE), as well as nonsteroidal anti-inflammatory drugs (NSAIDs). Ice should be applied to the injured ankle for approximately 20 minutes, 3-4 times per day. Compressive dressings should be used to control swelling. Weight bearing should be encouraged as soon as it is tolerated. With grade III injuries, an ankle brace should be worn at all times till the patient can ambulate pain free. Ankle braces can be used for support in all ankle sprains and may help promote earlier ambulation. Studies have found an air stirrup brace and ACE wrap are beneficial in grade 1 ankle sprains and may help in grade II and III sprains as well.

The early phase of rehabilitation is begun approximately 48 hours postinjury. Icing is continued and range of motion exercises are initiated. Writing the alphabet with the great toe moves the ankle through full range of motion in all planes. Stationary biking and stretching of the Achilles tendon are also beneficial.

As strength and mobility improve, isometric exercises for ankle dorsiflexion, plantar flexion, inversion, and eversion are initiated. The isometric exercises are followed by resistance exercises (initially using a Thera-Band strap) and then heel and toe raises. Agility training also aids in returning the athlete to sports. Proprioceptive and balance training are also extremely important to help the patient heal fully, especially in jumping athletes. Proprioceptive training should be incorporated into all rehabilitation protocols.

In grade III ankle sprains, some studies have shown that early mobilization and rehabilitation may provide earlier functional recovery relative to surgery, and there is general agreement to try a 6-week period of conservative management, including early, controlled mobilization and rehabilitation before considering surgery. 

Also, no difference is found in long-term outcome when comparing early surgical repair with delayed surgical repair following failed conservative therapy. Therefore, there is no indication for routine early surgical repair.

Related eMedicine topics:
Achilles Tendon Pathology
Achilles Tendon Rupture
Achilles Tendonitis
Toxicity, Nonsteroidal Anti-inflammatory Agents

Related Medscape topics:
Resource Center Adverse Drug Events Reporting
Specialty Site Surgery

Surgical Intervention

Primary repair of acute lateral ligament tears is rarely indicated. Open repair seems to offer no advantage over closed management at the time of the initial injury. Delayed repair may be necessary in patients with chronic mechanical instability on clinical examination and functional instability; however, surgical intervention in these cases should only be considered after an aggressive rehabilitation program has been unsuccessful.

Consultations

• An emergent consultation is rarely required.
• Consultation with an orthopedic surgeon should be obtained for patients with unstable ankles, dislocations, or associated fractures.

Recovery Phase

Rehabilitation Program

Physical Therapy

When the early phase rehabilitation goals of decreased swelling, full weight bearing, and no tenderness to palpation are met, more aggressive strengthening and proprioceptive training are added. Increased stretching of the Achilles tendon, as well as the gastrocnemius and soleus muscles, is performed using an incline board. Thera-Band exercises are continued for strengthening. Exercises such as one-leg stands and wobble board training are added for proprioception. This training continues until the ankle is at 80-90% of full strength and there are no deficits in proprioception. When these goals are met, the patient may be discharged from therapy.

Surgical Intervention

Maximum benefit from conservative therapy is reached after approximately 10 weeks of active rehabilitation. At this time, 20% of athletes continue to have symptoms secondary to either a functional or mechanical instability. If the patient has reached his or her maximal benefit from functional rehabilitation and has a persistent deficit, then surgical reconstruction should be considered.

Maintenance Phase

Rehabilitation Program

Physical Therapy

The patient should be independent with a home exercise program with sport-specific activities and gradually return to play when the functional goals are met. The physician and/or physical therapist may recommend taping or bracing the ankle upon returning to activity. Taping or bracing a previously injured ankle during athletic activity has been shown to reduce the incidence of recurrent injury.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

The goal of medical therapy is to reduce pain during the acute phase of recovery.

Related eMedicine topics:
Toxicity, Acetaminophen
Toxicity, Narcotics
Toxicity, Nonsteroidal Anti-inflammatory Agents

Related Medscape topics:
Resource Center Adverse Drug Events Reporting
Resource Center Opioids: A Guide to State Opioid Prescribing Policies
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches

Drug Category: Nonsteroidal Anti-inflammatory Drugs

NSAIDs have analgesic, anti-inflammatory, and antipyretic activities, which make these ideal agents for treating ankle injuries. The mechanism of action of NSAIDs is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation and various cell membrane functions. Many NSAIDs are currently on the market. In general, the mechanism of action of these agents is the same. No evidence exists that one NSAID is more efficacious than another; however, individual response may differ.

Acetaminophen, with or without an opiate analgesic, may be added to NSAID therapy (or used as a substitute).

Drug Category: Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who have sustained trauma or who have sustained injuries.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Return to Play

Athletes may return to sports following a talofibular ligament injury when they are able to run and pivot without pain while the ankle is braced. Bracing and taping of the injured ankle is continued during athletic activities for 6 months.

Related Medscape topic:
Resource Center Exercise and Sports Medicine

Complications

Up to 20% of patients with an acute inversion injury develop chronic functional instability. Electromyography (EMG) has demonstrated prolonged reaction times of the peroneal muscle in this group of patients. Strengthening and proprioception exercises can lead to improvement. Patients whose injury do not respond and have continued mechanical laxity and functional instability may be candidates for lateral ligament reconstruction.

Prevention

Completion of an adequate rehabilitation program, as well as functional bracing or taping for 6 months following the injury, minimizes the chance of recurrent injury.

Prognosis

Eighty percent of patients with lateral ankle injuries make a full recovery following conservative rehabilitation. Up to 20% demonstrate chronic ankle instability, requiring prolonged therapy and possibly surgical repair.

Education

To help prevent recurrent injury, patients should be instructed regarding the proper techniques for ankle taping and bracing. Ankle-strengthening and proprioception exercises should also be an important part of rehabilitation, and the patient should be instructed in an appropriate home exercise program.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical/Legal Pitfalls

• Failure to diagnose a fracture
• Misinterpretation of radiograph(s)
• Failure to recognize an unstable ankle
• Failure to refer significant injuries

Related Medscape topics:
Resource Center Fracture
Resource Center Medical Malpractice and Legal Issues
Resource Center Trauma
Specialty Site Orthopaedics
Specialty Site Radiology

ACKNOWLEDGMENTS

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Michael Taylor, MD, to the development and writing of this article.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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• Brukner P, Khan KM. Acute ankle injuries. Clinical Sports Medicine. 3^rd ed. San Francisco, Calif: McGraw-Hill; 2006.
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• Garrett WE Jr. Trauma: soft tissue. In: Fitzgerald RH Jr, ed. Orthopaedic Knowledge Update 2. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1987:89-96.
• 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].
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• Jayanthi N. Lower leg and ankle. In: McKeag DB, Moeller J, eds. ACSM's Primary Care Sports Medicine. 2^nd ed. Philadelphia, Pa: Lippincott, Williams and Wilkins; 2007.
• Kelikian H, Kelikian AS. Disruption of the fibular collateral ligament. In: Kelikian H, Kelikian AS, eds. Disorders of the Ankle. Philadelphia, Pa: WB Saunders; 1985:437-90.
• Kerkhoffs GM, Handoll HH, de Bie R, Rowe BH, Struijs PA. Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. Cochrane Database Syst Rev. Apr 18 2007;CD000380. [Medline].
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• Mann RA. Ankle and foot: reconstruction. In: Fitzgerald RH Jr, ed. Orthopaedic Knowledge Update 2. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1987:455-63.
• Mellion MB, Walsh WM, Shelton GL, eds. The Team Physician's Handbook. 3^rd ed. Philadelphia, Pa: Hanley and Belfus; 2002.
• Rubin A. Ankle ligament sprains. In: Sallis RE, Massimino F, eds. American College of Sports Medicine's Essentials of Sports Medicine. New York, NY: Churchill Livingstone; 1996:450-2.
• 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].
• Schepsis AA. Ligamentous injuries of the ankle. In: Yablon IG, Segal D, Leach RE, eds. Ankle Injuries. New York, NY: Churchill Livingstone; 1983:193-208.
• Scranton PE. Ankle and foot: trauma. In: Fitzgerald RH Jr, ed. Orthopaedic Knowledge Update 2. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1987:447-54.
• Simons S. Rehabilitation of ankle injuries. In: Sallis RE, Massimino F, eds. Simons S. Rehabilitation of ankle injuries. New York, NY: Churchill Livingstone; 1996:458-61.
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Article Last Updated: Aug 19, 2008