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Calcaneofibular Ligament Injury
Article Last Updated: Jan 2, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Bryan L Reuss, MD, Orthopedic Surgeon, Orlando Orthopedic Center
Coauthor(s):
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
Editors: 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; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; 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; Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Author and Editor Disclosure
Synonyms and related keywords:
ankle ligament injury, ankle injury, ligament injury, lateral ankle injury, sprain, ankle sprain, lateral ankle sprain, CFL injury
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 10º-45º 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
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.
Ankle Fracture
Compartment Syndromes
Other Problems to Be Considered
Anterior talofibular ligament injury (See also the eMedicine article Talofibular Ligament Injury.)
Achilles tendon injury (See also the eMedicine articles Achilles Tendon Injuries and Tendonitis [in the Physical Medicine and Rehabilitation section], Achilles Tendon Pathology [in the Orthopedic Surgery section], and Achilles Tendon Rupture and Achilles Tendonitis [in the Sports Medicine section].)
Bifurcate ligament injury
Deep peroneal nerve injury
Dislocations, Ankle
Fifth metatarsal fracture (Jones fracture) (See also the eMedicine article Metatarsals, Fractures.)
Medial/deltoid ligament injury
Osteochondral fracture of talus (See also the eMedicine articles Osteochondral Lesions of the Talus [the Orthopedic Surgery section] and Talus, Fractures [in the Radiology section].)
Peroneal tendon dislocation/injury (See also the eMedicine article Peroneal Tendon Syndromes.)
Posterior talofibular ligament injury
Posterior tibial nerve injury
Superficial peroneal nerve injury
Sural nerve injury
Syndesmosis injury
Lab Studies
- Laboratory studies are generally not needed in the assessment of an uncomplicated ankle inversion or CFL injury.
Imaging Studies
- Obtain plain films of the injured ankle to detect any bony lesions.
- Due to the high rate of ankle radiography (10% of all ED radiographs) but the relatively low incidence of ankle fractures, the Ottawa ankle rules were developed in an attempt to reduce costly and unnecessary ankle films.14 These rules consist of several simple clinical findings to help physicians in their decision to use radiographic studies for ankle inversion injuries.
- In an inversion sprain, the Ottawa ankle rules determine that a radiographic series is only necessary if the patient has malleolar pain and either bone tenderness at the posterior edge or tip of the lateral malleolus or the inability to bear weight on the ankle.
- Although the Ottawa ankle rules describe specific clinical situations in which radiographs are necessary, most clinicians choose to perform radiographic studies any time there is significant swelling, ecchymosis, or tenderness over the bony landmarks.
- Most situations in which radiographs are necessary for ankle injuries require an anteroposterior (AP), lateral, and mortise view. These routine films must be examined for avulsion fractures, osteochondral injuries, and occult fractures.
- Stress radiographs, ankle arthrograms, and magnetic resonance images (MRIs) can be helpful in the evaluation of high-performance athletes and surgical candidates, but these studies are rarely useful in the ED.
- The talar tilt film is the stress film that is most beneficial for the diagnosis of a CFL injury/tear. An abnormal talar tilt angle indicates a probable CFL tear.
- In ankle arthrograms, the joint capsule is most likely ruptured if the ankle joint accepts greater than the maximum allowable joint fluid volume (approximately 10 mL). In addition, CFL rupture can lead to extra-articular dye leakage into the peroneal tendon sheath.15
- Many authors believe that MRI has surpassed all other imaging studies beyond the plain films due to its high level of visual technology and interpretive expertise.16 The major limitations to MRI use are cost, availability, and whether or not its findings lead to a change in the treatment course.
- Obtaining an MRI without ever obtaining a plain radiograph is neither efficient nor helpful.
Acute Phase
Rehabilitation Program
Physical Therapy
Rest, ice, compression, and elevation (RICE) are vital components to a fast recovery.12, 17 Nonsteroidal anti-inflammatory drugs (NSAIDs) are appropriate for the presence of pain and swelling.18 Crutches are also acceptable for a short time after the injury occurs until ambulation is pain free. A widely agreed upon finding is that grade I and grade II ligamentous sprains should be treated nonsurgically, and these injuries have good to excellent prognosis with such treatment.17, 19 Occasionally, in grade II sprains, a plaster splint may be necessary for 48-72 hours. Reevaluate the injury at this time, and a cast may be applied if the patient continues to have severe pain. Ultimately, it is accepted that grade I and grade II sprains are treated conservatively, whereas the decision to treat grade III lateral ankle sprains (often associated with a complete tear of the ATFL and CFL) is approached on an individual basis.20, 21, 22
Medical Issues/Complications
Proper assessment and treatment ensure a decreased complication rate for ankle injuries (see Complications, below).
Surgical Intervention
In grade III sprains, many authors support the decision that younger athletes and patients should be treated surgically, whereas older patients should be casted, with the option of a secondary repair at a later time. Other investigators have shown that functional treatment (early controlled movement) is superior to surgical treatment for grade I, II, and III lateral ankle sprains. If acute surgical treatment is chosen, the operation consists of reapproximating the torn ligament with the ankle in a neutral dorsiflexed and slightly everted position.
Consultations
In patients with grade III ankle sprains who present to the ED or a physician's office, a posterior plaster splint and an orthopedic evaluation within 1-2 weeks of the injury is warranted because surgery may be necessary.
Recovery Phase
Rehabilitation Program
Physical Therapy
Whether the immediate treatment is surgical or conservative, rehabilitation of the weakened and often unstable ankle joint is paramount. Once the initial period of immobilization is over, it is important for the patient to begin a thorough rehabilitation program that focuses on muscle strengthening and proprioception. Implementation of ROM and ankle-strengthening exercises when the patient is pain free is important. Because immobilization and early mobilization with ankle rehabilitation provide equal long-term stability to the ankle, early mobilization should be the goal when possible; this therapy allows for an earlier return to work and activities and is more comfortable to the patient. The maximum therapy benefit is gained with at least 10 weeks of rigorous rehabilitation. Dedication of the patient to his/her rehabilitation reduces the chance of further injury to the ankle joint.
Medical Issues/Complications
See Complications, below.
Maintenance Phase
Rehabilitation Program
Physical Therapy
Prevention is the foundation of a good maintenance phase therapy. Stretching of the ankle, continuous strengthening exercises, and ankle stabilizers are important in preventing further injury. The patient should also apply common sense when encountering situations that may place the ankle at risk for another inversion injury. If chronic instability occurs in day-to-day situations in which a brace is impractical, surgical reapproximation of the torn ligament or ligamentous reconstruction is indicated to increase stability.
Medical Issues/Complications
See Complications, below.
The goal of pharmacotherapy is to decrease the patient's pain and inflammation.
Drug Category: Nonsteroidal anti-inflammatory drugs
NSAIDs are most commonly used for the relief of mild to moderate pain. Although the effects of NSAIDs in the treatment of pain tend to be patient specific, ibuprofen is usually the DOC for initial therapy. Other options include naproxen and ketoprofen.
| Drug Name | Ibuprofen (Motrin, Advil, Ibuprin, Nuprin) |
|---|
| Description | DOC for the treatment of mild to moderate pain if no contraindications are present. Inhibits inflammatory reactions and pain, probably by decreasing the activity of the enzyme cyclooxygenase, which results in the inhibition of prostaglandin synthesis. |
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| Adult Dose | 400 mg PO q4-6h, 600 mg PO q6h, or 800 mg PO q8h, while symptoms persist; not to exceed 3.2 g/d |
|---|
| Pediatric Dose | <12 years: Not established
>12 years: Administer as in adults |
|---|
| Contraindications | Documented hypersensitivity; avoid in patients in whom aspirin, iodides, or other NSAIDs induce hypersensitivity because of potential cross-sensitivity to other NSAIDs; contraindicated in the presence of diagnosed peptic ulcer disease, recent GI bleed or perforation, renal insufficiency, and in those at high risk of bleeding |
|---|
| Interactions | Probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of loop diuretics when administered concurrently; PT duration may increase when administered concurrently with anticoagulants; instruct patients to watch for the signs and symptoms of bleeding; ibuprofen and other NSAIDs may increase serum lithium levels and the risk of methotrexate toxicity |
|---|
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
|
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| Precautions | Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function |
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| Drug Name | Naproxen (Naprosyn, Aleve) |
|---|
| Description | Used for the relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing the activity of the enzyme cyclooxygenase, which results in a decrease of prostaglandin synthesis. |
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| Adult Dose | 200-250 mg PO q6-8h or 500 PO mg bid; not to exceed 1.25 g/d; may increase to 1.5 g/d for limited periods |
|---|
| Pediatric Dose | <12 years: Not established
>12 years: Administer as in adults |
|---|
| Contraindications | Documented hypersensitivity; contraindicated in those with diagnosed peptic ulcer disease, recent GI bleed or perforation, renal insufficiency, and those at high risk of bleeding |
|---|
| Interactions | Probenecid and lithium may increase the concentrations and, possibly, the toxicity of NSAIDs; the effect of loop diuretics may decrease when administered concurrently; PT duration may increase when administered concurrently with anticoagulants; instruct patients to watch for the signs and symptoms of bleeding; concurrent administration with phenytoin may increase serum phenytoin levels, resulting in an increase in the pharmacologic and toxic effects of phenytoin |
|---|
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
|
|---|
| Precautions | Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases the risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely and usually return to normal in ongoing therapy; discontinuation may be necessary if leukopenia, granulocytopenia, or thrombocytopenia persists |
|---|
| Drug Name | Ketoprofen (Orudis, Actron, Oruvail) |
|---|
| Description | Initially administer small doses to patients with a small body size, elderly patients, and patients with renal or liver disease. Doses >75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe the patient for a response. |
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| Adult Dose | 25-50 mg PO q6-8h prn; not to exceed 300 mg/d |
|---|
| Pediatric Dose | <12 years: Not established
>12 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity |
|---|
| Interactions | Probenecid and lithium may increase the concentrations and, possibly, the toxicity of NSAIDs; the effect of loop diuretics may decrease when administered concurrently; PT duration may increase when administered concurrently with anticoagulants; concurrent administration with phenytoin may increase serum phenytoin levels, resulting in an increase in the pharmacologic and toxic effects of phenytoin. |
|---|
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
|
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| Precautions | Avoid use in patients diagnosed with GI disease, cardiovascular disease, renal or hepatic impairment, and patients receiving anticoagulants. |
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| Drug Name | Celecoxib (Celebrex) |
|---|
| Description | Primarily inhibits COX-2. COX-2 is considered an inducible isoenzyme and is induced by pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited, thus the incidence of GI toxicity, such as endoscopic peptic ulcers, bleeding ulcers, perforations, and obstructions, may be decreased when compared with nonselective NSAIDs. Seek the lowest dose for each patient.
Neutralizes circulating myelin antibodies through anti-idiotypic antibodies; downregulates proinflammatory cytokines, including INF-gamma; blocks Fc receptors on macrophages; suppresses inducer T and B cells and augments suppressor T cells; blocks complement cascade; promotes remyelination; may increase CSF IgG (10%).
Has a sulfonamide chain and is primarily dependent upon cytochrome P450 enzymes (a hepatic enzyme) for metabolism. |
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| Adult Dose | 200 mg/d PO qd; alternatively, 100 mg PO bid |
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| Pediatric Dose | Not established |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Coadministration with fluconazole may cause an increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations. |
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| Pregnancy | D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
|
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| Precautions | May cause fluid retention and peripheral edema; caution in patients with compromised cardiac function, hypertension, conditions predisposing to fluid retention; caution in the presence of severe heart failure and hyponatremia because circulatory hemodynamics may deteriorate; NSAIDs may mask the usual signs of infection; caution in the presence of existing controlled infections; evaluate therapy when symptoms or laboratory results suggest liver dysfunction |
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Return to Play
Return-to-play decisions are individually based. Usually, patients resume full sports activities only when jumping, turning, and running are pain free.
Complications
Important complications of ankle injuries include continued pain and chronic instability, which should be addressed. The first treatment option should be a course of conservative management, including increasing the strength and flexibility around the ankle and the use of an orthosis with ankle and subtalar support. If conservative treatment is unsuccessful or unsatisfactory, surgical repair of the ligament is the preferred treatment. In addition, if the patient continues to have pain over the long term, other causes of the patient's pain should be explored (ie, talar dome osteochondral lesions).
Prevention
Due to the high rate of reinjury in athletes with a previous ankle injury, prophylactic bracing is often employed. Semi-rigid orthoses may provide adequate external support, not only to protect ligament healing or reconstructions, but also to prevent future sprains.
Prognosis
The prognosis of CFL injuries is usually good with proper treatment, and 75-100% of patients achieve good or excellent outcomes.
Education
Patient education should occur through an injury awareness program that highlights the importance of proper footwear, strengthening techniques, bracing support, and proprioceptive training.
Medical/Legal Pitfalls
- Proper treatment with acceptable follow-up can eliminate long-term complications of ankle injuries, such as instability and recurring pain.
| Media file 1:
Surgical dissection/ankle procedure in a right ankle. The superior blue vessel loop (at 2 o'clock meridian) is around the anterior talofibular ligament, and the inferior blue vessel loop (at 6-o'clock meridian) is around the calcaneofibular ligament. The fibula is seen on the left side of surgical wound. |
 |  View Full Size Image | |
Media type: Photo
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| Media file 2:
Anterior drawer test for the evaluation of anterior talofibular ligament sufficiency. |
 | View Full Size Image | |
Media type: Photo
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Calcaneofibular Ligament Injury excerpt Article Last Updated: Jan 2, 2008
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