Anterior talofibular ligament injury
Citation, DOI, disclosures and article data
At the time the article was created Yuranga Weerakkody had no recorded disclosures.View Yuranga Weerakkody's current disclosures
At the time the article was last revised Yahya Baba had no financial relationships to ineligible companies to disclose.View Yahya Baba's current disclosures
Anterior talofibular ligament (ATFL) injury is the most common of the ligament injuries that can occur as part of the lateral ligament complex injuries 2. The injuries can comprise either soft tissue tears, avulsion fractures or both.
On this page:
Anterior talofibular ligament injuries typically occur with an inversion injury to the ankle, either with or without plantar flexion. Approximately two-thirds of ankle sprains tend to be isolated injuries to the anterior talofibular ligament (ATFL), the weakest ligament in the lateral collateral complex of the ankle. There is general agreement that avulsion is more common at the fibular than at the talar end of the ligament 2.
AMA classification 8,9:
- grade I: ligament stretch
- partial tear
- partial loss of movement
- mild to moderate joint instability
- complete tear
- inability to bear weight
- significant joint instability
Many orthopedists favor a functional approach based on clinical examination:
grade I: stable injury
- provocative maneuvers do not elicit increased upper ankle joint laxity
- no ligament in the lateral complex is completely ruptured
grade II: unstable
- ruptured anterior talofibular ligament
- increased upper ankle joint laxity
grade III: unstable
- ruptured calcaneofibular ligament (CFL)
- increased upper ankle joint laxity
There are other grading systems, of course, such as the anatomic classification or grading by clinical presentation symptoms 9.
Many show an associated avulsion fracture at either the fibular end or, less commonly, the talar end.
May show ancillary features such as an ankle joint effusion and/or overlying lateral malleolar soft tissue swelling.
Has been shown to have high sensitivity and specificity rates for chronic anterior talofibular ligament tears 6.
Both the anterior and posterior talofibular ligaments are usually seen on a single axial image obtained slightly distal to the tibiofibular ligaments 4.
MRI may show detachment, discontinuity, thickening, thinning, contour irregularity of the ligament, a bright rim sign 5 or an associated bony avulsion. Heterogeneity with increased intraligamentous signal intensity on fat-suppressed T2-weighted or intermediate-weighted images is indicative of intrasubstance edema or hemorrhage.
- fluid within the joint serves to highlight the anterior talofibular ligament on T2-weighted images
- the ligament appears as a thin, straight, low signal intensity band extending from the talus to the fibular malleolus
- a bright rim sign (cortical defect with a bright dot-like or curvilinear high signal intensity lesion) may be seen on T2 weighted imaging
On MRI consider:
anterolateral ankle impingement 4
- repetitive synovial inflammation secondary to chronic lateral ankle instability produces a soft-tissue “mass” consisting of hypertrophic synovial tissue and fibrosis within the lateral gutter
- 1. 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. 2007;35(7):1144-52. doi:10.1177/0363546507299531 - Pubmed
- 2. Kumai T, Takakura Y, Rufai A, Milz S, Benjamin M. The Functional Anatomy of the Human Anterior Talofibular Ligament in Relation to Ankle Sprains. J Anat. 2002;200(5):457-65. doi:10.1046/j.1469-7580.2002.00050.x - Pubmed
- 3. Noh J, Yang B, Yi S, Lee S, Song C. Outcome of the Functional Treatment of First-Time Ankle Inversion Injury. J Orthop Sci. 2010;15(4):524-30. doi:10.1007/s00776-010-1481-1 - Pubmed
- 4. Rosenberg Z, Beltran J, Bencardino J. From the RSNA Refresher Courses. Radiological Society of North America. MR Imaging of the Ankle and Foot. Radiographics. 2000;20 Spec No(suppl_1):S153-79. doi:10.1148/radiographics.20.suppl_1.g00oc26s153 - Pubmed
- 5. Lee M, Cha J, Lee Y et al. The Bright Rim Sign on MRI for Anterior Talofibular Ligament Injury with Arthroscopic Correlation. AJR Am J Roentgenol. 2012;198(4):885-90. doi:10.2214/AJR.11.6868 - Pubmed
- 6. Hua Y, Yang Y, Chen S, Cai Y. Ultrasound Examination for the Diagnosis of Chronic Anterior Talofibular Ligament Injury. Acta Radiol. 2012;53(10):1142-5. doi:10.1258/ar.2012.120171 - Pubmed
- 7. Oae K, Takao M, Uchio Y, Ochi M. Evaluation of Anterior Talofibular Ligament Injury with Stress Radiography, Ultrasonography and MR Imaging. Skeletal Radiol. 2010;39(1):41-7. doi:10.1007/s00256-009-0767-x - Pubmed
- 8. Balduini F, Vegso J, Torg J, Torg E. Management and Rehabilitation of Ligamentous Injuries to the Ankle. Sports Med. 1987;4(5):364-80. doi:10.2165/00007256-198704050-00004 - Pubmed
- 9. Mark E. Easley, Sam W. Wiesel. Operative Techniques in Foot and Ankle Surgery. (2011) ISBN: 9781608319046 - Google Books
- 10. Cheng Y, Cai Y, Wang Y. Value of Ultrasonography for Detecting Chronic Injury of the Lateral Ligaments of the Ankle Joint Compared with Ultrasonography Findings. BJR. 2014;87(1033):20130406. doi:10.1259/bjr.20130406 - Pubmed