Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Updated: Apr 20 2022

Ankle Ligaments

Images
https://upload.orthobullets.com/topic/7005/images/key image_moved.jpg
https://upload.orthobullets.com/topic/7005/images/fibular notch_moved.jpg
https://upload.orthobullets.com/topic/7005/images/posterior-inferior_tibiofibular_ligament_(pitfl).jpg
https://upload.orthobullets.com/topic/7005/images/er stress test.jpg
https://upload.orthobullets.com/topic/7005/images/squeeze test.jpg
https://upload.orthobullets.com/topic/7005/images/awesome_ankle.jpg
  • Ankle Joint Osteology
    • Ankle Joint
      • consists of
        • tibial plafond
        • medial malleolus
        • lateral malleolus
        • talus
      • motion
        • main motion
          • plantar flexion
          • dorsiflexion
        • secondary motions
          • inversion/eversion
          • rotation
    • Distal tibiofibular joint
      • consists of
        • distal fibula
        • incisura fibularis
          • concave surface of distal lateral tibia
      • motion
        • fibular rotates within incisura during gait
        • mortise widens when ankle goes from plantar to dorsiflexion
        • syndesmosis screws limit external rotation
    • Joint reaction force
      • ankle joint
        • 5 times body weight with walking on level surfaces
  • Ankle Ligament Introduction
    • Primary ligaments of ankle include (see below for details)
      • medial
        • Deltoid ligament
        • Calcaneonavicular ligament (Spring Ligament)
      • lateral
        • Syndesmosis (includes AITFL, PITFL, TTFL, IOL, ITL)
        • Anterior talofibular ligament (ATFL)
        • Posterior talofibular ligament (PTFL)
        • Calcaneal fibular ligament (CFL)
        • Lateral talocalcaneal ligament (LTCL)
  • Syndesmosis
    • Function
      • responsible for integrity of ankle mortise
    • Anatomy
      • Syndesmosis components
        • Anterior-inferior tibiofibular ligament (AITFL)
        • Posterior-inferior tibiofibular ligament (PITFL)
          • deep portion of this ligament sometimes reffered to as the inferior transverse ligament
        • Transverse tibiofibular ligament(TTFL)
        • Interosseous ligament (IOL)
    • Physical Exam
      • test to identify a syndesmosis injury include
        • external rotation test
        • squeeze test
    • Imaging
      • AP and mortise ankle radiographs
        • used to evaluate the tibiofibular clear space and tibiofibular overlap
          • tibiofibular clear space should be < 5 mm
          • tibiofibular overlap for AP view > 10 mm
        • weight bearing mortise view is most accurate radiograph for diagnosis
        • CT scan is most accurate for assessment but true normals have not been validated and comparison to the uninjured side are helpful
    • Clinical conditions
      • high ankle sprain & syndesmosis injury
      • ankle fracture
  • Anterior Talofibular Ligament (ATFL)
    • Function
      • primary restraint to inversion in plantar flexion
      • resists anterolateral translation of talus in the mortise
      • weakest of the lateral ligaments
    • Anatomy
      • extends from the anteroinferior border of the fibula to the neck of the talus
        • origin is 10mm proximal to tip of fibula
        • inserts directly distal to articular cartilage of the talus (18mm distal to joint line)
        • runs 45°-90° to longitudinal axis of the tibia
    • Physical exam
      • anterior drawer in 20° of plantar flexion
        • test competency by anterior drawer in 20° of plantar flexion and compare to uninjured side
        • forward shift of more than 8 mm on a lateral radiograph is considered diagnostic for an ATFL tear
    • Imaging
      • stress radiographs
        • more accurate in chronic injuries
      • MRI
        • can diagnose injury
      • arthroscopic findings
        • can confirm MRI imaging
      • ultrasound
        • more accurate than radiographs
    • Clinical Conditions
      • low ankle sprains
  • Posterior Talofibular Ligament (PTFL)
    • Function
      • strongest of the lateral ligaments
      • plays only a supplementary role in ankle stability when the lateral ligament complex is intact
      • under greatest strain in ankle dorsiflexion and acts to limit posterior talar displacementwithin the mortise as well as talar external rotation
      • if ATFL and CFL are incompetent, then
        • short fibers of PTFL restrict internal and external rotation, talar tilt, and dorsiflexion;
        • long fibres inhibit only external rotation, talar tilt, and dorsiflexion
    • Anatomy
      • origin is posterior border of fibula
      • inserts on posterolateral tubercle of the talus
      • runs perpendicular to longitudinal axis of the tibia
    • Physical exam
      • no specific clinical test for isolated PTFL injury
    • Imaging
      • MRI can indicate structural injury, rarely indicated
    • Clinical Conditions
      • rarely injured, except in association with a complete dislocation of the talus
  • Calcaneal Fibular Ligament (CFL)
    • Function
      • primary restrain to inversion in neutral or dorsiflexed position
      • restrains subtalar inversion, thereby limiting talar tilt within mortise
    • Anatomy
      • origin is anterior border of fibula, 9mm proximal to distal tip
      • inserts on calcaneus 13mm distal to subtalar joint and deep to peroneal tendon sheaths
    • Physical exam
      • inversion (supination) test
        • perform with ankle in slight dorsiflexion
      • talar tilt test
        • angle formed by tibial plafond & talar dome is measured as inversion force is applied to hindfoot (<5 deg is normal for most ankles)
        • useful for evaluation of combined injury of both ATFL and CFL ligament
    • Imaging
      • talar tilt radiographs
      • ankle arthrograms
        • CFL rupture can lead to extra-articular dye leakage into the peroneal tendon sheath
      • MRI
    • Clinical Conditions
      • injury occurs with ankle inversion with the foot in the neutral position
      • low ankle sprain
  • Lateral Talocalcaneal Ligament (LTCL)
    • Function
      • thought to stabilize the talocalcaneal joint
    • Anatomy
      • short narrow ligamentous band that connects the lateral process of the talus to the lateral surface of the calcaneus
      • located anterior and medial to calcaneofibular ligament
    • Physical Exam
      • no specific test for this ligament
    • Imaging
      • LTCL ligament (red arrows) identified distinctly from the calcaneofibular ligament
      • relationship of the calcaneofibular ligament (green arrow) and the LTCL (red arrow)
    • Clinical conditions
      • often injured in conjunction with ATFL injuries
      • low ankle sprain
  • Deltoid Ligament
    • Function
      • primary restraint to valgus tilting of the talus
      • both the superficial and deep layers individually resist eversion of the hindfoot
      • stabilizes ankle against plantar flexion, external rotation and pronation
    • Anatomy
      • superficial layer
        • crosses both ankle and subtalar joints
        • originates from anterior colliculus and fans out to insert into the navicular neck of the talus, sustenaculum tali, and posteromedial talar tubercle
        • the tibiocalcaneal (sustenaculum tali) portion is the strongest component in the superficial layer and resists calcaneal eversion
      • deep layer
        • crosses only ankle joint
        • functions as the primary stabilizer of the medial ankle
          • prevents lateral displacement and external rotation of the talus
        • originates from inferior & posterior aspects of medial malleolus and inserts on medial and posteromedial aspects of the talus
    • Physical exam
      • eversion test
        • with ankle in neutral, evaluates superficial layer
        • external rotation stress test evaluates syndesmosis and deep layer
    • Imaging
      • radiographs
        • mortise radiograph with medial clear space widening can suggest injury
        • gravity stress view can identify medial clear space widening
      • MRI
        • normal deltoid ligament
        • ruptured deltoid ligament
    • Clinical conditions
      • ankle fracture
        • injury occurs with pronation (eversion) trauma leading to forced external rotation and abduction of ankle
        • may occur with fracture of the medial malleolus
      • high ankle sprain & syndesmosis injury
  • Calcaneonavicular Ligament (Spring Ligament)
    • Function
      • static stabilizer of the medial longitudinal arch and head of the talus
    • Anatomy
      • attaches from the sustentaculum tali to the inferior aspect of the navicular
      • consists of the superomedial and inferior calcaneonavicular ligaments 
        • superomedial ligament is larger and the most important stabilizer to medial longitudinal arch
    • Physical Exam
      • flattening of medial longitudinal arch
      • suspect injury in associated posterior tibial tendon pathology
    • Imaging
      • MRI
        • can diagnose tear
          • (green arrow, intact ligament; red arrow, disrupted ligament)
    • Clinical conditions
      • posterior tibial tendon dysfunction
        • calcaneonavicular ligament (spring ligament)
          • most likely to be attenuated in type II flatfoot deformity secondary to posterior tibial tendon dysfuction
      • acute spring ligament tear
        • acute trauma can occur with forceful landing on flat foot
        • the tibialis posterior tendon is usually normal
Card
1 of 1
Question
1 of 9
Private Note

Attach Treatment Poll
Treatment poll is required to gain more useful feedback from members.
Please enter Question Text
Please enter at least 2 unique options
Please enter at least 2 unique options
Please enter at least 2 unique options