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
Differential Diagnoses
| Achilles Tendon Rupture | Calcaneofibular Ligament Injury |
| Achilles Tendonitis | Peroneal Tendon Syndromes |
| Ankle Fracture | |
| Ankle Impingement Syndrome | |
| Ankle Sprain |
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
Laboratory 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.
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Resource Center Joint Disorders
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
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Specialty Site Radiology
Treatment
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.
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Achilles Tendon Pathology
Achilles Tendon Rupture
Achilles Tendonitis
Toxicity, Nonsteroidal Anti-inflammatory Agents
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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
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
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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
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).
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Dosing
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
Interactions
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Contraindications
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Precautions
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
Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Anaprox, Naprelan, Naprosyn)
For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Dosing
Adult
500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Interactions
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Contraindications
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Precautions
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, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug.
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.
Acetaminophen (Tempra, Tylenol, Feverall)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Dosing
Adult
325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h
Interactions
Rifampin can reduce the analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity.
Contraindications
Documented hypersensitivity; known G-6-P deficiency
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity is possible in persons with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products, and combined use with these products may result in cumulative APAP doses that exceed the recommended maximum dose.
Hydrocodone and acetaminophen (Vicodin, Lorcet-HD, Lortab)
Drug combination indicated for moderate to severe pain.
Dosing
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24 h
Interactions
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants.
Contraindications
Documented hypersensitivity; high altitude cerebral edema (HACE) or elevated intracranial pressure (ICP)
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
The tablets contain metabisulfite, which may cause hypersensitivity; caution in patients who are dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction
Acetaminophen and codeine (Tylenol with codeine)
Indicated for the treatment of mild to moderate pain.
Dosing
Adult
30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab q4h; not to exceed 4 g/d of acetaminophen
Pediatric
0.5-1 mg/kg/dose based on codeine PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen
Interactions
Toxicity increases with CNS depressants or tricyclic antidepressants
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients who are dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction
Follow-up
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
Medicolegal 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
References
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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
Contributor Information and Disclosures
Author
Marc A Molis, MD, Medical Director of Sports Medicine, Sports Medicine of Iowa
Marc A Molis, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Association, American Medical Society for Sports Medicine, and Iowa Medical Society
Disclosure: Nothing to disclose.
Coauthor(s)
David F Martin, MD, Program Director, Associate Professor, Department of Orthopaedic Surgery, Wake Forest University School of Medicine
David F Martin, MD is a member of the following medical societies: American College of Sports Medicine, American College of Surgeons, American Medical Association, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, International Society on Thrombosis and Haemostasis, Southern Medical Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.
Medical Editor
Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa, and Wilderness Medical Society
Disclosure: Nothing to disclose.
Pharmacy Editor
Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.
Managing Editor
Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood
Disclosure: Nothing to disclose.
CME Editor
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
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.
Chief Editor
Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.