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). Most ankle sprains can be managed with a short period of immobilization followed by rehabilitation therapy, but chronic instability is best treated surgically.^[11]

For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center. Also, see eMedicineHealth's patient education articles Ankle Sprain and Sprains and Strains.

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).

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, 12, 13, 14]}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 10 º -45 º 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.^[15]

Clinical Presentation

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Media Gallery

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.
Anterior drawer test for the evaluation of anterior talofibular ligament sufficiency.
Aircast providing rigid lateral ankle support.

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Author

Bryan L Reuss, MD Orthopedic Surgeon, Orlando Orthopedic Center

Disclosure: Nothing to disclose.

Coauthor(s)

Michael C Wadman, MD Associate Professor, Department of Emergency Medicine, University of Nebraska College of Medicine

Michael C Wadman, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Randy Schwartzberg, MD Director of Sports Medicine Education, Department of Orthopedic Surgery, Orlando Regional Healthcare System

Randy Schwartzberg, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Florida Medical Association, Southern Medical Association, Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Janos P Ertl, MD Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital; Chief, Sports Medicine and Arthroscopy, Indiana University School of Medicine

Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.