Talofibular Ligament Injury

Updated: May 12, 2023
  • Author: Marc A Molis, MD, FAAFP; Chief Editor: Sherwin SW Ho, MD  more...
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Practice Essentials

Ligamentous injuries of the ankle are common among athletes. [1, 2]  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. [3, 4, 5]

Ligamentous injuries of the ankle are classified into the following 3 categories, depending on the extent of damage to the ligaments [6, 7, 8, 9, 10] :

  • 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.


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.

See Workup for more detail.


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). As strength and mobility improve, isometric exercises for ankle dorsiflexion, plantar flexion, inversion, and eversion are initiated.

See Treatment and Medication for more detail.

Related Medscape Reference topics:

Ankle Impingement Syndrome

Ankle Sprain

Ankle Taping and Bracing

Related Medscape resources

Resource Center  Exercise and Sports Medicine

Resource Center  Joint Disorders

Specialty Site  Orthopaedics



United States statistics

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. [3, 4, 5]

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. [11] 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. [11] 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.



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.


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.


Patient 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.

For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center.