ankle ligaments

ankle ligaments

ligaments crossing medial and lateral aspects of the ankle joint, permitting ankle dorsiflexion/plantarflexion, but not restricting subtalar joint inversion/eversion (Table 1 and Figure 1)
  • lateral collateral ligament complex of the ankle see anterior talofibular; calcaneofibular ligament; posterior talofibular ligaments

  • medial collateral ligament of the ankle: see deltoid ligament (Table 2)

  • ankle sprain stress-related tension injury to an ankle joint collateral ligament; the cortical bone underlying the collateral ligament insertion may be avulsed by a severe sprain (Table 3 and Table 4)

  • lateral ankle sprain a relatively common injury, caused by sudden foot inversion during sports, or when slipping, e.g. off the edge of a kerb; the anterior talofibular ligament is the most susceptible to inversion injury, and the posterior talofibular ligament the least

  • medial ankle sprain/deltoid ligament sprain a much rarer ankle injury, but may be induced by sudden foot eversion

Table 1: Ligaments that support the medial longitudinal arch (MLA)
Anatomical featureLocation
Long plantar ligament (LPL)Plantar aspect of calcaneum (just anterior to calcaneal tuberosity); insert
• Deep portion: into plantar aspect of cuboid
• Superficial portion: base of 2-5 metatarsals
Short plantar ligament (SPL) (plantar calcaneocuboid ligament)Anterior tubercle of calcaneum; inserts into adjacent plantar surface of cuboid
Spring ligament (SL) (plantar calcaneonavicular ligament)Anterior margin of sustentaculum tali; inserts into plantar aspect of navicular
Interosseous ligament (IL) (talocalcaneal ligament)Within sinus tarsi; connects non-articular parts of subtalar joint
Deltoid ligament (DL) (medial collateral ankle ligament)Fans out from anterior, medial and posterior aspects of medial malleolus; insets into navicular, spring ligament, sustentaculum tali and adjacent talus
Plantar aponeurosis (PA) (deep plantar fascia)From calcaneal tuberosity to midfoot, where it splits into five bands
Each band attaches distally to plantar aspect of transverse intermetatarsal ligament (overlying and linking plantar aspects of all metatarsophalangeal joints) and plantar surface of respective proximal phalanx
Figure 1: Lateral collateral ligaments of the ankle. PTFL, posterior talofibular ligament; CFL, calcaneofibular ligament; ATFL, anterior talofibular ligament.
Table 2: Ligaments that support the medial longitudinal arch (MLA)
Anatomical featureLocation
Long plantar ligament (LPL)Plantar aspect of calcaneum (just anterior to calcaneal tuberosity); insert
• Deep portion: into plantar aspect of cuboid
• Superficial portion: base of 2-5 metatarsals
Short plantar ligament (SPL) (plantar calcaneocuboid ligament)Anterior tubercle of calcaneum; inserts into adjacent plantar surface of cuboid
Spring ligament (SL) (plantar calcaneonavicular ligament)Anterior margin of sustentaculum tali; inserts into plantar aspect of navicular
Interosseous ligament (IL) (talocalcaneal ligament)Within sinus tarsi; connects non-articular parts of subtalar joint
Deltoid ligament (DL) (medial collateral ankle ligament)Fans out from anterior, medial and posterior aspects of medial malleolus; insets into navicular, spring ligament, sustentaculum tali and adjacent talus
Plantar aponeurosis (PA) (deep plantar fascia)From calcaneal tuberosity to midfoot, where it splits into five bands
Each band attaches distally to plantar aspect of transverse intermetatarsal ligament (overlying and linking plantar aspects of all metatarsophalangeal joints) and plantar surface of respective proximal phalanx
Table 3: Classification of ankle ligament inversion injuries
TypeCharacteristics of the injury to the ankle ligament
Grade IHistory of mild inversion injury
Overstretching of lateral collateral ligament + microscopic tears of ATFL fibres
Stable ankle joint but some restriction in range of motion/weight-bearing
Mild local swelling without bruising/ecchymosis along lateral border of ankle
Pinpoint area of tenderness overlying area of ligament injury
Grade IIHistory of moderate inversion injury
Complete tear of ATFL and partial tear of CFL
Mild/moderate ankle instability with restricted range of motion
Moderate swelling over anterior lateral aspect of ankle with marked soft-tissue bruising/ecchymosis or haemorrhage in area of injury
Marked pain on direct palpation of ATFL
Grade IIIHistory of severe inversion injury
Complete tear of ATFL, CFL and underlying joint capsule
Marked instability and laxity of ankle with positive anterior drawer test, talar inversion tilt and inability to evert foot at subtalar joint
Severe swelling along lateral border of ankle and heel with marked haemorrhage and ecchymosis
Discrete pain and tenderness of soft tissues overlying ATFL, CFL and anterolateral joint capsule

ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament.

Table 4: Diagnostic tests of collateral ligament injury at the ankle
Test modalityComment
Anterior drawer test>4 mm anterior displacement of calcaneum = ATFL tear
Talar tilt testGreater than normal inversion of STJ = ATFL rupture
Additional dimpling below lateral malleolus = CFL rupture
Ankle arthrographyShows leakage of contrast medium from lateral ankle joint area
Dye leakage inferior to medial malleolus = ruptured deltoid ligament
Peroneal tenographyLeak of contrast medium from the peroneal tendon sheath = CFL tear (CFL is closely apposed to peroneal tendon sheath)
Magnetic resonance imagingPinpoints exact location of ligament/capsule/tendon injury
Computerised tomography scanDiagnoses associated with osseous microfracture, joint mice, loose bodies, avulsion fractures
ArthroscopyVisualizes bone fragments, synovial hypertrophy, chronic synovitis, osteochrondral defects, bone impingement

ATFL, anterior talofibular ligament; STJ, subtalar joint; CFL, calcaneofibular ligament.

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