 Ankle Joint SYNDESMOSIS

o consists of  Function
 tibial plafond o responsible for integrity of ankle
mortise
 medial malleolus
 Anatomy
 lateral malleolus
o Syndesmosis components
 talus
 Anterior-inferior tibiofibular
o motion
ligament (AITFL)
 main motion
 Posterior-inferior tibiofibular
 plantar flexion ligament (PITFL)

 dorsiflexion  deep portion of this

ligament sometimes
 secondary motions reffered to as the inferior
 inversion/eversion transverse ligament

 rotation  Transverse tibiofibular

ligament (TTFL)
 Distal tibiofibular joint
 Interosseous ligament (IOL
o consists of
 distal fibula
 incisura fibularis
 concave surface of distal
lateral tibia
o motion
 fibular rotates within incisura
during gait
 mortise widens when ankle goes
from plantar to dorsiflexion Physical Exam

 syndesmosis screws limit o test to identify a syndesmosis injury include

external rotation
 external rotation test
Primary ligaments of ankle include
o medial
 Deltoid ligament
 Calcaneonavicular ligament (Spring
Ligament)
o lateral
 Syndesmosis (includes AITFL, PITFL,
TTFL, IOL, ITL)
 squeeze test
 Anterior talofibular ligament (ATFL)
Clinical conditions
 Posterior talofibular ligament (PTFL)
 high ankle sprain & syndesmosis injury
 Calcaneal fibular ligament (CFL)
 ankle fracture
 Lateral talocalcaneal ligament (LTCL)
ANTERIOR TALOFIBULAR LIGAMENT (ATFL) POSTERIOR TALOFIBULAR LIGAMENT (PTFL)
 Function  Function
o primary restraint to inversion in plantar o strongest of the lateral ligaments
flexion
o plays only a supplementary role in ankle
o resists anterolateral translation of talus stability when the lateral ligament
in the mortise complex is intact
o weakest of the lateral ligaments o under greatest strain in ankle
dorsiflexion and acts to limit posterior
 Anatomy
talar displacement within the mortise as
o extends from the anteroinferior border well as talar external rotation
of the fibula to the neck of the talus
o if ATFL and CFL are incompetent, then
 origin is 10mm proximal to tip of
 short fibers of PTFL restrict
fibula
internal and external rotation,
 inserts directly distal to articular talar tilt, and dorsiflexion;
cartilage of the talus (18mm
 long fibres inhibit only external
distal to joint line)
rotation, talar tilt, and
 runs 45°-90° to longitudinal axis dorsiflexion
of the tibia
 Anatomy
 Physical exam
o origin is posterior border of fibula
o anterior drawer in 20° of plantar flexion
o inserts on posterolateral tubercle of the
 test competency by anterior talus
drawer in 20° of plantar flexion
o runs perpendicular to longitudinal axis
and compare to uninjured side
of the tibia
 forward shift of more than 8 mm
 Physical exam
on a lateral radiograph is
considered diagnostic for o no specific clinical test for isolated
an ATFL tear PTFL injury
 Imaging  Imaging
o stress radiographs o MRI can indicate structural injury, rarely
indicated
 more accurate in chronic injuries
 Clinical Conditions
o MRI : can diagnose injury
o rarely injured, except in association with
o ultrasound: more accurate than
a complete dislocation of the talus
radiographs
 Clinical Conditions
o low ankle sprains
CALCANEAL FIBULAR LIGAMENT (CFL) LATERAL TALOCALCANEAL LIGAMENT
(LTCL)
 Function
 Function
o primary restrain to inversion in neutral
or dorsiflexed position o thought to stabilize the talocalcaneal
joint
o restrains subtalar inversion, thereby
limiting talar tilt within mortise  Anatomy
 Anatomy o short narrow ligamentous band that
connects the lateral process of the talus
o origin is anterior border of fibula, 9mm
to the lateral surface of the calcaneus
proximal to distal tip
o located anterior and medial to
calcaneofibular ligament
 Physical Exam
o no specific test for this ligament
 Imaging
o LTCL ligament (red arrows) identified
distinctly from the calcaneofibular
ligament
o inserts on calcaneus 13mm distal to
subtalar joint and deep to peroneal
tendon sheaths
 Physical exam
o inversion (supination) test
 perform with ankle in slight
dorsiflexion
o talar tilt test
 angle formed by tibial plafond &
talar dome is measured as
inversion force is applied to
hindfoot (<5 deg is normal for o relationship of the calcaneofibular
most ankles) ligament (green arrow) and the LTCL
(red arrow)
 useful for evaluation of
combined injury of both ATFL  Clinical conditions
and CFL ligament
o often injured in conjunction with ATFL
 Imaging : talar tilt radiographs injuries
o ankle arthrograms o low ankle sprain
 CFL rupture can lead to extra-
articular dye leakage into the
peroneal tendon sheath
o MRI
 Clinical Conditions
o injury occurs with ankle inversion with
the foot in the neutral position
o low ankle sprain
DELTOID LIGAMENT
 Function  Physical exam
o primary restraint to valgus tilting of the o eversion test
talus
 with ankle in neutral, evaluates
o both the superficial and deep layers superficial layer
individually resist eversion of the
 external rotation stress test
hindfoot
evaluates syndesmosis and deep
o stabilizes ankle against plantar flexion, layer
external rotation and pronation
 Imaging
 Anatomy
o radiographs
o superficial layer
 mortise radiograph with medial
 crosses both ankle and subtalar clear space widening can suggest
joints injury
 originates from anterior  gravity stress view can identify
colliculus and fans out to insert medial clear space widening
into the navicular neck of the
o MRI
talus, sustenaculum tali, and
posteromedial talar tubercle  normal deltoid ligament
 the tibiocalcaneal (sustenaculum  ruptured deltoid ligament
tali) portion is the strongest
 Clinical conditions
component in the superficial
layer and resists calcaneal o ankle fracture
eversion
 injury occurs with pronation
o deep layer (eversion) trauma leading to
 crosses only ankle joint forced external rotation and
abduction of ankle
 functions as the primary
 may occur with fracture of the
stabilizer of the medial ankle
medial malleolus
 prevents lateral
o high ankle sprain & syndesmosis injury
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
CALCANEONAVICULAR LIGAMENT (SPRING
LIGAMENT)
 Function
o static stabilizer of the medial
longitudinal arch and head of the talus
 Anatomy
o attaches from the sustentaculum tali to
the inferior aspect of the navicular
 Physical Exam
o flattening of medial longitudinal arch
o suspect injury in associated posterior
tibial tendon pathology
 Imaging
o MRI
 can diagnose tear
 (green arrow, intact
ligament; red arrow,
disrupted ligament)
 Clinical conditions
o posterior tibial tendon dysfunction
 calcaneonavicular ligament is
the most likely ligament to be
attenuated in a patient with a type
II flatfoot deformity secondary
to posterior tibial tendon
dysfunction
o acute spring ligament tear
 acute trauma can occur with
forceful landing on flat foot
 the tibialis posterior tendon is
usually normal