Description
The Anterior Talo-Fibular Ligament (ATFL) is one of three ligaments that make up the Lateral Collateral Ligament of the ankle. The ATFL is a short muscle that extends slightly from top to bottom.[1]
Attachments
The anterior talofibular ligament arises from the anterior border of the lateral malleolus of the fibula and attaches to the neck of the talus anteriorly to the articular surface of the lateral malleolus [1].
Function
The function of the ATFL is to resist inversion and plantarflexion of the ankle. [2] An ATFL injury typically occurs when the athlete’s center of mass shifts past the lateral boundary of the weight-bearing leg causing the ankle to roll inward at high speed. ATFL is The weakest lateral collateral ligament and therefore the first to be injured. [2]
The mechanism of injury may include landing awkwardly on the opponent’s foot so that the outside of the foot touches the ground, or the slide touches the inside of the opponent’s weighted leg. [2]
Clinical relevance
Ankle ligamentous sprains are the single most common severe sports concussion. Ankle ligament ruptures were also reported to be the most common injury in college sports in the United States.[3] The anterior talofibular ligament is the most commonly injured muscle in the ankle.[4]
Assessment
If a patient presents with the possibility of an ATFL injury, a complete physical examination should be performed:
- Observe: Assess for gross abnormalities in edema ecchymosis and perform neurologic examination.[2]
- Palpation: Palpate the ATFL and other tender areas of the lateral collateral ligament. Check for dorsal-pedal pulse capillary refill and light touch sensation. Edema can be measured by measuring the figure 8 of the medial malleolus with a tape measure Lateral malleolus navicular and base of fifth metatarsal. [2]
- Range of motion: Active and passive range of motion should be measured bilaterally. [2]
- Special Tests:
- Anterior drawer test: While stabilizing the tibia and fibula with one hand, hold the foot in 20° plantarflexion with the other hand while simultaneously drawing the talus forward in the ankle cavity. The anterior drawer tests the integrity of the ATFL and the anterior joint capsule. a positive test The result was an anterior translation of the STJ greater than 5 mm compared to the uninjured ankle. There may also be an audible muffled sound during the test. [2] Due to the sharp increase in pain and swelling, the anterior drawer test was found to have a significantly increased sensitivity in Perform 4 to 5 days after injury. [2]
[5]
- Talar Tilt Test: This test is primarily used to determine the integrity of the calcaneofibular ligament (CFL), but can also provide valuable information about the ATFL. The test is performed with the ankle held in a neutral position while the talus is tilted into adduction and abduction. repeat Perform a plantarflexion test with the foot to assess the integrity of the ATFL. A positive test result is a 5° to 10° increase in varus compared to an uninjured ankle indicative of a CFL injury. [2]
[6]
Examination Findings:
- Swelling is observed distal to the lateral malleolus of the ankle and may extend to the foot if the lateral capsule is torn.
- Tenderness touches the ATFL and, in more severe cases, the CFL.
- The anterior drawer and talar tilt test may reveal joint loosening due to tears of the ATFL and/or CFL ligament.
- Stress radiographs may reveal excessive anterior translation of the talus or rotation of the talus.
Classification of Lateral Ankle Sprains:
- Grade 1: Microtears of the ATFL. Symptoms include minimal swelling and direct focus on the ATFL with minimal instability and the patient is able to walk with little or no pain.[2]
- Grade 2: Great tear of the ATFL. Symptoms include a wide area of pointed tenderness on the dorsal aspect of the ankle with painful or immobile ulceration and local swelling due to tears in the anterior ATFL joint and surrounding soft tissue so.
- Grade 3: Complete rupture of the ATFL with possible involvement of the CFL. Symptoms include diffuse swelling of the edges of the Achilles tendon that fails to move outside of the heel joint and weakness of the medial aspects.[2]
Radiography
Ottawa guidelines should be used to determine if radiographs are needed:
- Tenderness at base of medial malleolus lateral malleolus navicular and/or fifth metatarsal to palpation;
- Inability to bear weight immediately after injury or during clinical examination;
- Tenderness extending up to 6 cm from either ankle bone
If serious abnormalities are present, radiography should be performed immediately. Standard radiographic views include anteroposterior lateral and ankle mortises. [2]
Treatment
Acute Inflammatory Phase[2]
Physical therapy should be started to aid the normal healing process as well as to protect the ligament from further damage.
Grade 1 and 2 Sprains:
- Rest or modified activity – tolerable weight bearing
- Ice – Ice therapy is applied 20 minutes on/1 hour throughout the day to reduce painful edema and secondary hypoxic damage to injured tissue.
- Compression – Semi-rigid orthosis lacing braces or tape can be used to help provide support.
- Elevation
- Medications (NSAIDs) along with electrical stimulation (TEN) pulsed ultrasound anti-edema massage and low-level lasers may help reduce inflammation.
- Active Range of Motion (ROM) – Patients should be instructed to perform ankle pumps (10 to 20 per hour) within a pain-free range to reduce inflammation and increase circulation.
- Soft Tissue Technique – Active Release Technique Graston Technique Muscle Energy Technique and lateral friction massage applied directly to the ligament and surrounding soft tissue structures can be used to aid in early ligament healing.
Grade 3 Sprains:
A grade 3 sprain must be suspected if on initial examination the patient is unable to bear weight and exhibits significant ankle pain and swelling. The patient should be placed in a functional gait orthosis and instructed to walk without weight bearing and with crutches. The patient should then be instructed to perform the RICE protocol (resting ice compression elevation) until an MRI can be performed.
Reparative Phase[2]
- Reduce inflammation
- Joint mobilization/passive stretching: restores active and passive range of motion
- Strength Training
- Maintain cardiovascular fitness
- Proprioceptive rehabilitation
- Stabilization
Remodeling Phase[2]
- Advanced strength training
- Agility Training
- Multi-directional sports-specific proprioception training
References
- ↑ Jump up to:1.0 1.1 Bonnel FT, Toullec E, Mabit C, Tourné Y. Chronic ankle instability: biomechanics and pathomechanics of ligaments injury and associated lesions. Orthopaedics & traumatology: Surgery & research. 2010 Jun 1;96(4):424-32.
- ↑ Jump up to:2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 Dubin JC, Comeau D, McClelland RI, Dubin RA, Ferrel E. Lateral and syndesmotic ankle sprain injuries: a narrative literature review. Journal of chiropractic medicine. 2011 Sep 1;10(3):204-19.
- ↑ Fong DT, Chan YY, Mok KM, Yung PS, Chan KM. Understanding acute ankle ligamentous sprain injury in sports. BMC Sports Science, Medicine and Rehabilitation. 2009 Dec 1;1(1):14.
- ↑ Kumai T, Takakura Y, Rufai A, Milz S, Benjamin M. The functional anatomy of the human anterior talofibular ligament in relation to ankle sprains. Journal of anatomy. 2002 May;200(5):457-65.
- ↑ Clinically Relevant Technologies. Available from: http://www.youtube.com/watch?v=Z4rvAT3a7OY. [Last Accessed: 21 October 2020
- ↑ The Physio Channel. How to do the Talar Tilt Test for the ankle. Available from: https://www.youtube.com/watch?v=dp7usAmLl5c [Last Accessed: 21 October 2020]
