Anterior Talofibular Ligament (ATFL)

Where is it painful for a client with an ATFL injury?

Classical patient features for an ATFL injury

Age: Most common between 15-24 years of age,

Gender: Females show a higher risk for an ATFL sprain compared to males

Sport: Netball, AFL, soccer, Basketball, Volleyball, ultimate frisbee, tennis, badminton, squash

Area of symptoms for an ATFL injury

- Lateral ankle // slightly anterior to the lateral malleolus

- Will commonly notice pain in the inferior section of the malleolus

- Localised and easily palpable

- Common to have an increase in generalised pain if acute and large inflammatory reaction (bruising, swelling ect)

Characteristics of symptoms for a client with an ATFL injury

- Pop may be heard at the onset.

- Pain, swelling and tenderness on the lateral ankle.

- If it is an acute incident the patient will report the symptoms very localised // will be able to touch it with their finger.

- chronic presentations will be more general over the anterolateral aspect of the ankle

- Bruising at the site of injury

- Neural signs if present will be at the sural, superficial or deep fibular nerve distribution

Typical activity capability/restriction for an ATFL injury

- Difficulty weight-bearing and walking

- Decreased ankle function and range of motion

- Instability (Grade 2/3)

- Proprioception deficits may present as difficulty performing single-leg tasks

- reduced sporting performance

- inability to perform tasks with high levels of variability // especially if loaded

Behaviour of symptoms for a client with an ATFL injury

Agg: change of direction, inversion, uneven surfaces, landing

Ease: taping/bracing, rest, compression, ice, elevation,

24 hour pattern: Nil as mechanical

Typical history for a client with an ATFL injury

- Constitutes 10% of all acute injury presentations

- ATFL is frequently the first ligament to be compromised // ankle inversion cases have a 97% likelihood of rupture compared to 3% CFL

- Can occur in conjunction with medial ankle injuries // rare

- Swelling usually occurs immediately, although occasionally it may be delayed over several hours following the injury

Pathobiological mechanisms underlying a an ATFL injury

- Nociceptive pain mechanism

- Often compounded by a large inflammatory response

- Will have observable pro-inflammatory signs at the location of the injury

Proposed pathology for a an ATFL injury

- The most common mechanism of an ATFL injury is plantarflexion and inversion of the ankle

- This may occur with rapid change in direction, especially on uneven surfaces (grass fields etc).

- Also may occur when jumping, landing awkwardly or the ankle giving way

- An audible snap, crack, or tear may also be present

The ATFL is the weakest of the lateral ankle ligaments and is the most likely to be injured.

Grade 1 - partial tear, no laxity and mild swelling

Grade 2 - partial tear, mild laxity, moderate effusion, instability and tenderness on palpation.

Grade 3 - full tear or rupture, massive swelling, severe pain and laxity and instability of the ankle joint.

Physical impairments & associated structure/tissue sources (ie P/E findings)

Local:

- Observation - Swelling observed distal to the lateral malleolus, which may also extend to the foot. Bruising will also be present depending on the severity

- AROM - Limited in all directions secondary to pain and swelling // inversion will be the most affected and reproduce pain

Palpation - Tenderness over ATFL // common to also find tenderness in syndesmotic area and on the medial deltoid ligament

- boney assessment required to rule out fracture // Ottawa rules (high-level evidence)

Proprioception - Compare bilateral single-leg stance

Special tests

Positive - Anterior drawer test (Sensitivity 96%, Specificity 84%)

Positive - Talar tilt test (ATFL bias) (Sensitivity 50%, Specificity 88%) // note percentages based on CFL not ATFL so anterior draw will hold more value

Typical contributing factors for an ATFL injury

Intrinsic

- Increased BMI

- Reduced dorsiflexion

- Reduced eccentric strength of supinators/inverters

- Low PSR (Pronator supinator ratio)

- Reduced hip extensor strength

- Previous ankle sprains

- Reduced proprioception

Extrinsic

- Grass / unstable surface

- Non-use of ankle braces

- Non-use of high top shoes (Basketball)

Relevant precautions/ contraindications to P/E and treatment

- Depending on irritability/severity - limiting tests and going to P1

- Need to rule out a fracture with boney assessment or send for imaging

- If significant instability tape will not be sufficient for return to play

Relevant diagnostic imaging for an ATFL injury

Ottawa rules indicate if radiographs are indicated: (high-level evidence)

• Tenderness over the medial malleolus, lateral malleolus, navicular, and/or base of the fifth metatarsal upon palpation;

• An inability to weight bear immediately following injury or during the clinical evaluation;

• The tenderness that extends 6 cm superiorly from either malleolus"

Grade 1: don't typically require imaging

Grade 2: consider imaging (US or MRI)

Grade 3: consider imaging (US or MRI)

Indications for an MRI or CT scan

- If symptoms present for more than a week and previous radiographs inconclusive

Typical prognosis for an ATFL injury

Grade 1: Return to sports at 1 to 4 weeks. Taping is used as a means of protection and increasing proprioception

Grade 2: Return to sports at 2 to 6 weeks.

Grade 3: Return to sports at 6 to 12 weeks.

Management/treatment selection for an ATFL injury

Goals of Early management

- Manage symptoms (pain and swelling)

- Optimize ROM

- Recondition muscles (especially into inversion and eversion )

- proprioceptive

- functional exercises

- Return to sport

- After sustaining an ATFL injury compromised individuals are at increased risk of recurrence for 6-12 months

Immobilisation/restriction (high level evidence)

- Taping or bracing are common interventions for protection in the early phase

- Need to make sure no allergies or precautions for the use of tape

- Thought that tape increases proprioception at the ankle more so than reducing the range of motion

- Taping is NOT a form of rehabilitation // rationale for use during the high-risk period however rehabilitation is preferred to optimize long term management

High levels of evidence to support rehabilitation in grade 3 ATFL sprains

- compared to surgical control group there was a faster return to play times, equal stiffness and equal reinjury rates

- Due to these findings a minimum of 6-12week of conservative management is indicated

- If patient is still having instability or persistent pain after this trial surgical referral may be warranted

Differential diagnosis for an ATFL injury

- CFL // talar tilt in neutral and palpation

- PTFL //posterior draw and palpation

- Syndesmosis // compression, DF +OP, DF + eversion + OP

- Fractures // Tib/Fib/5th met/ calcaneus/ talus/greenstick

- Dislocation // history and laxity

- Chronic ligamentous instability // history and laxity

Dynamic assessment and tendon signs

- Peroneal Tendinopathy

- Tib post Tendinopathy

- Tib ant Tendinopathy

- CRPS // history, examination and exclusion

- Tarsal Coalition // imaging

- Chronic ligamentous instability

- synovitis

- Sinus tarsi syndrome

References

Bahr R. The IOC manual of sports injuries. 1st ed. Sweden: International Olympic Commitee; 2012.

Balduini, F.C., Vegso, J.J., Torg, J.S. and Torg, E., 1987. Management and rehabilitation of ligamentous injuries to the ankle. Sports medicine, 4(5), pp.364-380.

Brukner P, Khan K. Clinical sports medicine (volume 1 injuries). 5th ed. Australia: McGraw-Hill Education; 2017.

Chen, E.T., McInnis, K.C. and Borg-Stein, J., 2019. Ankle sprains: evaluation, rehabilitation, and prevention. Current sports medicine reports, 18(6), pp.217-223.

Fong, D.T., Chan, Y.Y., Mok, K.M., Yung, P.S. and Chan, K.M., 2009. Understanding acute ankle ligamentous sprain injury in sports. BMC Sports Science, Medicine and Rehabilitation, 1(1), pp.1-14.

Krabak B, 2019, 'Ankle Sprain' in Walter F, Julie K.S, Thomas D.R (eds) Essentials of Physical Medicine and Rehabilitation Musculoskeletal Disorders, Pain and Rehabilitation, Elsevier, Philadelphia PA, pp - 460-465

Petersen, W., Rembitzki, I.V., Koppenburg, A.G., Ellermann, A., Liebau, C., Brüggemann, G.P. and Best, R., 2013. Treatment of acute ankle ligament injuries: a systematic review. Archives of orthopaedic and trauma surgery, 133(8), pp.1129-1141.

Wang, D.Y., Jiao, C., Ao, Y.F., Yu, J.K., Guo, Q.W., Xie, X., Chen, L.X., Zhao, F., Pi, Y.B., Li, N. and Hu, Y.L., 2020. Risk factors for osteochondral lesions and osteophytes in chronic lateral ankle instability: a case series of 1169 patients. Orthopaedic Journal of Sports Medicine, 8(5), p.2325967120922821.