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Ankle sprain is the most common injury in athletic populations. Ligament and tendon pathologies of the ankle are common, ranging from traumatic injuries to degeneration leading to chronic pain and acquired foot deformities. MRI is the imaging modality of choice to evaluate tendon and ligament pathology of the ankle, specifically derangements of tendons and ligaments. 3-T MRI offers improved imaging characteristics relative to 1.5-T MRI, allowing for better delineation of anatomic detail and pathology. This article provides a review of the anatomy and common pathologies of the ankle ligaments and tendons using high-resolution 3-T MRI.

Ankle sprains are a common sports injury that can lead to chronic symptoms and residual instability. Ankle ligaments may be classified into four groups. This article reviews anatomy, MRI features, mechanisms of injury, and associated pathology of ankle ligaments.

Gout is the most common inflammatory arthritis due to deposition of monosodium urate (MSU) crystals in joints and connective tissues. In contrast to joint disease, the majority of extra-articular involvement remains asymptomatic in patients with gout. Achilles tendon is the most common site of involvement and the inflammation elicited by MSU crystals can be falsely attributed to injury or overuse. In addition, tendon or ligament damage secondary to MSU crystal deposition can lead to ligament tear or tendon rupture.However, the diagnosis of gout in patients with extra-articular involvement is often delayed or even missed because tissue sampling is not feasible in routine clinical practice. Advanced imaging techniques using ultrasound and dual-energy computer tomography (DECT) can detect MSU crystal deposition in a non-invasive manner and confirm the diagnosis of gout in patients with extra-articular involvement.The following case demonstrates an atypical presentation of gout causing multiple ligament tears in the ankle and highlights the role of DECT in the diagnosis of gout with extra-articular involvement.

Purpose Awideinter-individualvariabilityintermsofsize,orientationandinsertionisobservedregardingankleligaments. The aim of this study is to identify and describe the anatomical features of the posterior talocalcaneal ligament (PTCL) observed through the use of magnetic resonance imaging (MRI) of the ankle. Methods The study was retrospectively carried out on 893 ankle MRI’s exams. The exams have all been performed using a 1.5-T (T) MRI. The same scanning protocols and scan planes were carried out in all the exams. The first evaluated param- eter was the recognition of the PTCL. Subsequently, in all those cases where the ligament was present, its features such as insertion sites, length, and thickness were evaluated. Results The PTCL identification was possible in 77 exams (8.6% of the total number). Among these, we were able to iden- tify some variants regarding insertion sites, length, and thickness. The PTCL could be further classified into four categories based on the most common characteristics observed. Conclusions Our study has identified different characteristics of the PTCL that allow us to further understand the charac- teristics of the ligament itself. In conclusion, the need for further studies focused on the biomechanical role of the PTCL in the ankle joint appears mandatory.

Objective: The aim of this study is to demonstrate an original technique in which a stable construct is made by fibular and calcaneal bone tunnels producing a figure of 8 with a Polyester implant as revision for failed primary ligament reconstruction. Methods: This is a retrospective study of 19 patients with persistent lateral ankle instability diagnosis after a primary ligament repair treated between 2011 and 2019. The surgical technique is described in detail in which stabilization of the lateral ankle is performed. 11 men and 8 women with a mean age of 30.94 years (15-53). Follow up was 29.05 months (6-109). Pre and postoperative AOFAS ankle score were used as well as an AVS and a satisfaction questionnaire. Results: There was a significant improvement in AOFAS score, 76.31 to 91.47 (

Ankle sprains are common injuries involving the lateral ankle ligaments and affect athletes of all levels. Most patients heal uneventfully, but those with symptoms persisting past 3 months should be evaluated for chronic ankle instability and its associated conditions as well as for the presence of varus malalignment. Chronic ankle instability is initially treated nonoperatively, with surgical management reserved for those who have failed to improve after 3 to 6 months of bracing and functional rehabilitation. Anatomic repair using a modification of the Broström procedure is the preferred technique for initial surgery. Anatomic reconstruction with tendon graft should be considered when repair is not possible, as it maintains physiological joint kinematics. Nonanatomic reconstructions are seldom indicated. Arthroscopic repair or reconstruction of the lateral ankle ligaments is a promising new technique with results similar to those of open surgery.

Ankle joint is a complex synovial joint affected in many traumatic and non traumatic conditions resulting in many problems. And ankle ligaments are encountered in multiple situations leading to be investigated well for detecting the accurate management. Inour study, we analyze the reliability and validity of magnetic resonance imaging (MRI) for the detection of ankle ligaments injuries. Thirty patients who are clinically suspected to have ligament injury are examined by MRI and results are analyzed.

An increased interest in ankle instability has led to description of new concepts such as ankle microinstability or rotational ankle instability and the development of new arthroscopic techniques treating ankle instability. Ankle instability is constantly associated to intraarticular pathologies that contribute to generate pain and dysfunction. Arthroscopy plays an important role in identifying and treating all intraarticular abnormalities including ligament injuries. Despite a few studies are available in literature on arthroscopic treatment of medial collateral ligament injury, an arthroscopic all-inside repair of lateral and medial ankle ligaments has been proposed showing promising clinical results.

Ankle sprains are common and often develop into chronic ankle instability. Ankle laxity is usually assessed by manual testing followed by magnetic resonance imaging to confirm the diagnosis. Manual testing however provides a subjective measure and is limited to the assessor sensibility. Current available technologies incorporate arthrometers to objectively measuring ankle laxity, but are not capable to assess the structural integrity of the capsuloligamentous structures. To overcome these limitations, we developed a novel medical device to assist in the diagnosis of ankle ligament injuries—the Porto Ankle Testing Device. With this device, it is possible to combine and correlate the assessment of the capsuloligamentous’ structural integrity with the joint functional competence (ie, joint multiplanar laxity). The main purpose of this work is to present the fundamental aspects and step-by-step development of the Porto Ankle Testing Device. We discuss the design specifications and technical requirements with the purpose to design and develop this medical device, described the features of the different components and explained the mechanical systems that are incorporated emulate manual testing and to measure the multiplanar ankle laxity. The preliminary findings are presented with the purpose to display the assessment protocol, the method of laxity measurement and the obtained results. We propose a unique and reliable medical device to safety and effectively assess ankle ligament injuries and contribute to enhance diagnosis, refine treatment indications and allow objective measurement of ligament laxity before and/or after stabilization surgery.

A thorough knowledge of the anatomy of the ankle ligaments is indispensable for the diagnosis and treatment of patients with ankle instability. The evolution towards minimally invasive techniques and more anatomic procedures to restore normal joint mechanics increases the need for detailed information about the normal ligamentous anatomy, its possible variations, and the insertion sites in relation to local landmarks. In this chapter, the most important ligaments related to injury and instability are described. The ligaments around the ankle are divided into groups according to their anatomic position: the lateral ligament complex, the medial ligament complex, the ligaments of the tibiofibular syndesmosis, and the subtalar ligaments.

The ankle and foot are anatomically complex areas with a broad spectrum of intra- and extra-articular pathologies. This chapter reviews basic anatomical features and gives an overview on common pathologic conditions with an emphasis on trauma/sports injuries and MR imaging.

The present article describes the ultrasound (US) appearance of ligaments and paraligamentous structures which are not included in standard US imaging of the ankle: the posterior inferior tibiofibular ligament (PITFL), the transverse tibiofibular ligament (TTFL), the posterior talofibular ligament (PTFL), the posterior intermalleolar ligament (PIL), the synovial recess (SR) of the posterior joint and the os trigonum (OT). Two skilled operators examined 15 ankles in 15 healthy volunteers. Correlation between thickness of the main ligaments and body mass index (BMI) was also analyzed. Compound and tissue harmonic imaging (THI) were carried out using 12-, 6–15- and 9-MHz linear probes. Exploration of the posterior ankle ligament complex is accurately described including correct ankle position, echogenicity, shape, direction and thickness. Both operators identified and measured the main ligaments (PITFL, TTFL and PTFL) in all volunteers (Intraclass Correlation Coefficient ranged from 0.8 to 1); both operators also detected SR and OT in 2/15 ankles and posterior intermalleolar ligament (PIL) in 5/15 ankles. Pearson’s test showed a significant correlation (

The extensor retinaculum is a reinforcement of the anterior crural fascia. Usually includes the superior extensor retinaculum and inferior extensor retinaculum which are both in continuity with the anterior fascia of the leg. Herein, there will be presented details of anatomy and clinical implications of these structures in the topic of lateral ankle instability.

The most common injury sustained to the ankle ligaments is a result of inversion of the foot. This mechanism results in injury to the anterior talofibular ligament alone or in conjunction with the calcaneofibular ligament and posterior talofibular ligament. Patients experiencing recurrent ankle sprains despite nonoperative measures often require surgical management. Recent focus has been on augmentation procedures to improve the stability of a lateral ankle ligament repair by protecting it during the healing phase and supporting early mobilization. This article describes, with video illustration, anterior talofibular ligament repair with suture tape augmentation.

The anterior talofibular ligament and the calcaneofibular ligament are the most commonly injured ankle ligaments. This study aimed to investigate if the double fascicular anterior talofibular ligament and the calcaneofibular ligament are associated with the presence of interconnections between those two ligaments and connections with non-ligamentous structures. A retrospective re-evaluation of 198 magnetic resonance imaging examinations of the ankle joint was conducted. The correlation between the double fascicular anterior talofibular ligament and calcaneofibular ligament and connections with the superior peroneal retinaculum, the peroneal tendon sheath, the tibiofibular ligaments, and the inferior extensor retinaculum was studied. The relationships between the anterior talofibular ligament’s and the calcaneofibular ligament’s diameters with the presence of connections were investigated. Most of the connections were visible in a group of double fascicular ligaments. Most often, one was between the anterior talofibular ligament and calcaneofibular ligament (74.7%). Statistically significant differences between groups of single and double fascicular ligaments were visible in groups of connections between the anterior talofibular ligament and the peroneal tendon sheath (p p p p p p p p

Purpose: The purpose of this study was to investigate if the calcaneofibular ligament (CFL) presents morphologic variants and measure the morphometrics of the ligament and its footprints Methods: An anatomical study of 47 fresh-frozen below-the-knee ankle specimens was performed. Lateral ankle structures were dissected to expose the CFL. Overdissection was avoided to not modify the native morphology. The morphology (number and orientation of CFL bundles) and measurements of CFL insertions were recorded with ankle secured in neutral position. Results: Four distinct morphological-oriented shapes of the CFL were observed. These included single bundle, Y-shape double bundle, V-shape double bundle, and associated with the lateral talocalcaneal ligament. The most frequent CFL morphology observed was the single bundle and the Y-shape double bundle, present in 21 (44.7%) and 13 (27.7%) ankles. The V-shape double bundle and the CFL double bundle associated with the lateral talocalcaneal ligaments were less common, appearing only in eight (17.0%) and five (10.6%) ankles. The CFL length was higher in single bundle and Y-shaped double bundle CFL variants, about 30 mm each. Footprint morphometrics were heterogenous amongst the different CFL variants. Conclusion: The CFL presents four distinct morphological-oriented shapes. The double bundle, V-shaped and Y-shaped CFL variants are uncommon and poorly reported in the literature. Their relation to the lateral talocalcaneal ligament and the inferior fascicle of the anterior talofibular ligament requires further research. The CFL morphology provides detailed knowledge of CFL anatomy that can improve diagnostic procedures. Furthermore, this information can fine-tune graft selection and sizing and allow a more precise anatomic placement during surgical reconstruction.

The ankle is a highly congruent synovial, hinge-type joint, in which the talus fits perfectly into the mortise formed by the tibial plateau, and the tibial and fibular malleoli. This anatomical conformation allows movement through only one axis, the bimalleolar axis, through which dorsiflexion and plantarflexion movements are produced. Normal values of the range of motion are 13–33° for dorsiflexion and 23–56° for plantarflexion [1].

Background: Ankle sprains are the most common musculoskeletal injury in the United States. Chronic lateral ankle instability can ultimately require operative intervention to decrease pain and restore stability to the ankle joint. There are no anatomic studies investigating the vascular supply to the lateral ankle ligamentous complex. Purpose: To define the vascular anatomy of the lateral ligament complex of the ankle. Study Design: Descriptive laboratory study. Methods: Thirty pairs of cadaveric specimens (60 total legs) were amputated below the knee. India ink, followed by Ward blue latex, was injected into the peroneal, anterior tibial, and posterior tibial arteries to identify the vascular supply of the lateral ligaments of the ankle. Chemical debridement was performed with 8.0% sodium hypochlorite to remove the soft tissues, leaving casts of the vascular anatomy intact. The vascular supply to the lateral ligament complex was then evaluated and recorded. Results: The vascular supply to the lateral ankle ligaments was characterized in 56 specimens: 52 (92.9%) had arterial supply with an origin from the perforating anterior branch of the peroneal artery; 51 (91.1%), from the posterior branch of the peroneal artery; 29 (51.8%), from the lateral tarsal branch of the dorsalis pedis; and 12 (21.4%), from the posterior tibial artery. The anterior branch of the peroneal artery was the dominant vascular supply in 39 specimens (69.6%). Conclusion: There are 4 separate sources of extraosseous blood supply to the lateral ligaments of the ankle. In all specimens, the anterior talofibular ligament was supplied by the anterior branch of the peroneal artery and/or the lateral tarsal artery of the dorsalis pedis, while the posterior talofibular ligament was supplied by the posterior branch of the peroneal artery and/or the posterior tibial artery. The calcaneofibular ligament received variable contributions from the anterior and posterior branches of the peroneal artery, with few specimens receiving a contribution from the lateral tarsal or posterior tibial arteries. Clinical Relevance: Understanding the vascular anatomy of the lateral ligament complex is beneficial when considering surgical management and may provide insight into factors that lead to chronic instability.

Ankle trauma is commonly encountered and is most often a sprain injury affecting the ligaments. Accurate diagnosis and appropriate treatment rest on knowledge of complex ligamentous anatomy of ankle and the entire spectrum of pathologies. Magnetic resonance imaging (MRI) is the imaging modality of choice for diagnosing ligament pathologies because of its multiplanar capability and high soft tissue contrast. With MRI, it is possible to triage and attribute the cause of post traumatic ankle pain to bone, ligament, or tendon pathologies, which otherwise overlap clinically. In this pictorial essay, emphasis is given to the intricate and unique anatomy and orientation of ankle ligaments. Pathologies of ankle ligaments have been elaborated.

Objectives To establish patterns of subsequent injury in U18 rugby, to quantify the burden of within season injury recurrence. Design Secondary analysis of prospective data. Setting 28 Schools in Ireland. Participants 825 male rugby players (aged 15–18 years). Main outcome measures Subsequent injuries were classified as: new, local or recurrent (same site and type as index injury). All recurrent injuries were sub-grouped by body part and diagnosis. Burden was based on frequency, days lost and injury proportion ratios. Results A total of 426 injuries were eligible for analysis, of which, 121 were subsequent injuries. The majority of subsequent injuries involved a different body part than their index injury. There were n = 23 cases of within season recurrence. 78% of recurrences occurred within 2 months of return to play. Recurrent injuries comprised 5% of all injuries and their cumulative time loss was 1073 days. Recurrent injury to the ankle ligaments, lumbar muscles and concussions carried the greatest burden. Conclusion The burden of recurrent injury in U18 rugby is lower than in the professional game. However, this population could benefit from targeted secondary prevention efforts including reconsideration of return-to-play protocols for ankle sprain, lumbar muscles and potentially concussion.

Lateral ankle sprain is one of the most common ankle injuries, especially in sports. When not treated properly, chronic ankle instability (CAI) may develop causing recurrent sprains and permanent damage to ankle ligaments. In this study, the design, implementation and validation of a smart wearable device connected to a smartphone application is described. This device can predict and prevent the occurrence of ankle sprain. Prediction of potentially harmful motion is achieved by continuous monitoring of ankle kinematics using inertial motion sensors. Detection of such a motion immediately triggers electrical stimulation of the peroneal muscles causing foot dorsiflexion, and hence prevents potential injury. The proposed device has the advantage of having a very short response time of eight milliseconds which is sufficient to halt the sprain motion. Laboratory validation testing using a custom designed trapdoor showed an accuracy of 96% in detecting and correcting hazardous motion. Furthermore, this device complies well with the design constrains of a wearable device such as small size and low power consumption. It is also low cost and unobtrusive due to the wireless connection between all components. Future work is recommended to test the clinical effectiveness of the proposed device in patients with CAI.

Bandverletzungen des Sprunggelenks sind die mit Abstand haufigsten Sport- und Freizeitverletzungen. Bereits bei der Erstanamnese sollten Sie komplikationstrachtige Falle herausfiltern. Im Folgenden geht es um Diagnostik und Therapie der akuten Distorsion und der chronischen Instabilitat des oberen Sprunggelenks.

Ligament sprains account for a majority of injuries to the foot and ankle complex among athletic populations. The infeasibility of measuring the in situ response and load paths of individual ligaments has precluded a complete characterization of their mechanical behavior via experiment. In the present study a fiber-based modeling approach of in situ ankle ligaments was developed and validated for determining the heterogeneous force-elongation characteristics and the consequent injury patterns. Nine major ankle ligaments were modeled as bundles of discrete elements, corresponding functionally to the structure of collagen fibers. To incorporate the progressive nature of ligamentous injury, the limit strain at the occurrence of fiber failure was described by a distribution function ranging from 12% to 18% along the width of the insertion site. The model was validated by comparing the structural kinetic and kinematic response obtained experimentally and computationally under well-controlled foot rotations. The simulation results replicated the 6 degree-of-freedom bony motion and ligamentous injuries and, by implication, the in situ deformations of the ligaments. Gross stiffness of the whole ligament derived from the fibers was comparable to existing experimental data. The present modeling approach provides a biomechanically realistic, interpretable and computationally efficient way to characterize the in situ ligament slack, sequential and heterogeneous uncrimping of collagen fascicles and failure propagation as the external load is applied. Applications of this model include functional ankle joint mechanics, injury prevention and countermeasure design for athletes.

It was nearly a centenary ago that severe ankle sprain was recognized as an injury of the ankle ligament(s). With the recent technological advances and tools in imaging and surgical procedures, the management of ankle sprains - including subtalar injuries - has drastically improved. The repair or reconstruction of ankle ligaments is getting more anatomical and less invasive than previously. More specifically, ligamentous reconstruction with tendon graft has been the gold standard in the management of severely damaged ligament, however, it does not reproduce the original ultrastructure of the ankle ligaments. The anatomical ligament structure of a ligament comprises a ligament with enthesis at both ends and the structure should also exhibit proprioceptive function. To date, it remains impossible to reconstruct a functionally intact and anatomical ligament. Cooperation of the regenerative medicine and surgical technology in expected to improve reconstructions of the ankle ligament, however, we need more time to develop a technology in reproducing the ideal ligament complex.

Background Chronic subtalar instability is a disabling complication after acute ankle sprains. Currently, the literature describing the anatomy of the intrinsic subtalar ligaments is limited and equivocal which causes difficulties in diagnosis and treatment of subtalar instability. The purpose of this study is to assess the anatomical characteristics of the subtalar ligaments and to clarify some points of confusion. Methods In 16 cadaveric feet, the dimensions and locations of the subtalar ankle ligaments were assessed and measured. CT-scans before dissection and after indication of the footprints with radio-opaque paint allowed to generate 3D models and assess the footprint characteristics. Results The cervical ligament (CL) had similar dimensions as the lateral ligaments: anterior length 13.9 ± 1.5 mm, posterior length 18.5 ± 2.9 mm, talar width 13.6 ± 2.2 mm, calcaneal width 15.8 ± 3.7 mm. The anterior capsular ligament (ACaL) and interosseous talocalcaneal ligament (ITCL) were found to be smaller structures with consistent dimensions and locations. Conclusion This study identified consistent characteristics of the intrinsic subtalar ligaments and clarifies the local anatomical situation. The dimensions and footprints of the intrinsic ligaments of the subtalar joint suggest a more important role of the CL and ACaL in the stability of the subtalar joint. The results of this study are relevant to improve diagnostic tools and offer some guidelines when reconstructing the injured ligaments.

Both the plantaris tendon and the peroneus tertius tendon are used as auto- and allogenous graft materials to reconstruct the ankle ligament complex. However, it is unclear to what extent these graft materials resemble the load-deformation behavior of the ankle ligaments. A total of 34 human ankle ligaments and 35 tendons were assessed mechanically deploying a quasi-static tensile testing setup. Tendons were significantly stiffer (median elastic moduli: plantaris tendon = 465.7 MPa, peroneus tertius tendon = 338.5 MPa, medial ligament = 61.4 MPa, lateral ligament = 49.3 MPa; p ≤ 0.035), but more distensible (median strain at maximum force: plantaris tendon = 15.1%, peroneus tertius tendon = 15.3%, medial ligament = 9.3%, lateral ligament = 9.6%; p ≤ 0.008) and mechanically tougher (median ultimate tensile strength: plantaris tendon = 51.0 MPa, peroneus tertius tendon = 40.5 MPa, medial ligament = 4.1 MPa, lateral ligament = 3.5 MPa; p ≤ 0.033) when compared to medial and lateral ankle ligaments. The lateral ligaments of the right ankle were significantly tougher compared to the left side (p = 0.015). The elastic modulus of the medial ligament (r = 0.489, p = 0.045) and the peroneus tertius tendon (r = 0.517, p = 0.014) yielded an age-dependent increase. Both tendons seem biomechanically suitable graft materials to replace the medial and lateral ankle ligaments during physiological loading. The age-dependent increase in tissue elastic properties of the medial vs. lateral ankle ligaments, and differences in ultimate tensile strength between the lateral ligaments left vs. right, may reflect the complex asymmetric loading behavior of both ankle ligaments.

Purpose This study aims to systematically investigate if normal ankle ligaments can be assessed with CT imaging, using MRI as reference standard. Methods 35 patients (mean age: 47 ± 15 years; female n = 19) with combined CT and MRI exams and without MR-morphologic signs of ankle ligamental injury were retrospectively identified. 3 readers independently evaluated the syndesmotic, the lateral and medial ankle ligaments in terms of visibility on a 4-point Likert scale (0–3 points) in multiplanar MDCT images in standard bone kernel reconstructions. In consensus CT-based ligament density and thickness were measured and the appearance was rated for each ligament. Results were compared and validated with corresponding MRI images. Results Almost all ankle ligaments identified in MRI images could be adequately depicted in standard multiplanar bone kernel CT images with a mean visual score of 2.7/3 (± 0.2). Difficulties in CT morphological delineation of ankle ligaments occurred in cases of filiform TNL and TCL and in cases of concurrent soft tissue edema. Interreader agreement for the CT-assessment of ankle ligaments was excellent, with Fleiss Kappa values >0.8. Mean density of evaluated medial and lateral ankle ligaments was 68 ± 2.9 HU, with substantially inter- and intraindividual variations. Thickness measurements and assessment of appearance of ankle ligaments showed a good concordance between CT and MRI. Conclusions Assessment of normal ankle ligaments via standard CT in bone kernel reconstructions is feasible, with some restrictions concerning the medial collateral ligaments and in the presence of soft tissue edema.

Background: Numerous epidemiological studies have emphasized the burden of lateral ankle sprains in youth soccer players. However, no prospective study has identified intrinsic physical and modifiable risk factors for these injuries in this particular population. Although injury prevention programs in soccer incorporate proximal hip and core stability exercises, it is striking that the relationship between impaired proximal hip function and ankle sprains has not yet been prospectively investigated in youth soccer players. Hypothesis: This prospective study aimed to examine whether hip muscle strength is a risk factor for sustaining a lateral ankle sprain in youth soccer players. We hypothesized that decreased hip muscle strength would predispose youth soccer players to an increased risk of lateral ankle sprains. Study Design: Case-control study; Level of evidence, 3. Methods: This study included a total of 133 male youth soccer players (age divisions U11-U17) for analysis. At the beginning of the season, anthropometric characteristics were collected and hip muscle strength was assessed using a handheld dynamometer. Injury registration was performed by the team medical staff during 3 consecutive seasons. A principal-component, multivariate Cox regression analysis was performed to identify potential risk factors for sustaining a lateral ankle sprain. Results: Twelve participants (18% of all reported injuries) sustained a lateral ankle sprain (0.36 per 1000 athletic-exposure hours). After adjustment for body size dependencies and other hip muscle forces, an increase in hip muscle extension force was associated with a significant decrease in the hazard of the injury (hazard ratio, 0.3; 95% confidence interval, 0.1-0.9; P = .028). No other study variable could be identified as a risk factor for lateral ankle sprains. Conclusion: Reduced hip extension muscle strength is an independent risk factor for lateral ankle sprains in male youth soccer players. Other hip muscle strength outcomes were not identified as risk factors. Replication in larger samples with more injured cases is warranted to further ascertain the importance of this risk factor.

This article describes the augmentation of a Brostrom anatomic repair for ankle lateral ligament instability by the use of the internal brace. The paper describes the role of the internal brace in allowing the natural tissues to progressively strengthen while encouraging early rehabilitation. The su

The ankle is one of the most common sites of musculoskeletal injury. In a series of 1176 athletic injuries, 14% were found to be injuries of the ankle, and 85% of those were specifically sprains of ankle ligaments [1]. Although many ankle ligaments can be well assessed by an operator trained in ultrasound techniques, evaluation by magnetic resonance imaging (MRI) offers the advantages of a comprehensive and operator-independent examination [2]. In this article, a practical review of MRI of ankle ligaments is presented. The discussion is limited primarily to the ligaments surrounding the tibiotalar joint, particularly the inferior tibiofibular syndesmotic ligaments and the medial and lateral collateral ligaments (Table 1). Because of its close association with the deltoid ligament, the spring ligament is also included. Ligament names are represented by unambiguous abbreviations similar to those appearing in the literature [3e5]. For each ligament, normal anatomy, MRI appearance, and function will be addressed. Next, with regards to the injured ligament, basic mechanisms of injury will be reviewed, taking into consideration differing opinions in the literature that, in some cases, diverge from the classic teachings of Lauge and Hansen [3]. Because ligament injury usually manifests itself in similar ways, such as abnormal signal intensity (intrasubstance or periligamentous) or abnormal morphology (thickening, thinning, discontinuity, absence, irregularity, indistinctness, or heterotopic ossification) [2,4,6], additional imaging clues to injury that are ligamentspecific will be emphasized. Finally, because chronic injury

Objective: Ankle sprains constitute approximately 85% of all ankle injuries and up to 70% of people experience residual symptoms. Whilst the injury to ligaments is well understood the potential role of other foot and ankle structures has not been explored. The objective was to characterise and compare selected ankle structures in participants with and without a history of lateral ankle sprain. \ud Methods: 71 participants were divided into 31 healthy, 20 coper, and 20 chronic ankle instability groups. Ultrasound images of the anterior talofibular and calcaneofibular ligaments, fibularis tendons and muscles, tibialis posterior and Achilles tendon were obtained. Thickness, length, and cross sectional areas were measured and compared between groups. \ud Results: When under tension the anterior talofibular ligament was longer in copers and chronic ankle instability groups compared to healthy participants (p < 0.001 and p = 0.001 respectively). The chronic ankle instability group had the thickest ATFL and CFL among the three groups (p < 0.001). No significant differences (p > 0.05) in tendons and muscles were observed between the three groups. \ud Conclusions: The ultrasound protocol proved reliable and was used to evaluate the length, thickness, and CSA of selected ankle structures. The length of the ATFL and the thickness of the ATFL and CFL were longer and thicker in injured groups compared to healthy.

Background Various imaging techniques have been utilized for the diagnosis of chronic lateral ankle ligament injury. This systemic review will explore the effectiveness of different imaging techniques in diagnosing chronic lateral ankle ligament injury. Methods Relative studies were retrieved after searching 3 databases (MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trails). Eligible studies were summarized. Data were extracted to calculate pooled sensitivity and specificity of magnetic resonance imaging (MRI), ultrasonography (US), stress radiography, and arthrography. Results Fifteen studies met our inclusion and exclusion criteria. A total of 695 participants were included. The pooled sensitivities in diagnosing chronic ATFL injury were 0.83 [0.78, 0.87] for MRI, 0.99 [0.96, 1.00] for US, and 0.81 [0.68, 0.90] for stress radiography. The pooled specificities in diagnosing chronic ATFL injury were 0.79 [0.69, 0.87] for MRI, 0.91 [0.82, 0.97] for US, and 0.92 [0.79, 0.98] for stress radiography. The pooled sensitivities in diagnosing chronic CFL injury were 0.56 [0.46, 0.66] for MRI, 0.94 [0.85, 0.98] for US, and 0.90 [0.73, 0.98] for arthrography. The pooled specificities in diagnosing chronic CFL injury were 0.88 [0.82, 0.93] for MRI, 0.91 [0.80, 0.97] for US, and 0.90 [0.77, 0.97] for arthrography. Conclusion This systematic review with meta-analysis investigated the accuracy of imaging for the diagnosis of chronic lateral ankle ligament injury. Ultrasound manifested high diagnostic accuracy in diagnosing chronic lateral ankle ligament injury. Clinicians should be aware of the limitations of MRI in detecting chronic CFL injuries.

Ankle instability is a condition that often requires surgery to stabilize the ankle joint that will improve pain and function if nonoperative treatments fail. Ankle stabilization surgery may be performed as a repair in which the native existing anterior talofibular ligament or calcaneofibular ligament (or both) is imbricated or reattached. Alternatively, when native ankle ligaments are insufficient for repair, a reconstruction of the ligaments may be performed in which an autologous or allograft tendon is used to reconstruct the anterior talofibular ligament or calcaneofibular ligament (or both). Currently, ankle stabilization surgery is most commonly performed through an open incision, but arthroscopic ankle stabilization using repair techniques has been described and is being used more often. We present our technique for anatomic ankle arthroscopic reconstruction of the lateral ligaments (anti-ROLL) performed in an all–inside-out manner that is likely safe for patients and minimally invasive.

An accurate assessment of ankle ligament kinematics is crucial in understanding the injury mechanisms and can help to improve the treatment of an injured ankle, especially when used in conjunction with robot-assisted therapy. A number of computational models have been developed and validated for assessing the kinematics of ankle ligaments. However, few of them can do real-time assessment to allow for an input into robotic rehabilitation programs.An ankle computational model was proposed and validated to quantify the kinematics of ankle ligaments as the foot moves in real-time. This model consists of three bone segments with three rotational degrees of freedom (DOFs) and 12 ankle ligaments. This model uses inputs for three position variables that can be measured from sensors in many ankle robotic devices that detect postures within the foot-ankle environment and outputs the kinematics of ankle ligaments. Validation of this model in terms of ligament length and strain was conducted by comparing it with published data on cadaver anatomy and magnetic resonance imaging.The model based on ligament lengths and strains is in concurrence with those from the published studies but is sensitive to ligament attachment positions.This ankle computational model has the potential to be used in robot-assisted therapy for real-time assessment of ligament kinematics. The results provide information regarding the quantification of kinematics associated with ankle ligaments related to the disability level and can be used for optimizing the robotic training trajectory.

Background: Various ankle ligaments have different structural composition. The aim of this study was to analyze the morphological structure of ankle ligaments to further understand their function in ankle stability. Methods: One hundred forty ligaments from 10 fresh-frozen cadaver ankle joints were dissected: the calcaneofibular, anterior, and posterior talofibular ligaments; the inferior extensor retinaculum, the talocalcaneal oblique ligament, the canalis tarsi ligament; the deltoid ligament; and the anterior tibiofibular ligament. Hematoxylin-eosin and Elastica van Gieson stains were used for determination of tissue morphology. Results: Three different morphological compositions were identified: dense, mixed, and interlaced compositions. Densely packed ligaments, characterized by parallel bundles of collagen, were primarily seen in the lateral region, the canalis tarsi, and the anterior tibiofibular ligaments. Ligaments with mixed tight and loose parallel bundles of collagenous connective tissue were mainly found in the inferior extensor retinaculum and talocalcaneal oblique ligament. Densely packed and fiber-rich interlacing collagen was primarily seen in the areas of ligament insertion into bone of the deltoid ligament. Conclusions: Ligaments of the lateral region, the canalis tarsi, and the anterior tibiofibular ligaments have tightly packed, parallel collagen bundles and thus can resist high tensile forces. The mixed tight and loose, parallel oriented collagenous connective tissue of the inferior extensor retinaculum and the talocalcaneal oblique ligament support the dynamic positioning of the foot on the ground. The interlacing collagen bundles seen at the insertion of the deltoid ligament suggest that these insertion areas are susceptible to tension in a multitude of directions. Clinical Relevance: The morphology and mechanical properties of ankle ligaments may provide an understanding of their response to the loads to which they are subjected.

sprains remain the single most frequent injury in modern sports. With the growing knowledge on ankle joint disorders, it appears that this injury causes more damage to the ankle joint than was previously assumed. Previously, few papers have investigated the concomitant injuries that may be associated with a “simple lateral ankle sprain”. The editors have selected peer-reviewed articles for this current special edition, which present updated scientific information on the pathologies associated with an ankle sprain. We hope that the reader will be in a position, after reading this edition, to incorporate this information into common daily practice when managing ankle injuries and in this way reduce the morbidity associated with this seemingly innocuous condition. The cornerstone of clinical practice is sound knowledge of surgical anatomy. For this reason, we have decided to republish Golano’s article on the anatomy of the ankle ligaments as the leading paper in this issue with an addendum from one of Golano’s former co-workers, Mik Dalmau Pastor, representing the Barcelona School of Orthopaedic Surgical Anatomy [5]. KSSTA is proud to present a special issue on ankle joint disorders following a lateral ankle sprain. Lateral ankle

Musculoskeletal pathology of the ankle can involve many different structures, including bone, cartilage, ligament, tendon, and neurovascular structures. Soft tissue disorders of the ankle are very common. This chapter focuses on four of the most frequently injured soft tissue structures of the ankle: the Achilles tendon, peroneal tendons, posterior tibial tendon, and ankle ligaments. Many of the problems associated with these structures can be effectively managed nonsurgically. If nonsurgical treatments are unsuccessful, then operative intervention is at times appropriate.

Injury of the ankle ligaments is very common during sports participation. These injuries may result in mechanical and/or functional ankle instability, which if not treated properly might develop into chronic instability. Diagnosis is made through comprehensive medical history taking and manual testing, which may be complemented with imaging studies. Both conservative and surgical treatments have shown good results; however, when considering elite athletes, the surgical management is preferred. Several preventive strategies have emerged providing a cost-effective approach to reduce the risk of ankle ligament injury. Tibiofibular syndesmotic injuries should be treated conservatively when stable and surgically when unstable. Similarly, isolated superficial deltoid ligament injuries may be treated through a conservative approached, and, in case of insufficiency, the approach should be surgical. A rapid return to sports participation should be expected with a reasonable return to the pre-injury levels.

Ankle sprains constitute the majority of ankle injuries, and result in pain, limited mobility/exercise and loss of school/work days. Ankle sprains involve at least one of the ankle ligaments and range from a micro tear to complete tear of the ligament or group of ligaments. The most common mechanism of ankle sprains is inversion stress of a plantar-flexed foot, while the most frequently injured ligament is the anterior talofibular ligament. The attending clinician needs to stratify the risk of fracture through history-taking and physical examination, manage the pain, assess long-term complications and provide certification for rest and recovery. The Ottawa ankle rules may be useful. Graduated exercises to maintain the ankle’s range of motion should be started early, after the resolution of initial pain and swelling. The risk of recurrent ankle injuries is often a combination of both mechanical and functional disabilities.

The aim of this work is to provide a computational tool for the mechanical characterization of the hindfoot ligaments. The investigation is performed by a coupled numerical and experimental approach. For this purpose, a numerical model that represents the complex structural configuration of the hindfoot and the typical features of the mechanical behaviour of the ligament tissue is developed. The geometrical analysis of the anatomical site is performed starting from the processing of computed tomography and magnetic resonance images. Accounting for morphometric measurements, the virtual solid model provides an averaged configuration of the hindfoot structure. In order to specify the mechanical behaviour of the ligament tissue, a fibre-reinforced visco-hyperelastic model is adopted. The formulation accounts for the anisotropic configuration, geometric non-linearity, non-linear elasticity and time-dependent phenomena. Numerical analyses are performed to evaluate the biological tissues and structure mechanics with regard to physiological boundary conditions, accounting for dorsiflexion and plantarflexion movements. In order to evaluate the reliability of the numerical model developed, the experimental data are compared with the numerical results. The numerical results are in agreement with the range of values obtained by experimental test confirming the accuracy of the procedure adopted.

Ligament sprains, defined as tearing of bands of fibrous tissues within ligaments, account for a majority of injuries to the foot and ankle complex in field-based sports. External rotation of the foot is considered the primary injury mechanism of syndesmotic ankle sprains with concomitant flexion and inversion/eversion associated with particular patterns of ligament trauma. However, the influence of the magnitude and direction of loading vectors to the ankle on the in situ stress state of the ligaments has not been quantified in the literature. The objective of the present study was to search for the maximum injury tolerance of a human foot with an acceptable subfailure distribution of individual ligaments. We used a previously developed and comprehensively validated foot and ankle model to reproduce a range of combined foot rotation experienced during high-risk sports activities. Biomechanical computational investigation was performed on initial foot rotation from $$20{^{\circ }}$$ of plantar flexion to $$15{^{\circ }}$$ of dorsiflexion, and from $$15{^{\circ }}$$ of inversion to $$15{^{\circ }}$$ of eversion prior to external rotation. Change in initial foot rotation shifted injury initiation among different ligaments and resulted in a wide range of injury tolerances at the structural level (e.g., 36–125 Nm of rotational moment). The observed trend was in agreement with a parallel experimental study that initial plantar flexion decreased the incidence of syndesmotic injury compared to a neutral foot. A mechanism of distributing even loads across ligaments subjected to combined foot rotations was identified. This mechanism is potential to obtain the maximum load-bearing capability of a foot and ankle while minimizing the injury severity of ligaments. Such improved understanding of ligament injuries in athletes is necessary to facilitate injury management by clinicians and countermeasure development by biomechanists.

The aim of this work is to provide a computational tool for the investigation of ankle mechanics under different loading conditions. The attention is focused on the biomechanical role of ankle ligaments that are fundamental for joints stability. A finite element model of the human foot is developed starting from Computed Tomography and Magnetic Resonance Imaging, using particular attention to the definition of ankle ligaments. A refined fiber-reinforced visco-hyperelastic constitutive model is assumed to characterize the mechanical response of ligaments. Numerical analyses that interpret anterior drawer and the talar tilt tests reported in literature are performed. The numerical results are in agreement with the range of values obtained by experimental tests confirming the accuracy of the procedure adopted. The increase of the ankle range of motion after some ligaments rupture is also evaluated, leading to the capability of the numerical models to interpret the damage conditions. The developed computational model provides a tool for the investigation of foot and ankle functionality in terms of stress-strain of the tissues and in terms of ankle motion, considering different types of damage to ankle ligaments.

As is true for orthopedics in general, the assessment of a sports related injuries of the foot and ankle begins with a good history and physical. While many maladies are readily diagnosed, often a differential remains. In these instances, imaging assessment is often useful. Additionally, as our understanding of injury to the foot and ankle evolves, a more nuanced approach to treatment has developed. Imaging is often required to optimize treatment. This brief chapter is intended to provide an overview to imaging sports related pedal injuries. This chapter is not a comprehensive review. Whole books intended to provide such information have been written. Rather, this manuscript is intended to provide information to guide the reader in deciding when and with what imaging modality to assess a patient further. By necessity and design, this manuscript is based much upon the author’s opinions and experience. It is understood that different imaging approaches to a clinical problem are possible, depending upon the experience of the imager and which imaging modalities are readily available.

Background: Treatment of patients with repeated ankle sprains and chronic lateral ankle instability tends to focus on the lateral collateral ligaments. We reviewed records to ascertain the prevalence of abnormalities of the deltoid ligament in this population. Methods: Retrospective review of MR images and surgical reports was performed for all patients during a 3-year period that underwent surgical treatment of chronic ankle instability at a single institution. Forty-seven ankles (46 patients) met inclusion criteria. None had medial ankle pain. Results: On MRI, all patients had anterior talofibular ligament tear, plus injury to one or more additional ligaments. Ninety-one percent had injury of calcaneofibular ligament. Injury to the posterior talofibular ligament was less common (49%). Deltoid ligament injuries were seen in 72% of cases (23% superficial deltoid only, 6% deep deltoid only, 43% both superficial and deep components). Of patients with injury to the superficial deltoid, 32% had an intact deep deltoid ligament. MRI correlated well to surgical findings. Conclusion: Deltoid ligament injuries were common in patients with lateral ankle instability who underwent reconstruction. Level of Evidence: IV, Retrospective Case Series

Biofidelic devices are used in the automobile industry to assess injury risk during a vehicular accident. Similar biofidelic devices may have broad applicability in the field of sports injury prevention and could be used to enhance player safety. Ankle sprains constitute one of the most common sports injuries. Past studies have suggested that high rotational traction at the shoe—surface interface may increase the likelihood of lower-extremity injury. Researchers have assessed this risk by measuring the peak torque during an applied rotation. On the other hand, ankle sprains may be dependent upon the amount of strain developed in the ankle ligaments during rotation of the foot—ankle complex and not the magnitude of torque. The current study quantifies the torsional stiffness of the human foot—ankle complex based on cadaver experiments. The development of a surrogate foot—ankle complex is then detailed and compared with the human response. Finally, the results of a rotational traction study on a couple of football shoe—surface interfaces are presented using the surrogate ankle. The testing resulted in a new outcome variable, namely the peak twist of the ankle, that may allow assessment of the risk of injury to the ankle due to excessive rotational traction at the shoe—surface interface.

Background: In the assessment of lateral ankle instability, the anterior drawer test has been found to be inaccurate and the focus on pure anterior translation cannot properly perceive the anterolateral rotatory nature of the talar displacement. In order to address this, the anterolateral drawer test can be done with digital palpation of the talar displacement anterolaterally with a controlled angle of plantarflexion as well as application of the translational force. Materials and Methods: We evaluated the anterolateral drawer test and the original anterior drawer test in 10 fresh below-the-knee specimens using a direct anatomic measurement (DAM) loaded by a Telos stress device as a reference. Specimens were assigned into three groups: intact ligaments, ATFL-cut, and ATFL&CFL-cut. The examiners were blinded with one performing the anterolateral drawer test (E1) while the other performed the original anterior drawer test (E2). Results: Pearson's correlation coefficient indicated a statistically significant linear relationship between DAM/E1 r = 0.931, p < 0.001 but not between DAM/E2 r = 0.519, p = 0.124. Intraclass correlation coefficient show correlation between DAM/E1 and DAM/E2 to be 0.945 ( p < 0.001) and 0.683 ( p = 0.051). When 3 mm or more was used as the threshold to diagnose a lateral ligament rupture, sensitivity and specificity were E1(100%, 100%) and E2(75%, 50%). Conclusion: The anterolateral drawer test showed high accuracy in the determination of lateral ankle instability and in the diagnosis of a ligament rupture. Clinical Relevance: Further investigation regarding the accuracy and reliability of this test in comparison with the original anterior drawer test is warranted in a patient population with ankle instability.

The presence of sensorimotor deficits in patients who have suffered ankle sprains or who have chronic ankle instability has been recognized for several decades; however, a body of research literature has developed that elucidates potential physiologic explanations for these deficits. Alterations in a spectrum of sensorimotor measures make it apparent that conscious perception of afferent somatosensory information, reflex responses, and efferent motor control deficits are present with ankle instability. The specific origin of these deficits local to the ankle ligaments or at the spinal or supraspinal levels of motor control have yet to be fully elucidated. It is clear, however, that both feedback and feedforward mechanisms of motor control are altered with ankle instability.

Zusammenfassung: Die chronische Sprunggelenkinstabilität ist eine typische Pathologie im Sport und entwickelt sich bei 20 bis 40% der Sportler nach erlittener akuter Sprunggelenkdistorsion. Man unterscheidet zwischen einer lateralen und medialen Sprunggelenkinstabilität, wobei die Kombination beider als Rotationsinstabilität des oberen Sprunggelenks bezeichnet wird. Des Weiteren kann pathophysiologisch eine mechanische oder funktionelle Sprunggelenkinstabilität unterschieden werden, die sich durch eine strukturelle Bandläsion bzw. durch eine Schwächung der neuromuskulären Kontrolle manifestiert. Durch die erschwerte Diagnose und eine komplexe Therapie, die oft eine operative Rekonstruktion bedingt, stellt die chronische Sprunggelenkinstabilität für den behandelnden Arzt eine vielschichtige Entität dar. Die vorliegende Übersichtsarbeit erörtert Pathomechanismen, Möglichkeiten der Diagnostik, Indikationen zur konservativen und operativen Therapie sowie potenzielle Langzeitschäden wie die posttraumatisch-ligamentäre Sprunggelenksarthrose