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Lateral ankle ligament injury

118 citationsUpdated Sep 2026

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Overview

Lateral ankle ligament injuries account for more than 75% of all ankle ligament injuries, predominantly involving the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) [8]. The lateral collateral ligament complex comprises three components: the posterior talofibular, anterior talofibular, and calcaneofibular ligaments [8]. Medial ligament injuries are usually seen in association with a fracture or joint injury [8]. A typical history involves a twisting injury followed by pain, bruising, and swelling [8]. In an ATFL sprain, tenderness is maximal just distal and slightly anterior to the lateral malleolus, and the slightest attempt at passive inversion is extremely painful [8]. Because stability assessment is not possible in the acute phase, it is essential to examine the entire leg and foot to identify easily missed undisplaced fractures of the ankle, proximal fibula, tarsal bones, and peroneal tendon sheath [8]. Imaging is guided by the Ottawa ankle rules, requiring anteroposterior, lateral, and mortise views (15–20 degrees internally rotated) [8]. Weight-bearing views help determine stability, while computed tomography and magnetic resonance imaging may be needed to fully characterize injuries or in patients with persistent pain, swelling, instability, and impaired function over 6 weeks or longer [8].

The majority of grades I, II, and III lateral ankle ligament ruptures can be managed without surgery [2]. Successful treatment of grade II and III acute injuries can be achieved with individualized aggressive, non-operative measures [3]. Surgical repair for acute ruptures is indicated on an individual basis [2], potentially yielding better results in professional athletes [3]. If disruption of the lateral ligaments is noted at operation, repair is indicated as it markedly increases the chances for a stable ankle [6]. Ankle arthroscopy followed by open anatomic ligament repair is a reliable procedure for patients requiring return to high-demanding sports after severe acute ankle sprains [172].

Chronic lateral ankle instability is frequently encountered in military service members [4]. Appropriate nonoperative treatment should be attempted initially, but surgical management is warranted when nonoperative treatment fails to prevent long-term sequelae [4]. Surgical repair is indicated if the patient needs a painless, stable ankle for heavy duty [63]. Operative management of serious injury to the fibular collateral ligament is satisfactory [5], and reconstruction of the lateral ankle ligament is a relatively stable treatment for chronic instability [13]. Lateral ligament reconstruction with allograft represents a valid treatment option in patients with severe chronic lateral ankle instability, leading to satisfying outcomes and reduced joint morbidity [12]. Arthroscopic lateral ankle ligament repair yields favorable short-term clinical outcomes [11], and when feasible, produces similarly favorable outcomes compared with open repair [23]. Endoscopic ligament reconstruction is a safe procedure that produces good clinical results with minimal complications [25], and ultrasound-guided ATFL repair with or without augmentation is safe and results in clinical improvement at 6 months [21]. Although only fair-quality evidence exists in support of open operative treatment of chronic ankle instability, this systematic review helps reassure clinicians of their current practices [74]. Arthroscopic ankle stabilisation repair and reconstruction techniques hold considerable promise but require further evaluation to better determine the indications of repair versus reconstruction and to obtain information on long-term outcomes [43]. It is likely that arthroscopic rather than open lateral ankle ligament repair will become the standard of care in the future [14]. Operative procedures that only focus on part of the pathology should be approached with caution until assessment of a patient with ankle instability defines all deficiencies [22]. The literature would benefit greatly from the standardization of the definition of ankle instability treatment failure [71].

Anatomy & Pathophysiology

Bony Anatomy

The ankle mortise is formed by the tibial plafond, medial malleolus, and lateral malleolus, articulating with the dome of the talar body [86]. The talar dome is wider anteriorly and narrower posteriorly, causing the mortise to widen and become more stable in dorsiflexion [86]. This widening measures 1 to 1.5 mm during motion from plantar flexion to dorsiflexion [86]. Consequently, medial and superior clear spaces appear wider with the foot in plantar flexion [86]. The distal fibula features a convex medial surface that articulates with the concave incisura fibularis of the distal lateral tibia [86]. During ankle motion and ambulation, the fibula rotates approximately 2 degrees within the incisura [86]. Ankle dorsiflexion results in external rotation and proximal translation of the fibula [86]. The distal tibiofibular joint (ankle syndesmosis) and fibula provide stability against lateral talar translation [86].

Radiographic measurements are sensitive to limb position. Plantar flexion of the ankle produces changes in radiographic measurements of the medial clear space [110]. The size of the medial clear space more than doubles depending upon the rotational position of the limb [95]. There is a significant increase in medial clear space with ankle plantarflexion [95]. The talocrural angle is approximately 83 degrees and symmetrical with the contralateral ankle [95]. The medial clear space should be less than 5 mm and no more than 2 mm greater than the tibiotalar clear space [95]. The tibiofibular clear space, measured 10 mm above the joint line, is relatively constant with rotation and has an accepted normal parameter of greater than 5 mm [95]. In contrast, tibiofibular overlap, measured 10 mm above the joint line, is highly variable dependent on rotation, with accepted normal parameters of less than 5 mm on AP view and less than 1 mm on the mortise view [95]. The "ball sign" is a confirmatory visual cue for fibular length, described as an unbroken curve connecting the recess in the distal tip of the fibula and the lateral process of the talus when the fibula is out to length [95]. Shortening of the fibula results in lateral and valgus subluxation of the talus [95].

The ankle joint is responsible for most sagittal plane motion of the foot and ankle, with 23 to 48 degrees of plantar flexion and 10 to 23 degrees of dorsiflexion [86]. The ankle joint also contributes to inversion/eversion and rotation [86]. A simplified model of the ankle joint has a horizontal axis from anteromedial to posterolateral and a coronal axis from superomedial directed distally and laterally to the tip of the fibula [86].

Ligamentous Anatomy

The lateral ankle ligaments function as restraints to varus/inversion forces at the ankle [86]. The anterior talofibular ligament (ATFL) originates from the anteroinferior aspect of the lateral malleolus, 1 cm proximal to its tip, and extends to the lateral aspect of the talar neck [86]. The calcaneofibular ligament (CFL) extends from the tip of the lateral malleolus to the lateral aspect of the calcaneus [86]. The CFL can lead to avulsion injuries of the distal tip of the fibula [86]. The posterior talofibular ligament (PTFL) extends from the posterior lateral malleolus to the posterolateral talus [86]. The ATFL is the weakest ankle ligament [86]. The PTFL is the strongest ankle ligament [86]. The ATFL inferior fascicle is connected to the calcaneofibular ligament [180]. The ATFL superior fascicle is an intra-articular structure [180].

The deltoid ligament complex is the primary ankle stabilizer during stance [86]. It consists of two distinct layers: the superficial and deep layers [92]. The deltoid ligament consists of at most six bands, of which only three are constant: the tibionavicular ligament, tibiospring ligament, and deep posterior tibiotalar ligament [92]. The superficial deltoid ligament extends from the distal medial malleolus to the navicular bone, sustentaculum tali of calcaneus, medial talus, and spring ligament [86]. It functions primarily to resist valgus/eversion ankle forces [86]. The superficial layer is a broad, bandlike structure that originates from the anterior malleolus and fans out to insert into the navicular, neck of the talus, sustentaculum tali, and posteromedial talar tubercle [92]. The tibiocalcaneal portion of the superficial deltoid ligament is the strongest component and resists eversion of the calcaneus [92]. The deltoid ligament, and specifically the tibiocalcaneal ligament, primarily prohibits eversion and abduction [92].

The deep deltoid ligament extends from the apex of the medial malleolus to the medial talar body and functions primarily to resist lateral talar translation and external rotation [86]. The posterior deep deltoid is the most important component of the deep deltoid ligament [86]. The deep portion of the deltoid ligament is the primary medial stabilizer of the ankle joint [92]. It is organized into two short, thick, discrete bands: the anterior and posterior deep tibiotalar ligaments [92]. Both deep tibiotalar ligaments are intra-articular but extrasynovial [92]. The deep posterior band comprises the largest band of the deltoid complex [92]. The anterior deep tibiotalar ligament arises from the anterior malleolus and attaches to the medial aspect of the talus [92]. The posterior deep tibiotalar ligament originates from the posterior malleolus and inserts on the medial body of the talus [92]. The posterior deep tibiotalar ligament is the strongest of the entire deltoid complex [92]. The deep deltoid, primarily the deep posterior tibiotalar ligament, functions to resist external rotation when the foot is dorsiflexed [92]. The deep deltoid is responsible for the greatest restraint against lateral translation [92]. Valgus tilting of the talus within the mortise requires complete rupture of both the superficial and deep deltoid [92]. The deep deltoid ligament has the highest load to failure at 713.8 N ± 69.3 compared with the lateral collateral ligaments [92]. The dominant mode of failure for the deep deltoid ligament occurs as an intrasubstance rupture near its talar insertion [92]. The failure of the superficial deltoid ligament is most commonly at its insertion on the anterior malleolus [92].

The deltoid ligament has a rich vascular supply from three separate extraosseous sources: the medial tarsal artery, the posterior tibial artery, and the tibialis anterior artery [92]. The deltoid ligament also has a component of intraosseous vascular supply from either the talus or the medial malleolus [92].

The distal tibiofibular syndesmosis is a complex arrangement of ligaments whose purpose is to maintain the relationship between the distal tibia and the fibula [184]. The syndesmotic ligamentous complex primarily acts to control translational and rotational forces while allowing small amounts of physiologic motion [184]. The most important ligaments of the syndesmosis include the anterior-inferior tibiofibular ligament, the posterior-inferior tibiofibular ligament, the transverse tibiofibular ligament, and the interosseous ligament [184]. The deltoid ligament contributes to syndesmotic stability by preventing lateral translation of the talus [184]. The anterior-inferior tibiofibular ligament originates from the anterior distal tibia (Chaput tubercle) and inserts into the anterior aspect of the distal fibula (Wagstaffe tubercle) [184]. The posterior-inferior tibiofibular ligament originates from the posterior distal tibia (Volkmann tubercle) and inserts into the posterior aspect of the lateral malleolus [184]. The posterior-inferior tibiofibular ligament is the strongest component of the syndesmosis [184]. The interosseous ligament represents a distal thickening of the interosseous membrane, transversely connecting the tibia and the fibula [184].

Pathophysiology & Mechanism of Injury

More than 75% of ankle ligament injuries involve the lateral ligament complex, particularly the anterior talofibular ligament and calcaneofibular ligament [8]. The most common mechanism of injury to the ankle ligaments is inversion of the foot [42]. With an inversion mechanism of injury, the anterior talofibular ligament is the first or only ligament to sustain injury [42]. The most common mechanism of injury to the lateral ankle ligaments occurs from a forced plantar flexion and inversion of the ankle, where the ATFL is injured first, followed by the CFL [24]. A total rupture of the lateral ligaments involves the calcaneofibular ligament and the posterior talofibular ligaments as well [42]. An eversion injury causes damage to the deltoid ligaments [42]. A hyperdorsiflexion trauma might cause an injury to the syndesmotic ligaments [42].

The classic low ankle sprain is defined as a sprain that results in an injury to the lateral ligamentous structures of the ankle, which occur below the level of the distal tibiofibular syndesmosis [57]. Excessive inversion of the plantarflexed foot leads to injury to the anterior talofibular ligament [57]. Excessive inversion of the dorsiflexed foot causes injury to the calcaneofibular ligament and, less commonly, the posterior talofibular ligament [57]. An increased propensity for inversion injuries occurs in conjunction with obvious cavovarus foot deformity as well as in conjunction with subtle cavovarus foot deformity [57].

The classic high ankle sprain is an injury to the distal tibiofibular syndesmosis [184]. High ankle sprains represent less than 10% of all ankle sprains, although this incidence is higher in collision sports [184]. High ankle sprains are invariably rotational injuries, usually caused by external rotation of the foot relative to the leg [184]. Excessive external rotation causes the talus to drive the distal tibia and fibula apart, leading to a failure of the ligaments that normally maintain their position relative to one another [184]. Associated injuries with high ankle sprains include Weber type B and C ankle fractures, osteochondral defects, and peroneal tendon injuries [184].

The greatest increases in laxity after sectioning the ATFL occurred in ankle positions and loads corresponding to common modes of injury [56]. The biomechanical model explains clinical observations by demonstrating that stability is predominantly a function of the tibio-talar sector [111]. The dynamic congruency of the joint, which is influenced by ligamentous integrity, remains the main anatomical component in mechanical ankle instability [89]. Patients with mechanical ankle instability have more of an internally rotated talus than a variation of fibular position [119]. Abnormal internal rotation of the talus in patients with mechanical ankle instability was decreased after ankle lateral stabilization surgery [140].

The development of chronic lateral ankle instability is multifactorial and can involve a patient’s abnormal neuromuscular response and proprioception, abnormal gait mechanics, global ligamentous laxity, increased body weight, and anatomic features of the hindfoot and ankle including cavus alignment and hindfoot stiffness [52]. The intra-articular position of an injured ATFL superior fascicle is thought to impair healing, similar to the resynovialization process of a ruptured anterior cruciate ligament remnant in the knee [180]. This theory of impaired healing reinforced the concept of microinstability [180]. Apoptosis occurs in the anterior talofibular ligament of patients with chronic lateral ankle instability [174]. The number of mechanoreceptors was negatively correlated with ankle sensorimotor dysfunction in chronic ankle joint instability [132]. Patients with chronic ankle instability had longer electromechanical delay times in neutral but not when the ankle was placed in inversion [131]. Athletes with chronic ankle instability had a relatively inverted ankle, reduced muscle co-contraction, and a lower dynamic stiffness in the ankle joint during the landing phase of sports maneuvers [127]. Alterations of kinematics in athletes with chronic ankle instability were found not only at the ankle but also at hip joints during the side-cutting movement [104]. Dynamic balance deficits in individuals with chronic ankle instability were attested to reduced sagittal plane motions at the hip, knee and ankle joints, and reduced capacity of the stance limb to avail of its supporting base [116]. The CAI, coper, and control groups displayed different ankle joint coupling patterns and coordination variability during a walking gait cycle [137]. Most studies found distinct characteristics of the incisura fibularis morphology associated with ligamentous ankle lesions, potentially due to lower osseous resistance against tibiofibular displacement [133]. The operative ankle exhibited greater syndesmosis length and altered kinematics compared to the healthy side during all tested activities following syndesmosis repair [91].

Classification

Epidemiology and Mechanism

More than 75% of ankle ligament injuries involve the lateral ligament complex, particularly the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) [8]. The ATFL is the most frequently ruptured and most important component of the lateral ligaments of the ankle [41]. The most common mechanism of injury is forced plantar flexion and inversion [24]. In these injuries, the ATFL is injured first, followed by the CFL [24]. A total rupture of the lateral ligaments involves the calcaneofibular ligament and the posterior talofibular ligaments [42]. Isolated lateral ligament ankle injury is not as common as is believed [7].

Grading Systems

Grade I: Includes a partial tear of the lateral ligament complex [167]. Grade II: Involves decreased motion, some loss of function, a torn anterior talofibular ligament with an intact calcaneofibular ligament, some ligamentous instability (positive anterior drawer and negative talar tilt), swelling, hemorrhage, and point tenderness [167]. Grade III: Involves almost total loss of function, diffuse swelling and hemorrhage, extreme point tenderness, disruption of the ankle capsule, and a complete tear of the lateral ligament complex evidenced by marked ligamentous instability (positive anterior drawer and talar tilt test results) [167]. 4-Grade System: Used to classify ankle sprains in elite track and field athletes [160].

Associated Injuries

Six exclusive injury patterns are defined based on lateral and syndesmotic ligament involvement, ranging from no injury to complete ATFL/CFL/PTFL and syndesmotic disruption [29]. Intact tibiofibular ligaments were found equally frequently among patients with normal or any grade of lateral ligament damage [35]. More severe injuries to the syndesmotic ligaments were associated with normal or minimally traumatized lateral ligaments [35]. Isolated lateral ankle ligament injuries do not directly affect syndesmotic stability [205]. In athletes with an acute ligamentous ankle injury, a prevalence for osteochondral lesions of 14% was established using 3T MRI [39].

Diagnostic Assessment

In the acute setting, clinical evaluation can exclude complete discontinuity and identify athletes with a high probability of complete discontinuity of the lateral ankle ligaments [34]. Ultrasound manifested high diagnostic accuracy in diagnosing chronic lateral ankle ligament injury [27] and can be used in primary diagnostics of acute lateral ankle ligament injury [28]. Grading of the three major ligamentous complexes and individual ankle ligaments according to the Schneck grading system on 3 T MRI resulted in limited diagnostic reliability [128]. Two distinct ATFL fascicles may be identified in the majority of ankles on MRI [37].

Clinical Presentation

Mechanism and Epidemiology

Ankle ligament injury is the most frequent cause of acute ankle pain [42] and represents one of the most common athletic injuries [18]. In adolescent athletes, ankle sprains are the most common reason for missed athletic participation [57]. More than 75% of ankle ligament injuries involve the lateral ligament complex, particularly the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) [8]. The ATFL is the most frequently ruptured and most important component of the lateral ligaments [41]. The calcaneofibular ligament (CFL) is less commonly involved than the ATFL [79], while the strong posterior talofibular ligament (PTFL) is rarely implicated in lateral ankle sprains [79].

The most common mechanism of injury is inversion of the foot [42]. With an inversion mechanism, the ATFL is the first or only ligament to sustain injury [42]. A total rupture of the lateral ligaments involves the calcaneofibular ligament and the posterior talofibular ligaments as well [42]. Isolated lateral ligament ankle injury is not as common as is believed [7]. Prior ankle injuries were present in more than 50% of elite college football players attending the NFL Combine [117]. For women in NCAA ice hockey, low ankle sprains were the most common injury and resulted in the most moderate time lost [120].

History and Symptoms

A history of a twisting injury followed by pain, bruising, and swelling is typical of an ankle ligament injury [8]. Patients often recall a twisting mechanism, typically inversion [79]. Acute low ankle sprains typically manifest by a large amount of lateral ankle swelling, pain with weight bearing, and pain in the lateral ankle [57]. Swelling, ecchymosis, and pain with weight bearing are common findings in ankle sprains [79]. An acute lateral ankle sprain significantly decreases physical activity across the lifespan [1].

Residual ankle symptoms were found in 33% of patients following acute ankle sprains [40]. Persistent abnormal changes of the ankle were found in 60% of patients following acute ankle sprains [40]. Intra-articular pathological findings are observed in patients with anterolateral pain after an ankle sprain despite no demonstrable abnormal lateral laxity [50]. Antero-lateral ankle impingement syndrome is closely linked to anterior talo-fibular ligament injury and, in some patients, to chronic ankle instability [113]. Posteromedial impingement lesions should not be overlooked in the management of patients with refractory ankle symptoms after severe sprains [108]. Patients may develop complex regional pain syndrome following ankle sprain [79]. Injury to branches of the superficial peroneal nerve can cause numbness over the dorsal midfoot following an inversion mechanism [79].

Physical Examination

In an ATFL sprain, tenderness is maximal just distal and slightly anterior to the lateral malleolus [8]. The physical examination characteristically shows focal tenderness to palpation over the involved lateral ankle ligamentous structures in acute low ankle sprains [57]. The slightest attempt at passive inversion of the ankle is extremely painful in an ATFL sprain [8]. Pain with resisted eversion of the foot is a sign of peroneal tendon injury during the inversion episode [57]. It is essential to examine the entire leg and foot because undisplaced fractures of the ankle, the more proximal fibula, tarsal bones, and the peroneal tendon sheath are easily missed [8].

Stability assessment in the acute phase is not possible [8]. In the acute setting, clinical evaluation can exclude complete discontinuity and identify athletes with a high probability of complete discontinuity of the lateral ankle ligaments [34]. The diagnosis of lateral ankle sprain is made clinically by assessing pain, swelling, and ligamentous laxity via the talar tilt and anterior drawer tests [99]. The anterior drawer test involves anterior translation of the slightly plantarflexed foot, where excessive anterior translation represents chronic laxity of the injured ATFL [57]. Inversion stress testing of the neutral foot may demonstrate increased laxity, such as in the setting of an attritional calcaneofibular ligament [57].

Assessment for recurrent instability requires evaluation for hindfoot varus [79]. Patients should be questioned about symptoms of a loose body or osteochondral injury, such as mechanical symptoms like locking or catching [79]. Chronic ankle instability is defined by ongoing symptoms of at least 6 months including recurrent sprains, pain, and impairments with perceived instability during sportive activity [96]. Clinical examination for chronic mechanical ankle instability includes the anterior talar drawer and talar tilt test [96].

Imaging

The need for X-ray is guided by the Ottawa ankle rules for when to X-ray [8]. The Ottawa Ankle Rules have been proven as a reliable tool for determining when radiography is necessary in the evaluation of an acute ankle sprain [57]. A fracture is suspected when there is difficulty with weight bearing, tenderness to palpation over the medial or lateral malleolus, tenderness over the navicular, or tenderness over the base of the fifth metatarsal [57]. When radiographs are necessary, weight-bearing AP, lateral, and mortise views are recommended [57]. Anteroposterior, lateral, and 'mortise' (15–20 degrees internally rotated) views of the ankle should be obtained [8]. Weight-bearing views are useful in helping determine stability [8]. Varus stress views can be used to evaluate for excessive talar tilt in the setting of ATFL laxity [57]. External rotation stress views should be obtained to rule out a syndesmotic injury [57].

Computed tomography (CT) and magnetic resonance imaging (MRI) may be needed to fully characterize an injury or in those who have persistent pain, swelling, instability, and impaired function over 6 weeks or longer [8]. MRI is rarely warranted, except in the setting of prolonged pain or instability [57]. MRI may demonstrate attenuation or tear of the lateral ligamentous structures [79]. Two distinct ATFL fascicles may be identified in the majority of ankles on MRI [37]. Bone bruising is common in severe sprains and may result in longer time to pain-free activity and return to sports [79]. CT scanning is considered for evaluation of a suspected or identified lateral process fracture [79].

Ultrasound manifested high diagnostic accuracy in diagnosing chronic lateral ankle ligament injury [27]. Ultrasonography could be used in primary diagnostics of acute lateral ankle ligament injury [28]. In athletes with an acute ligamentous ankle injury, a prevalence for osteochondral lesions (OCLs) of 14% was established using 3T MRI [39]. OCLs are frequently seen in patients with ankle fractures when assessed both directly after and at least 12 months after initial trauma (45–47%, respectively), with the vast majority located in the talus [123]. Syndesmotic injuries are rare, debilitating, and frequently misdiagnosed, often resulting in longer recovery times than lateral ankle sprains [16]. There is a low level of evidence and a paucity of literature on syndesmosis injuries compared with lateral ankle sprains, resulting in no clear guidelines for assessing severity, choosing imaging, deciding on operative versus nonoperative treatment, or determining return-to-play timing [20].

Investigations

Clinical Examination and History

In an anterior talofibular ligament (ATFL) sprain, tenderness is maximal just distal and slightly anterior to the lateral malleolus [8]. Stability assessment in the acute phase of an ankle ligament injury is not possible [8]. The entire leg and foot must be examined to identify undisplaced fractures of the ankle, proximal fibula, tarsal bones, and peroneal tendon sheath [8]. Anterior drawer testing evaluates the competency of the anterior talofibular ligament (ATFL) [52], while talar tilt stress evaluates the competency of the calcaneofibular ligament (CFL) [52]. Patients with chronic lateral ankle instability should be assessed for evidence of global ligamentous laxity and weight-bearing hindfoot alignment [52]. Intra-articular pathological findings are observed in patients with anterolateral pain after an ankle sprain despite no demonstrable abnormal lateral laxity [50].

Plain Radiography

Anteroposterior, lateral, and mortise views (15–20 degrees internally rotated) of the ankle should be obtained for ankle ligament injuries [8]. The Ottawa ankle rules criteria for X-ray include pain around the malleolus, inability to take weight on the ankle immediately after injury, inability to take four steps in the Emergency Department, and bone tenderness at the posterior edge or tip of either malleolus or the base of the fifth metatarsal bone [8]. For lateral ankle instability, AP, mortise, and lateral weight-bearing radiographs of the ankle are performed [52]. Stress radiographs can be used to confirm instability by obtaining a lateral radiograph while performing the anterior drawer test and a mortise radiograph while performing the talar tilt test [52]. Traditional radiographic measurements should not be relied on solely for determining if the syndesmosis is intact and the ankle mortise is stable [191]. Stress radiography did not distinguish between intact and single-ligament disruption and was unreliable in distinguishing between sequential transection models of syndesmotic instability [200].

Magnetic Resonance Imaging (MRI)

MRI may be needed to fully characterize an injury or in those who have persistent pain, swelling, instability, and impaired function over 6 weeks or longer [8]. MRI is useful in evaluating for associated pathology to the peroneal tendons or talar articular surface [52]. MRI will confirm the abnormal appearance of affected ligaments which may be thickened or indistinct but does not help determine functional instability [52]. MRI has excellent interobserver reliability (intraclass correlation coefficient, 0.915) for detecting ATFL injuries in patients with clinical suspicion of chronic lateral ankle instability [162]. Preoperative MRI is a reliable and valid decision-making tool for the choice of surgical stabilization technique in patients with chronic lateral ankle instability [195]. MRI detected a posterior syndesmosis injury in 93.5% of patients acutely but became less reliable with time [159]. MRI scanning revealed a syndesmotic lesion in 15% of patients and should be recommended in patients with ongoing pain at rest following ankle sprains [164]. Clinical implementation of optimal high-field MRI sequences in a standard clinical ankle MRI exam can aid in the diagnosis of syndesmotic injuries, augment pre-operative planning, and facilitate anatomic repair [179]. The oblique axial magnetic resonance imaging scan revealed that the prevalence of transverse ligament and posterior inferior tibiofibular ligament injuries in syndesmosis-injured ankles were 76.5% and 41.2%, respectively [182]. The oblique axial-coronal plane could be added to the MRI scanning protocol during clinical practices to improve the diagnostic accuracy of ATFL injury [201]. In athletes with an acute ligamentous ankle injury, a prevalence for osteochondral lesions (OCLs) of 14% was established using 3T MRI [39].

Ultrasound

Based on current available data, ultrasound could be used in primary diagnostics of acute lateral ankle ligament injury [28]. Point-of-care ankle ultrasound is as precise as MRI for detecting major ankle ligament and Achilles tendon injuries and could be used for immediate diagnosis and further pre-operative imaging [155]. Ultrasonography may be used as an option of imaging modality for lateral ankle sprain in children [185].

Arthroscopy

Arthroscopy plays a crucial role in the definitive assessment of ligament lesions in patients with chronic ankle instability, supplying far more accurate information than any of the current imaging studies [198]. Arthroscopy can be used to diagnose the cause of residual pain after an ankle sprain in most cases that are otherwise undiagnosable by clinical examination and imaging study [204]. Preoperative ankle arthroscopy revealed an essential amount of information that would otherwise have been undetected, showing that abnormalities of different structures are involved in chronic ankle instability with no single causal entity [206].

Treatment

Non-Operative

Most acute lateral ankle injuries recover with conservative treatment [51]. All patients with acute ankle sprains are started on a rest, ice, compression, and elevation (RICE) protocol with limited weight bearing if there is marked ankle joint-line tenderness or pain with weight-bearing activity [79]. Progressive and protected weight bearing is initiated as symptoms allow [79]. Physical therapy for balance, proprioception, and peroneal strengthening is associated with a decreased rate of reinjury [79]. Neuromuscular training paired with functional bracing reduces the risk of recurrence of low ankle sprains more than neuromuscular training alone [79]. A new support for the treatment of stable injuries of the lateral ligament of the ankle was noticeably better than Tubigrip and eversion strapping in a study of 175 consecutive patients [147]. Interventions based on improving self-efficacy might enhance and speed recovery from ankle injuries [152]. Appropriate nonoperative treatment should be attempted initially for chronic lateral ankle instability [4]. Ardèvol and colleagues favor non-operative functional treatment for complete ruptures of the ankle ligaments [61].

Operative

Indications: Surgery is reserved for chronic instability or failed non-operative management of acute lateral ankle injuries [51]. Surgical management is warranted for chronic lateral ankle instability when nonoperative treatment fails to prevent long-term sequelae [4]. Operative treatment is reserved for patients with recurrent and symptomatic instability with excessive and asymmetric talar tilt and positive anterior drawer test [79]. Operative treatment is also reserved for patients with symptomatic osteochondral defects [79]. When patients exhibit symptoms of chronic lateral ankle instability after 3 to 6 months of nonsurgical treatment, surgical treatment is considered [49]. The operation for reconstruction of the lateral ligament is suggested to be considered in all patients with chronic inversion instability of the ankle in whom conservative measures have failed [189]. There is a trend towards earlier surgical treatment after failure of non-surgical treatment in patients with mechanical ligament laxity and in high-level athletes [194]. Acute repair may yield better results in professional athletes with acute lateral ankle ligament injuries [3]. Surgical repair for acute lateral ankle ligament injuries is indicated on an individual basis [2]. If disruption of the lateral ligaments is noted at operation for lateral malleolar fractures, repair is indicated as it markedly increases the chances for a stable ankle [6]. Surgical management is indicated for fractures with unstable syndesmotic injuries [171]. Nonsurgical management is used for stable ligamentous injuries without frank diastasis [171]. Instability can occur without ligamentous issues, such as peroneal tendinopathy, osteochondral defects, fracture nonunion, or anterior ankle impingement [79].

Surgical Approach / Technique: The Broström procedure for chronic lateral ankle instability has been reported with twenty-six-year results [1]. Anatomic reconstruction of the anterior talofibular and calcaneofibular ligaments using a semitendinosus tendon allograft and interference screws is a described technique [1]. Repair of only the anterior talofibular ligament resulted in similar outcomes to those of repair of both the anterior talofibular and calcaneofibular ligaments [1]. The Chrisman-Snook operation for reconstruction of the lateral ligaments of the ankle will restore good long-term function in a high percentage of patients disabled by ankle instability due to unhealed or neglected tears [46]. Operative management of chronic lateral ankle instability using an anatomic technique with three suture anchors provides stable fixation for patients refractory to conservative management [78]. Arthroscopic rather than open lateral ankle ligament repair is likely to become the standard of care in the future [14]. Ultrasound-guided anterior talofibular ligament (ATFL) repair with or without augmentation for chronic lateral ankle instability is safe and results in clinical improvement at 6 months [21]. Ultrasound-guided ATFL repair with or without augmentation produced statistically significant improvements at two years for chronic lateral ankle instability [76]. Arthroscopic treatment of chronic ankle instability is a safe and successful procedure [68]. Ankle stability resumed with a high clinical success rate following a new arthroscopic Broström procedure for chronic lateral ankle instability [130]. Symptomatic chronic lateral ankle instability could be successfully managed with a specific surgical reconstruction method [135]. Both Ahlgren-Larsson and arthroscopic methods are safe and effective for chronic lateral ankle instability [156]. Arthroscopic diagnosis and treatment of intra-articular lesions associated with chronic lateral ankle instability is a safe and effective method [153]. Simultaneous arthroscopic treatment of an osteochondral lesion and open lateral ankle stabilization is a safe and effective procedure [154]. MCL reconstruction or resection of medial impingement lesions performed in addition to LCL reconstruction is effective for treating chronic combined MCL and LCL injuries of the ankle [145]. The application of allogeneic tendons to treat malunited lateral malleolar avulsion fractures combined with chronic lateral ankle instability appeared safe and effective [69]. Lateral ligament reconstruction with allograft represents a valid treatment option in patients with severe chronic lateral ankle instability [12]. Arthroscopic ankle stabilisation repair and reconstruction techniques hold considerable promise but require further evaluation to determine indications of repair versus reconstruction and long-term outcomes [43].

Implant Selection: Synthetic suture is now commonly utilized to decrease the rate of recurrent instability [79].

Other Considerations: When treating chronic lateral ankle instability, surgeons should consider ligament quality [26]. Nonanatomic peroneal tendon procedures (Evans procedure, Chrisman-Snook) or allograft procedures are reserved for recurrent instability after initial operative treatment [79]. The success of lateral ankle instability surgery depends on proper phases of the rehabilitation period [70]. Postoperative treatment for chronic ankle instability is similar to the treatment advised after an acute ankle sprain [134]. Although only fair-quality evidence exists in support of open operative treatment of chronic ankle instability, current practices are supported by systematic review [74]. A survey of practices in chronic ankle instability in France reflected the heterogeneity of surgical practices and provided indications for areas of research in clinical situations with the least consensus [45]. The majority of patients who did not return to their preinjury level after modified Broström lateral ankle ligament reconstruction cited a non–ankle-related factor as the reason [190].

Complications

Post-traumatic Osteoarthritis

Ligamentous posttraumatic ankle osteoarthritis was identified in 30 patients (33 ankles) with a mean age of 58.6 years who sustained one or more ligamentous lesions without other injury to the same ankle or lower leg [17]. Following acute ankle sprains, residual ankle symptoms were found in 33 per cent of patients [40]. Persistent abnormal changes of the ankle were found in 60 per cent of patients following acute ankle sprains [40].

Chronic Instability and Functional Deficits

Chronic lateral ankle instability is frequently encountered in military service members, and surgical management is warranted when nonoperative treatment fails to prevent long-term sequelae [4]. Long-term isokinetic strength deficits persist in subjects with lateral ankle sprain, which may contribute to the high incidence of recurrence in very active individuals [59]. An acute lateral ankle sprain significantly decreases physical activity across the lifespan [1].

Surgical Complications and Outcomes

Neurologic complications occurred in 10% of patients undergoing arthroscopic ligament repair or reconstruction for chronic ankle instability, manifesting as transient dysesthesia and neuroma [170]. Cutaneous complications and infection occurred in 4.2% of patients undergoing arthroscopic ligament repair or reconstruction for chronic ankle instability, requiring surgical revision [170]. The rate of cutaneous complications in arthroscopic ligament repair or reconstruction was at least half that of open surgery [170]. Overall complication rates for arthroscopic repair or reconstruction of the lateral ankle ligament ranged between 11.5% and 18% [170]. Two-stage arthroscopy was associated with significantly higher complication rates compared with single-stage arthroscopy [170]. Higher complication rates were noted with suture anchor fixation (29%) compared with suture fixation (9%) in arthroscopic lateral ligament repair [170]. Entrapment of the peroneus tertius, extensor tendons, and the superficial peroneal nerve can occur when tying sutures for the anterior talofibular ligament during arthroscopic repair [170]. A 17% complication rate was observed in a systematic review of level IV studies for arthroscopic Broström techniques [170]. Anterolateral impingement, which can present with synovitis and fibrosis, is present in 12% of patients with chronic ankle instability [170]. Ankle arthroscopy performed alongside lateral ligament reconstruction was associated with a lower rate of ankle arthrodesis as a second procedure and lower complications compared to reconstruction without arthroscopy [170]. Ultrasound-guided anterior talofibular ligament repair with or without augmentation for chronic lateral ankle instability is safe and results in clinical improvement at 6 months [21]. Ultrasound-guided anterior talofibular ligament repair with or without augmentation produced statistically significant improvements at two years for chronic lateral ankle instability [76].

Associated Injuries and Diagnostic Considerations

Syndesmotic injuries are rare, debilitating, and frequently misdiagnosed, often resulting in longer recovery times than lateral ankle sprains [16].

Recovery

Light activity (weeks): The provided evidence does not specify a typical week range for light activity, such as desk work, driving, or light activities of daily living.

Full activity (months): The provided evidence does not specify a typical month range for full activity, including manual work, sport, or full range of motion and strength return.

Complete recovery / outcome plateau (months): The provided evidence does not specify a month range for complete recovery or outcome plateau.

Rehabilitation protocol: The provided evidence does not detail specific rehabilitation protocols, including physical therapy phasing, immobilisation duration, weight-bearing or range of motion progression, or sling and brace removal timing.

Functional milestones: The AnkleGO score effectively tracks recovery following arthroscopic anatomic lateral ankle ligament reconstruction in the short term [82]. Short-term AOFAS functional outcome scores were significantly improved with arthroscopic lateral ankle repair compared to open repair [77]. Ultrasound-guided anterior talofibular ligament repair with or without augmentation results in clinical improvement at 6 months for chronic lateral ankle instability [21].

Other Considerations: An inability to complete jumping and landing tasks within 2 weeks of a first-time lateral ankle sprain was predictive of eventual chronic ankle instability outcome [209]. Poorer dynamic postural control 6 months after a first-time lateral ankle sprain was predictive of eventual chronic ankle instability outcome [209]. Lower self-reported function 6 months after a first-time lateral ankle sprain was predictive of eventual chronic ankle instability outcome [209]. Arthroscopic repair of lateral ankle ligament produced similarly favorable outcomes to open lateral ankle repair when feasible [23]. Endoscopic ligament reconstruction for chronic lateral ankle instability produces good clinical results with minimal complications [25]. Both the conluent L-shaped tunnel technique and the Y-graft technique significantly improved symptoms, ankle function, and radiographic outcomes in patients with chronic lateral ankle instability at mid- to long-term follow-up [202]. The Chrisman-Snook operation restores good long-term function in a high percentage of patients who are disabled by ankle instability due to unhealed or neglected tears of the lateral ligaments [46]. At follow-up, all patients except one reported that the affected ankle felt stable after a simple operation for correction of chronic lateral instability [84]. One year after the procedure, roentgenograms showed stable ankles with a full range of motion [85]. The review identifies a clear deficiency in the literature pertaining to consistent, meaningful postoperative return to sport timeline following lateral ankle ligament repair [36]. Arthroscopic ankle stabilisation repair and reconstruction techniques require further evaluation to obtain information on long-term outcomes [43].

Key Evidence

• [L1] The majority of grades I, II and III lateral ankle ligament ruptures can be managed without surgery, with surgical repair indicated on an individual basis. [2] (10.1007/s00402-013-1742-5)
• [L4] Successful treatment of grade II and III acute lateral ankle ligament injuries can be achieved with individualized aggressive, non-operative measures, though acute repair may give better results in professional athletes. [3] (10.1007/s00167-012-2252-7)
• [L5] Chronic lateral ankle instability is frequently encountered in military service members; appropriate nonoperative treatment should be attempted initially, but surgical management is warranted when nonoperative treatment fails to prevent long-term sequelae. [4] (10.1016/j.csm.2014.06.011)
• [L4] Operative management of serious injury to the fibular collateral ligament of the ankle is satisfactory. [5] (10.2106/00004623-195436040-00014)
• [L4] If disruption of the lateral ligaments is noted at operation, repair is indicated as it markedly increases the chances for a stable ankle. [6] (10.2106/00004623-198971090-00018)
• [L4] Isolated lateral ligament ankle injury is not as common as is believed. [7] (10.1177/2325967113517078)
• [L4] The current systematic review demonstrated that arthroscopic lateral ankle ligament repair yields favorable clinical outcomes in the short term. [11] (10.1016/j.arthro.2018.02.034)
• [L4] Lateral ligament reconstruction with allograft represents a valid treatment option in patients with severe chronic lateral ankle instability, leading to satisfying outcomes and reduced joint morbidity. [12] (10.1007/s00402-013-1911-6)
• [L1] Reconstruction of the lateral ankle ligament is a relatively stable treatment for chronic ankle instability. [13] (10.1016/j.injury.2020.05.031)
• [L5] ALALR can produce favorable clinical outcomes in the short term, and it is likely that arthroscopic rather than open lateral ankle ligament repair will become the standard of care in the future. [14] (10.1016/j.arthro.2018.05.001)
• [L5] Syndesmotic injuries are rare, debilitating, and frequently misdiagnosed, often resulting in longer recovery times than lateral ankle sprains. [16] (10.2519/jospt.2006.2195)
• [L4] [17] (10.1177/0363546505281813)
• [L5] There is a low level of evidence and a paucity of literature on syndesmosis injuries compared with lateral ankle sprains, resulting in no clear guidelines for assessing severity, choosing imaging, deciding on operative versus nonoperative treatment, or determining return-to-play timing. [20] (10.1177/0363546507302545)
• [L4] Ultrasound-guided ATFL repair with or without augmentation for chronic lateral ankle instability is safe and results in clinical improvement at 6 months. [21] (10.1016/j.jisako.2025.100386)
• [L5] Operative procedures that only focus on part of the pathology should be approached with caution until assessment of a patient with ankle instability defines all deficiencies. [22] (10.2106/jbjs.21.00726)
• [L3] When compared with open lateral ankle repair, arthroscopic repair of lateral ankle ligament when feasible produced similarly favorable outcomes. [23] (10.1177/0363546517698675)
• [Paper] The most common mechanism of injury to the lateral ankle ligaments occurs from a forced plantar flexion and inversion of the ankle, where the ATFL is injured first, followed by the CFL. [24] (10.1016/s0278-5919(03)00095-4)
• [L2] Endoscopic ligament reconstruction for chronic lateral ankle instability is a safe procedure that produces good clinical results with minimal complications. [25] (10.1007/s00167-019-05793-9)
• [L4] Therefore, when treating chronic lateral ankle instability, surgeons should consider ligament quality. [26] (10.1007/s00167-022-07211-z)
• [L1] Ultrasound manifested high diagnostic accuracy in diagnosing chronic lateral ankle ligament injury. [27] (10.1186/s13018-018-0811-4)
• [L1] Therefore, based on the current available data, it could be used in primary diagnostics of acute lateral ankle ligament injury. [28] (10.1016/j.injury.2024.111730)
• [L3] [29] (10.1177/0363546514529643)
• [L3] In the acute setting, clinical evaluation can exclude complete discontinuity and identify athletes with a high probability of complete discontinuity of the lateral ankle ligaments. [34] (10.1002/ksa.12079)
• [L3] Intact tibiofibular ligaments were found equally frequently among patients with normal or any grade of lateral ligament damage, but the more severe injuries to the syndesmotic ligaments were associated with normal or minimally traumatized lateral ligaments. [35] (10.1177/03635465020300061101)
• [L4] The review identifies a clear deficiency in the literature pertaining to consistent, meaningful postoperative return to sport timeline following lateral ankle ligament repair. [36] (10.1136/jisakos-2016-000064)
• [L3] Two distinct ATFL fascicles may be identified in the majority of ankles on MRI. [37] (10.1007/s00167-022-07275-x)
• [L3] In athletes with an acute ligamentous ankle injury a prevalence for (O)CLs of 14% was established using 3T MRI. [39] (10.1016/j.jisako.2025.100419)
• [L4] Residual ankle symptoms were found in 33 per cent. of the patients, and persistent abnormal changes of the ankle were found in 60 per cent. [40] (10.2106/00004623-195537060-00011)
• [L4] The anterior talofibular ligament is the most frequently ruptured and most important component of the lateral ligaments of the ankle. [41] (10.2106/00004623-194931020-00013)
• [L5] [42] (10.1007/s00167-010-1100-x)
• [L3] Arthroscopic ankle stabilisation repair and reconstruction techniques hold considerable promise but require further evaluation to better determine the indications of repair versus reconstruction and to obtain information on long-term outcomes. [43] (10.1016/j.otsr.2018.09.005)
• [L4] This survey reflected the heterogeneity of surgical practices in ankle instability and provided indications for areas of research in clinical situations with the least consensus. [45] (10.1177/2325967120s00009)
• [L4] Based on the findings in this study, we concluded that this procedure will restore good long-term function in a high percentage of patients who are disabled by ankle instability due to unhealed or neglected tears of the lateral ligaments. [46] (10.2106/00004623-198567010-00001)
• [L1] [49] (10.1177/2325967119873852)
• [L4] Intra-articular pathological findings are observed in patients with anterolateral pain after an ankle sprain despite no demonstrable abnormal lateral laxity. [50] (10.1007/s00167-014-3454-y)
• [L5] The article concludes that most acute lateral ankle injuries recover with conservative treatment, while surgery is reserved for chronic instability or failed non-operative management. [51] (10.1302/0301-620x.98b7.36588)
• [L5] The greatest increases in laxity after sectioning the ligament occurred in ankle positions and loads corresponding to common modes of injury. [56] (10.2106/00004623-198365010-00011)
• [L3] These impairments may contribute to the high incidence of recurrence of lateral ankle sprain in very active individuals. [59] (10.1016/j.clinbiomech.2014.09.010)
• [L5] Ardèvol and colleagues, like all but one previous study in the field, favors non-operative functional treatment for complete ruptures of the ankle ligaments. [61] (10.1007/s00167-002-0327-6)
• [L4] Surgical repair is indicated in a sprained ankle if the patient needs a painless, stable ankle for heavy duty. [63] (10.2106/00004623-196143020-00011)
• [L4] This study suggests that arthroscopic repair for chronic lateral instability of the ankle is a safe and successful procedure. [68] (10.1016/j.arthro.2008.04.062)
• [L4] In this population and with this follow-up, the application of allogeneic tendons to treat malunited lateral malleolar avulsion fractures combined with chronic lateral ankle instability appeared safe and effective. [69] (10.1186/s12891-023-06390-1)
• [L5] The success of lateral ankle instability surgery also depends on proper phases of the rehabilitation period. [70] (10.1177/2325967124s00376)
• [L4] The literature would benefit greatly from the standardization of the definition of ankle instability treatment failure. [71] (10.1177/03635465231153165)
• [L2] Although only fair-quality evidence exists in support of open operative treatment of chronic ankle instability, this systematic review helps reassure clinicians of their current practices. [74] (10.1136/jisakos-2018-000265)
• [L4] For chronic lateral ankle instability, ultrasound-guided ATFL repair—with or without augmentation—produced statistically significant improvements at two years (all p < 0.001). [76] (10.1016/j.jisako.2025.101043)
• [L1] Short-term AOFAS functional outcome scores were significantly improved with arthroscopic lateral ankle repair compared to open repair. [77] (10.1007/s00167-018-5100-6)
• [L4] Operative management of chronic lateral ankle instability using an anatomic technique with three suture anchors will provide a stable fixation for patients with chronic lateral ankle instability refractory to conservative management to return to their normal functional activity level. [78] (10.1186/1749-799x-4-41)
• [L2] This shortterm study confirmed that the AnkleGO score effectively tracks recovery following AALALR. [82] (10.1002/ksa.70296)
• [L4] At follow-up, all patients except one reported that the affected ankle felt stable. [84] (10.1016/0020-1383(83)90038-4)
• [L3] This supports the interpretation that the dynamic congruency of the joint, which is influenced by ligamentous integrity remains the main anatomical component in mechanical ankle instability. [89] (10.1186/s12891-025-09458-2)
• [L4] The operative ankle exhibited greater syndesmosis length and altered kinematics compared to the healthy side during all tested activities. [91] (10.2106/jbjs.20.01787)
• [L4] [96] (10.1186/s13018-020-01847-8)
• [L2] [99] (10.1177/03635465251410554)
• [L3] Alterations of kinematics in athletes with chronic ankle instability were found not only at the ankle but also at hip joints during the side-cutting movement. [104] (10.1007/s00167-015-3745-y)
• [L4] We recommend that this cause of pain not be overlooked in the management of patients with refractory ankle symptoms after severe sprains. [108] (10.1177/03635465010290050501)
• [L4] Plantar flexion of the ankle produces changes in radiographic measurements of the medial clear space. [110] (10.2106/jbjs.i.00084)
• [L3] The biomechanical model explains clinical observations by demonstrating that stability is predominantly a function of the tibio-talar sector. [111] (10.1007/s00167-007-0372-2)
• [L4] Antero-lateral ankle impingement syndrome is closely linked to anterior talo-fibular ligament injury and, in some patients, to chronic ankle instability. [113] (10.1016/j.otsr.2017.09.004)
• [L3] This was attested to reduced sagittal plane motions at the hip, knee and ankle joints, and reduced capacity of the stance limb to avail of its supporting base. [116] (10.1007/s00167-015-3744-z)
• [L3] Prior ankle injuries were present in more than 50% of elite college football players attending the NFL Combine. [117] (10.1177/2325967118786227)
• [L3] Patients with mechanical ankle instability have more of an internally rotated talus than a variation of fibular position. [119] (10.1055/s-0043-106741)
• [L4] For men, contusions were the most commonly diagnosed injury, although high ankle sprains resulted in the most significant time lost; for women, low ankle sprains were the most common and resulted in the most moderate time lost. [120] (10.1177/2325967119865908)
• [L4] OCLs are frequently seen in patients with ankle fractures when assessed both directly after and at least 12 months after initial trauma (45–47%, respectively), with the vast majority located in the talus. [123] (10.1007/s00167-020-06187-y)
• [L3] Athletes with chronic ankle instability had a relatively inverted ankle, reduced muscle co-contraction, and a lower dynamic stiffness in the ankle joint during the landing phase of sports maneuvers, which may jeopardize the stability of the ankle. [127] (10.1177/0363546511406868)
• [L4] Grading of the three major ligamentous complexes and of the individual ankle ligaments according the Schneck grading system resulted in limited diagnostic reliability. [128] (10.1136/jisakos-2020-000503)
• [L4] Ankle stability resumed with a high clinical success rate. [130] (10.1186/s13018-023-03789-3)
• [L3] Patients with chronic ankle instability had longer electromechanical delay times in neutral but not when the ankle was placed in inversion. [131] (10.1007/s00167-016-4243-6)
• [L5] The number of mechanoreceptors was negatively correlated with ankle sensorimotor dysfunction. [132] (10.1177/03635465231217490)
• [L2] Most studies found distinct characteristics of the incisura fibularis morphology associated with ligamentous ankle lesions, potentially due to lower osseous resistance against tibiofibular displacement. [133] (10.1016/j.jisako.2024.100361)
• [Paper] [134] (10.1016/j.csm.2015.06.004)
• [L4] Symptomatic chronic lateral ankle instability could be successfully managed with this easy and effective surgical reconstruction method. [135] (10.1016/j.injury.2003.09.035)
• [L3] The CAI, coper, and control groups displayed different ankle joint coupling patterns and coordination variability during a walking gait cycle. [137] (10.1177/23259671221139482)
• [L3] Abnormal internal rotation of the talus in patients with mechanical ankle instability was decreased after ankle lateral stabilization surgery. [140] (10.1177/23259671211023447)
• [L4] Outcomes in the patients indicated that MCL reconstruction or resection of medial impingement lesions, performed in addition to LCL reconstruction, is effective for treating chronic combined MCL and LCL injuries of the ankle. [145] (10.1177/0363546517700859)
• [L2] [147] (10.1016/0020-1383(86)90075-6)
• [L2] Interventions based on improving self-efficacy might enhance and speed recovery from ankle injuries. [152] (10.1016/j.injury.2016.09.016)
• [L4] Arthroscopic diagnosis and treatment of intra-articular lesions associated with chronic lateral ankle instability is a safe and effective method. [153] (10.1177/0363546508319050)
• [L4] Simultaneous arthroscopic treatment of an OLT and open lateral ankle stabilization is a safe and effective procedure. [154] (10.1177/0363546509351556)
• [L3] Point-of-care ankle ultrasound is as precise as MRI for detecting major ankle ligament and Achilles tendon injuries; it could be used for immediate diagnosis and further pre-operative imaging. [155] (10.1016/j.injury.2017.07.015)
• [L2] Both Ahlgren-Larsson and arthroscopic methods are safe and effective for chronic lateral ankle instability. [156] (10.1007/s00402-021-03799-y)
• [L3] MRI detected a posterior syndesmosis injury in 93.5% of patients acutely but became less reliable with time. [159] (10.1007/s00167-019-05581-5)
• [L1] [160] (10.1177/0363546509338107)
• [L3] This study showed that MRI has excellent interobserver reliability (intraclass correlation coefficient, 0.915) for detecting ATFL injuries in patients in whom there is a clinical suspicion of chronic lateral ankle instability. [162] (10.1016/j.arthro.2015.02.024)
• [L1] MRI scanning revealed a syndesmotic lesion in 15% of patients and should be recommended in patients with ongoing pain at rest following ankle sprains. [164] (10.1007/s00167-015-3604-x)
• [L1] [167] (10.1177/0363546506288676)
• [L5] Nonsurgical management is used for stable ligamentous injuries without frank diastasis, while surgical management is indicated for fractures with unstable syndesmotic injuries. [171] (10.5435/jaaos-d-13-00135)
• [L3] Ankle arthroscopy followed by open anatomic ligament repair is a reliable procedure for patients requiring return to high demanding sports after severe acute ankle sprains. [172] (10.1186/s12891-022-05260-6)
• [L5] [174] (10.1097/corr.0000000000002404)
• [L2] Clinical implementation of optimal high-field MRI sequences in a standard clinical ankle MRI exam can aid in the diagnosis of syndesmotic injuries, augment pre-operative planning, and facilitate anatomic repair. [179] (10.1007/s00167-014-3399-1)
• [L5] [180] (10.1002/ksa.12538)
• [L4] The oblique axial magnetic resonance imaging scan revealed that the prevalence of transverse ligament and posterior inferior tibiofibular ligament injuries in syndesmosis-injured ankles were 76.5 and 41.2%, respectively. [182] (10.1186/s12891-022-05220-0)
• [L2] Ultrasonography may be used as an option of imaging modality for lateral ankle sprain in children. [185] (10.1186/s12891-020-03287-1)
• [L4] The operation is suggested to be considered in all patients with chronic inversion instability of the ankle in whom conservative measures have failed. [189] (10.1016/0020-1383(75)90065-0)
• [L4] The majority of patients who did not return to their preinjury level cited a non–ankle-related factor as the reason for not returning to sport. [190] (10.1177/23259671211068541)
• [L2] Traditional radiographic measurements should not be relied on solely for determining if the syndesmosis is intact and the ankle mortise is stable. [191] (10.1097/01.blo.0000161090.86162.19)
• [L5] There is a trend towards earlier surgical treatment after failure of non-surgical treatment in patients with mechanical ligament laxity and in high-level athletes. [194] (10.1007/s00167-017-4556-0)
• [L3] Preoperative MRI is a reliable and valid decision making tool for the choice of surgical stabilization technique in patients with chronic lateral ankle instability. [195] (10.1016/j.arthro.2017.04.066)
• [L2] Arthroscopy plays a crucial role in the definitive assessment of ligament lesions in patients with chronic ankle instability, supplying far more accurate information than any of the current imaging studies. [198] (10.1016/j.otsr.2018.09.008)
• [L5] Stress radiography did not distinguish between intact and single-ligament disruption and was unreliable in distinguishing between sequential transection models. [200] (10.1016/j.arthro.2016.11.008)
• [L5] The oblique axial-coronal plane could be added to the MRI scanning protocol during clinical practices to improve the diagnostic accuracy of ATFL injury. [201] (10.1186/s13018-019-1102-4)
• [L3] Both the conluent L-shaped tunnel technique and the Y-graft technique significantly improved symptoms, ankle function, and radiographic outcomes in patients with chronic lateral ankle instability at mid- to long-term follow-up. [202] (10.1007/s00167-022-06880-0)
• [L2] The present results suggest that arthroscopy can be used to diagnose the cause of residual pain after an ankle sprain in most cases that are otherwise undiagnosable by clinical examination and imaging study. [204] (10.1177/0363546504270566)
• [L5] The findings suggest that isolated lateral ankle ligament injuries do not directly affect syndesmotic stability. [205] (10.1007/s00167-022-06985-6)
• [L4] Preoperative ankle arthroscopy revealed an essential amount of information that would otherwise have been undetected, showing that abnormalities of different structures are involved in chronic ankle instability with no single causal entity. [206] (10.1177/03635465020300031601)
• [L2] An inability to complete jumping and landing tasks within 2 weeks of a first-time lateral ankle sprain and poorer dynamic postural control and lower self-reported function 6 months after a first-time lateral ankle sprain were predictive of eventual chronic ankle instability outcome. [209] (10.1177/0363546516628870)

See Also

• Ankle arthroscopy
• Lateral ligament reconstruction
• Chronic ankle instability
• Ankle impingement
• Syndesmotic injury
• Ankle osteoarthritis
• Ankle arthrodesis

References

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[26] Anterior talofibular ligament remnant quality is important for achieving a stable ankle after arthroscopic lateral ankle ligament repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-07211-z

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[39] The Prevalence, Size and Anatomical Location of Cartilage and Osteochondral Lesions in Athletes with an Acute Ligamentous Ankle Injury. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2025.100419

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