Joints and ligaments · Lower limb
ATFL !
The anterior talofibular ligament (ATFL), at the front of the outer ankle, is the ligament most often hurt in an ankle sprain.
Official name: Anterior talofibular ligament
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What it is
A small, flat ligament on the front of the outer ankle, from the fibula to the talus.
What it does
Stops the talus from sliding forward and resists the ankle rolling inward, especially when the foot is pointed.
Key facts
- Attaches
- Anterior border of lateral malleolus to neck of talus
- Function
- Limits anterior displacement of talus and inversion; weakest lateral ligament, most commonly sprained
- Tight in
- Plantarflexion with inversion
Relations
- Above
- Anterior inferior tibiofibular ligament of the syndesmosis; its lowest slip (Bassett's ligament) can rub on the talus and cause anterolateral impingement
- Below
- CFL, which arises just below it near the tip of the fibula
- Deep
- Ankle joint capsule, of which it is a thickening, and the lateral talar dome in the anterolateral gutter
- Superficial
- Skin and branches of the superficial fibular nerve (intermediate dorsal cutaneous nerve), at risk in lateral ligament repair and anterolateral arthroscopy portals
How to find it
A soft hollow just in front of the lateral malleolus, running forward to the talar neck; tenderness here without bony tenderness fits an ATFL sprain. It is felt best with the foot slightly pointed and turned in.
Examination
- Anterior drawer: ankle in slight plantarflexion, tibia held still, heel drawn forward; more glide than the other side, a soft endpoint or a dimple below the front of the fibula suggests an ATFL tear
- Talar tilt (inversion stress) in plantarflexion mainly stresses the ATFL; more tilt than the other side suggests laxity
On imaging
Ottawa ankle rules: X-rays are needed if there is malleolar pain plus bone tenderness on the back edge or tip of the lower 6 cm of either malleolus, or the person cannot take four steps both right after the injury and in the emergency department. X-rays look for fractures; ultrasound (dynamic, during a drawer) or MRI shows the ligament itself.
Common problems
- Ankle sprain: rolling the ankle inward stretches or tears it. It is the most commonly injured ankle ligament.
- Chronic instability: after repeated sprains, the ankle may keep giving way.
- Often injured together with the CFL.
How it is diagnosed
A physical exam (swelling, tenderness, anterior drawer test). X-rays rule out a fracture. MRI or ultrasound for ongoing problems.
Treatment
- Most sprains heal without surgery: rest, ice, compression, a brace or boot, then balance and strengthening exercises.
- Chronic instability: surgery to repair and tighten the ligament.
- If the ligament tissue is poor: reconstruction with a tendon graft from the patient or a donor.
Clinical notes
- Grades: I, fibres stretched with no laxity; II, partial tear with some laxity; III, complete tear with clear laxity, often with the CFL
- Chronic lateral instability: anatomic repair shortens and reattaches the ATFL to the fibula (Broström type), often reinforced with the inferior extensor retinaculum
- Repeated sprains can leave scar or synovial tissue in the anterolateral gutter that catches on the talus (anterolateral impingement)
- A sprain-like injury may hide a fracture of the lateral talar process, the anterior calcaneal process or the fifth metatarsal base, or a high ankle sprain
Anatomical variants
- May be a single band or have two (sometimes three) separate bands; texts differ on how often each pattern occurs
Memory aid
ATFL: "Always Tears First".
Related conditions
Test yourself
Think of the answer, then tap the question to see it.
Where does the anterior talofibular ligament (ATFL) attach?
From the anterior border of the lateral malleolus to the neck of the talus.
In which foot position is the anterior talofibular ligament most often torn?
Plantarflexion with inversion: the ATFL turns vertical and the narrower front of the talar dome sits in the mortise.
Which test assesses the anterior talofibular ligament?
The anterior drawer: more forward glide than the other side, a soft endpoint or a dimple suggests an ATFL tear.
In what order are the lateral ankle ligaments usually torn as force increases?
ATFL, then CFL, then (rarely) PTFL.
Educational information, not medical advice. For any symptom, see a health professional.
Its names
- Official Latin (TA2)
- ligamentum talofibulare anterius TA2 1919
- Official Spanish (DeCS)
- Ligamento talofibular anterior DeCS D017844
- English (TA2)
- Anterior talofibular ligament
- Also called
- ligamentum fibulotalare anterius
Related
Sources: Terminologia Anatomica (TA2); DeCS; Anatomy, Bony Pelvis and Lower Limb: Ankle Joint.
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Representative model, for educational purposes only.
