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Total rupture of left ATFL (ankle ligament) and associated joint capsule damage in a soccer kickabout with friends. Continuing to assess extent of injury and treatment plan day by day. Rehab already started.

World golf number 1 Rory McIlroy on Instagram, nine days before the British Open, 6 July 2015

Ankle injury is arguably the most common sporting injury. In 24 of the 70 sports for which there are quality data, ankle injury holds the number 1 spot.1 In sports such as volleyball, ankle injuries account for nearly half of all injuries.2

Ankle injuries include, but are not limited to ‘ankle sprains’. The first half of this chapter focuses on anatomy, clinical assessment and management of lateral ligament injuries after ankle sprain and their sequelae. We address less common immediate diagnoses for ankle sprains: medial ligament injury and significant ankle fractures.

Importantly for clinicians who work in sport, a ‘sprained ankle’ can mask damage to other structures, such as subtle fractures around the ankle joint, osteochondral fractures of the dome of the talus, and dislocation or longitudinal rupture of the peroneal tendons. Such injuries and their complaints persist longer than would be expected with a straightforward lateral ligament sprain. This is often referred to as ‘the difficult ankle’ and it is the focus of the second half of this chapter.


The ankle contains three joints (Fig. 41.1):

  1. talocrural (ankle) joint

  2. inferior tibiofibular joint (syndesmosis)

  3. subtalar joint.

Figure 41.1

Anatomy of the ankle. (a) Talocrural (ankle) joint (b) Subtalar joint (c) Ligaments of the ankle-lateral view (d) Ligaments of the ankle-medial view

The talocrural or ankle joint (Fig. 41.1a) is a hinge joint formed between the inferior surface of the tibia and the superior surface of the talus.

The medial and lateral malleoli provide additional articulations and stability to the ankle joint. The ankle joint can plantarflex and dorsiflex. As the ankle is least stable in plantarflexion, where most stability is provided by the ligaments, injuries are more common when the foot is in this position.

The distal parts of the fibula and tibia articulate at the inferior tibiofibular joint where they are supported by the inferior tibiofibular ligaments or syndesmosis. The small amount of movement present at this joint is extremely important for normal walking and running. Injuries to this joint are more common than previously recognised.

The subtalar joint (Fig. 41.1b), between the talus and calcaneus, is divided into an anterior and posterior articulation separated by the sinus tarsi.

Inversion and eversion occur at the subtalar joint. It provides shock absorption and permits the foot to adjust to uneven ground. The subtalar ...

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