Clinicians › Ankle

Lateral ankle ligament injury

123 citationsUpdated Sep 2026

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 complex comprises the posterior talofibular, ATFL, and CFL [8]. Medial ligament injuries are typically associated with fractures or joint injuries [8]. Clinically, patients present with a history of twisting injury followed by pain, bruising, and swelling [8]. In ATFL sprains, tenderness is maximal just distal and slightly anterior to the lateral malleolus, and passive inversion is extremely painful [8]. Stability assessment is not possible in the acute phase [8]. Examination of the entire leg and foot is essential to exclude undisplaced fractures of the ankle, proximal fibula, tarsal bones, or peroneal tendon sheath injuries [8]. Imaging is guided by the Ottawa ankle rules, requiring anteroposterior, lateral, and mortise views [8]. Weight-bearing views help determine stability, while CT and MRI are reserved for characterizing injuries or persistent symptoms exceeding six weeks [8].

The majority of grade I, II, and III lateral ankle ligament ruptures are managed non-operatively [2]. Successful treatment of grade II and III injuries is achieved with individualized aggressive non-operative measures [3]. Surgical repair for acute ruptures is indicated on an individual basis [2], particularly for professional athletes where acute repair may yield better results [3]. If lateral ligament disruption is noted at operation, repair is indicated to markedly increase the chances for a stable ankle [6]. Surgical intervention is also indicated when a painless, stable ankle is required for heavy duty [63].

Chronic lateral ankle instability is frequently encountered in military service members [4]. Appropriate nonoperative treatment should be attempted initially, with surgical management warranted when nonoperative treatment fails to prevent long-term sequelae [4]. Operative management of serious fibular collateral ligament injury is satisfactory [5]. Reconstruction of the lateral ankle ligament is a relatively stable treatment for chronic instability [10]. Arthroscopic lateral ankle ligament repair yields favorable short-term clinical outcomes [13, 16]. When feasible, arthroscopic repair produces similarly favorable outcomes compared with open repair [23], and it is likely to become the standard of care in the future [16]. Lateral ligament reconstruction with allograft is a valid treatment option for severe chronic instability, leading to satisfying outcomes and reduced joint morbidity [14]. Ultrasound-guided ATFL repair with or without augmentation is safe and results in clinical improvement at six months [15]. Endoscopic ligament reconstruction is a safe procedure producing good clinical results with minimal complications [24]. Arthroscopic ankle stabilisation repair and reconstruction techniques hold considerable promise, though further evaluation is required to determine indications for repair versus reconstruction and to obtain long-term outcome data [42]. Operative procedures focusing only on part of the pathology should be approached with caution until all deficiencies are defined [22]. Ankle arthroscopy followed by open anatomic ligament repair is reliable for patients requiring return to high-demand sports after severe acute sprains [172]. Although only fair-quality evidence supports open operative treatment of chronic ankle instability, current practices are reassured by systematic review data [75]. The literature would benefit from standardization of the definition of ankle instability treatment failure [72].

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 [85]. During motion from plantar flexion to dorsiflexion, the mortise widens 1 to 1.5 mm [85]. The joint permits 23 to 48 degrees of plantar flexion and 10 to 23 degrees of dorsiflexion [85]. The distal fibula features a convex medial surface that articulates with the concave incisura fibularis of the distal lateral tibia [85]. During ankle motion and ambulation, the fibula rotates approximately 2 degrees within this incisura [85]. Ankle dorsiflexion results in external rotation and proximal translation of the fibula [85].

Radiographic assessment requires attention to positional changes. Plantar flexion produces changes in medial clear space measurements, with the size more than doubling depending on the rotational position of the limb [94]. There is a significant increase in medial clear space with ankle plantarflexion [94]. The talocrural angle is approximately 83 degrees and symmetrical with the contralateral ankle [94]. Normal radiographic parameters include a medial clear space less than 5 mm and no more than 2 mm greater than the tibiotalar clear space [94]. The tibiofibular clear space 10 mm above the joint line should be greater than 5 mm, while tibiofibular overlap at this level should be less than 5 mm on the AP view and less than 1 mm on the mortise view [94]. On the mortise view, the articular margins of the distal fibula and the lateral process of the talus should be parallel and equal to the tibiotalar joint space [94].

Fibular length and incisura morphology influence stability. Shortening of the fibula results in lateral and valgus subluxation of the talus [94]. The "ball sign," an unbroken curve connecting the recess in the distal tip of the fibula and the lateral process of the talus, indicates proper fibular length; its absence indicates a short and malreduced fibula [94]. Syndesmoses with a deep incisura and the fibula not engaged into the tibial incisura are at risk of overcompression [93]. Anteverted incisuras are at risk of anterior fibular translation, while retroverted incisuras are at risk of posterior fibular translation [93]. Most studies found distinct characteristics of the incisura fibularis morphology associated with ligamentous ankle lesions, potentially due to lower osseous resistance against tibiofibular displacement [131].

Ligamentous Anatomy

The lateral ankle ligaments function as restraints to varus and inversion forces at the ankle [85]. 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 [85]. The calcaneofibular ligament (CFL) extends from the tip of the lateral malleolus to the lateral aspect of the calcaneus [85]. The posterior talofibular ligament (PTFL) extends from the posterior lateral malleolus to the posterolateral talus [85]. The ATFL is the weakest ankle ligament, whereas the PTFL is the strongest [85]. The distal tibiofibular joint and fibula provide stability against lateral talar translation [85].

The deltoid ligament complex resists valgus and eversion forces. The deep deltoid ligament extends from the apex of the medial malleolus to the medial talar body, functioning primarily to resist lateral talar translation and external rotation [85]. The posterior deep deltoid is the most important component of this complex [85]. The superficial deltoid ligament extends from the distal medial malleolus to the navicular bone, sustentaculum tali of calcaneus, medial talus, and spring ligament [85]. 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 [91]. The tibiocalcaneal portion of the superficial deltoid ligament is the strongest component and resists eversion of the calcaneus [91]. The deep portion is organized into two short, thick, discrete bands: the anterior and posterior deep tibiotalar ligaments [91]. The deep posterior band comprises the largest band of the deltoid complex [91].

Biomechanical strength and failure modes vary across these structures. The deep deltoid ligament has the highest load to failure at 713.8 N ± 69.3 compared with the lateral collateral ligaments [91]. The dominant mode of failure for the deep deltoid ligament is an intrasubstance rupture near its talar insertion [91]. In contrast, the failure of the superficial deltoid ligament is most commonly at its insertion on the anterior malleolus [91]. The deltoid ligament has a rich vascular supply from the medial tarsal artery, posterior tibial artery, and tibialis anterior artery, along with a component of intraosseous vascular supply from either the talus or the medial malleolus [91].

The distal tibiofibular syndesmosis is a complex arrangement of ligaments that maintains the relationship between the distal tibia and fibula [184]. This 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, posterior-inferior tibiofibular ligament, transverse tibiofibular ligament, and 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].

Specific fascicular anatomy of the ATFL has distinct clinical implications. The ATFL inferior fascicle is connected to the calcaneofibular ligament [180]. The ATFL superior fascicle is an intra-articular structure [180]. The intra-articular position of an injured ATFL superior fascicle is thought to impair healing [180].

Vascular & Neural Anatomy

Neural structures near the lateral ankle require careful identification during surgical approaches. The superficial peroneal nerve penetrates the deep fascia and lies subcutaneously 8 to 10 cm proximal to the tip of the lateral malleolus [89]. The deep peroneal nerve accompanies the anterior tibial artery between the tendons of the anterior tibial and extensor digitorum longus, just lateral to the extensor hallucis longus [89]. The deep peroneal nerve usually lies just lateral to the anterior tibial artery [89]. Medially, the saphenous nerve is located just medial or posterior to the saphenous vein in a slightly deeper plane 3 to 5 cm proximal to the tip of the medial malleolus [89].

Pathophysiology

More than 75% of ankle ligament injuries involve the lateral ligament complex, particularly the ATFL and CFL [8]. The most common mechanism of injury to the ankle ligaments is inversion of the foot [41]. With an inversion mechanism of injury, the ATFL is the first or only ligament to sustain injury [41]. A total rupture of the lateral ligaments involves the CFL and PTFL as well [41]. An eversion injury causes damage to the deltoid ligaments [41]. A hyperdorsiflexion trauma might cause an injury to the syndesmotic ligaments [41].

Specific ankle positions dictate which ligaments are at risk. Excessive inversion of the plantarflexed foot leads to injury to the ATFL [57]. Excessive inversion of the dorsiflexed foot causes injury to the CFL and, less commonly, the PTFL [57]. An increased propensity for inversion injuries occurs in conjunction with obvious cavovarus foot deformity [57]. An increased propensity for inversion injuries also occurs in conjunction with subtle cavovarus foot deformity [57]. Biomechanical studies indicate that the greatest increases in laxity after sectioning the ATFL occurred in ankle positions and loads corresponding to common modes of injury [56]. The ankle ligamentous injury resulted from a motion combining internal rotation and inversion on the ankle joint instead of plantar flexion and inversion [127].

Chronic lateral ankle instability is multifactorial and can involve abnormal neuromuscular response, 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]. Patients with chronic lateral ankle instability present with the sensation of instability, often with recurrent and frequent inversion injuries [52]. Symptoms occur with walking on uneven ground or participating in athletic activity [52]. An ankle effusion may be present in chronic lateral ankle instability because of chronic instability and synovitis or from an associated osteochondral lesion or loose body [52]. MRI does not help determine functional instability in chronic lateral ankle instability [52].

Mechanical instability is driven by dynamic joint congruency. The dynamic congruency of the joint, which is influenced by ligamentous integrity, remains the main anatomical component in mechanical ankle instability [88]. Three-dimensional talar shape seems not a factor in chronic mechanical ankle instability [88]. Patients with mechanical ankle instability have more of an internally rotated talus than a variation of fibular position [118]. Abnormal internal rotation of the talus in patients with mechanical ankle instability was decreased after ankle lateral stabilization surgery [138]. Stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus [149]. The biomechanical model explains clinical observations by demonstrating that stability is predominantly a function of the tibio-talar sector [110]. Normal ankles can exhibit tilts up to 25 degrees, challenging the use of bilateral symmetry or fixed degree thresholds as sole criteria for ankle instability [144].

Neuromuscular and cellular changes characterize chronic instability. 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 [130]. Patients with chronic ankle instability had longer electromechanical delay times in neutral but not when the ankle was placed in inversion [129]. 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 [125]. 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 [103]. The CAI, coper, and control groups displayed different ankle joint coupling patterns and coordination variability during a walking gait cycle [135]. 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 [115]. The presence of CAI negatively affected ankle function and HRQoL in adolescent athletes [148]. An acute lateral ankle sprain significantly decreases physical activity across the lifespan [1].

Classification

Epidemiology and Prevalence

More than 75% of ankle ligament injuries involve the lateral ligament complex [8]. The anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) constitute the primary components of this complex in such injuries [8]. Isolated lateral ligament ankle injury is not as common as is believed [7].

Injury Patterns and Associated Pathology

Six exclusive injury patterns are defined based on lateral and syndesmotic ligament involvement, ranging from no injury to complete ATFL and CFL disruption with or without syndesmotic injury [27]. Intact tibiofibular ligaments were found equally frequently among patients with normal or any grade of lateral ligament damage [33]. More severe injuries to the syndesmotic ligaments were associated with normal or minimally traumatized lateral ligaments [33]. Isolated lateral ankle ligament injuries do not directly affect syndesmotic stability [65]. In athletes with an acute ligamentous ankle injury, the prevalence of osteochondral lesions (OCLs) is 14% using 3T MRI [38].

Grading Systems

Schneck Grading System: * 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 Classification System: Used to classify ankle sprains in elite track and field athletes [160].

Anatomical Subdivisions

Two distinct ATFL fascicles may be identified in the majority of ankles on MRI [36]. The anterior talofibular ligament is the most frequently ruptured and most important component of the lateral ligaments of the ankle [40].

Diagnostic Reliability

Grading of the three major ligamentous complexes and individual ankle ligaments according to the Schneck grading system resulted in limited diagnostic reliability on 3 T MRI [126].

Clinical Presentation

Mechanism and Epidemiology

More than 75% of ankle ligament injuries involve the lateral ligament complex, specifically 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 [40]. Inversion of the plantarflexed foot injures the ATFL, which is the first or only ligament to sustain injury in an inversion mechanism [41, 57]. Inversion of the dorsiflexed foot causes injury to the CFL and, less commonly, the posterior talofibular ligament [57]. Total rupture involves the CFL and posterior talofibular ligaments [41]. An increased propensity for inversion injuries occurs with both obvious and subtle cavovarus foot deformity [57]. Ankle sprains are among the most common athletic injuries, with 90% being low ankle sprains that represent the most common reason for missed athletic participation in adolescents [19, 57]. Prior ankle injuries were present in more than 50% of elite college football players attending the NFL Combine [116]. Isolated lateral ligament ankle injury is less common than believed [7].

History and Physical Examination

A history of a twisting injury followed by pain, bruising, and swelling is typical but may range from a sprain to a displaced fracture [8]. Detailed history and careful physical examination are crucial for diagnosis and management, as they reveal injury severity [53]. The patient’s ability to walk after the injury helps grade the level of injury, and the injury mechanism guides the examination [53]. Patients who have undergone ankle sprains are prone to re-injury [53]. Acute low ankle sprains typically manifest with large lateral ankle swelling, pain with weight bearing, and lateral ankle pain [57]. Swelling, ecchymosis, and pain with weight bearing are common findings [78].

Inspection and palpation must include the entire leg and foot because undisplaced fractures of the ankle, proximal fibula, tarsal bones, and peroneal tendon sheath are easily missed [8]. The physician should check for swelling and ecchymosis and palpate the fibula to feel for fractures [53]. Tenderness should be checked using the sites of Ottawa Ankle Rules, as distal tibial or fibular tenderness may reveal a fracture accompanying an eversion or inversion strain [53]. An osteochondral talar dome fracture may be inferred by pain and tenderness on tibio-talar joint line palpation [53]. The physical examination characteristically shows focal tenderness to palpation over the involved lateral ankle ligamentous structures [57].

Range-of-motion assessment includes checking for pain on passive gentle eversion and inversion [53]. The patient may have pain with resisted eversion of the foot, a sign of peroneal tendon injury during the inversion episode [57]. If a tissue deficit or tenderness is found, the Thompson Test should be carried out to exclude a tendo Achilles injury [53].

Stability and special tests include the anterior drawer test, which involves anterior translation of the slightly plantarflexed foot; excessive anterior translation represents chronic laxity of the injured ATFL and may be positive in patients with a history of numerous ankle sprains [57]. Inversion stress testing of the neutral foot may demonstrate increased laxity, such as in the setting of an attritional calcaneofibular ligament [57]. Clinical examination including the anterior talar drawer and talar tilt test is performed to diagnose unilateral mechanical ankle instability [95]. 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 [32].

Red-flag patterns and associated symptoms require specific attention. Assessment for recurrent instability requires evaluation for hindfoot varus [78]. Patients should be questioned about symptoms of a loose body or osteochondral injury, such as mechanical symptoms like locking or catching [78]. Intra-articular pathological findings are observed in patients with anterolateral pain after an ankle sprain despite no demonstrable abnormal lateral laxity [50]. 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 [95].

Imaging

The need for X-ray is guided by the Ottawa ankle rules, which have been proven as a reliable tool for determining when radiography is necessary in the evaluation of an acute ankle sprain [8, 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]. Anteroposterior, lateral, and ‘mortise’ (15–20 degrees internally rotated) views of the ankle should be obtained [8]. When radiographs are necessary, weight-bearing AP, lateral, and mortise views are recommended [57]. AP, mortise, and lateral x-rays of the ankle are obtained, with weight-bearing x-ray preferable if the patient can tolerate it [78]. Foot x-rays should be obtained for any pain on examination—especially at base of fifth metatarsal or anterior process of calcaneus—to rule out fracture [78]. A lower threshold for obtaining radiographs exists after a patient referral in the outpatient setting because referrals are often made in situations of more severe injury or chronic symptoms [57].

Radiographs should be evaluated for lateral process of the talus fracture, anterior process fracture, osteochondral defects, and mortise or syndesmosis instability [78]. 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, which is characteristic of a high ankle sprain [57]. CT scanning is considered for evaluation of a suspected or identified lateral process fracture [78]. Lateral process talar fractures are especially important to consider in the differential diagnosis; as many as 42% of these injuries are initially misdiagnosed as ankle sprains [57]. Talar body and neck fractures can occasionally be overlooked in low-energy trauma patients thought to have minor ankle injuries [57].

MRI is rarely warranted, except in the setting of prolonged pain or instability [57]. MRI is typically reserved for patients with continued pain despite weeks of conservative treatment or concern about a loose body or osteochondral defect [78]. MRI is performed to evaluate for associated injuries such as peroneal tendon pathology, talar osteochondral lesions, fractures of the anterior calcaneal process, or fractures of the lateral talar process [57]. MRI may demonstrate attenuation or tear of the lateral ligamentous structures [78]. Bone bruising is common in severe sprains and may result in longer time to pain-free activity and return to sports [78]. Ultrasound manifested high diagnostic accuracy in diagnosing chronic lateral ankle ligament injury [26]. Two distinct ATFL fascicles may be identified in the majority of ankles on MRI [36]. In athletes with an acute ligamentous ankle injury a prevalence for (osteo)chondral lesions of 14% was established using 3T MRI [38].

Associated Pathology and Complications

Syndesmotic injuries are rare, debilitating, and frequently misdiagnosed, often resulting in longer recovery times than lateral ankle sprains [11]. 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 [21]. Intact tibiofibular ligaments were found equally frequently among patients with normal or any grade of lateral ligament damage [33]. More severe injuries to the syndesmotic ligaments were associated with normal or minimally traumatized lateral ligaments [33]. Isolated lateral ankle ligament injuries do not directly affect syndesmotic stability [65].

Neurological and soft tissue complications include injury to branches of the superficial peroneal nerve from an inversion injury, causing numbness over the dorsal midfoot [78]. Direct trauma to the area may cause injury, herniation, and subsequent entrapment to the superficial peroneal nerve [78]. If persistent nerve symptoms occur, neurotomy and burial may be needed [78]. Patients may develop complex regional pain syndrome following ankle sprain [78]. Complex regional pain syndrome involves dysfunction in motor, sensory and autonomic nerve systems [78]. Pain in complex regional pain syndrome is out of proportion to findings on exam [78]. Most cases of complex regional pain syndrome in the lower extremity develop after trauma or elective surgery [78].

Impingement syndromes are closely linked to lateral ligament injury. Antero-lateral ankle impingement syndrome is closely linked to anterior talo-fibular ligament injury and, in some patients, to chronic ankle instability [112]. The accessory anteroinferior tibiofibular ligament is a normal anatomical finding but could lead to anterolateral impingement in cases with coexistent ankle instability [60]. Posteromedial impingement lesions should not be overlooked in the management of patients with refractory ankle symptoms after severe sprains [107].

Long-term outcomes show that residual ankle symptoms were found in 33 per cent of patients following acute ankle sprains [39]. Persistent abnormal changes of the ankle were found in 60 per cent of patients following acute ankle sprains [39]. Long term isokinetic strength deficits persist in subjects with lateral ankle sprain [59]. These impairments may contribute to the high incidence of recurrence of lateral ankle sprain in very active individuals [59].

Investigations

Clinical Examination: Stability assessment of the ankle is not possible in the acute phase [8]. Anterior drawer testing and talar tilt stress are performed to evaluate competency of the ATFL and CFL, respectively [52]. Patients should be assessed for evidence of global ligamentous laxity and weight-bearing hindfoot alignment [52].

Plain radiography: Anteroposterior, lateral, and mortise views of the ankle should be obtained [8]. Stress radiographs can be used to confirm instability; a lateral radiograph is obtained 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 [201].

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 does not help determine functional instability [52]. 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]. 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]. The oblique axial-coronal plane could be added to the MRI scanning protocol during clinical practices to improve the diagnostic accuracy of ATFL injury [202]. 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]. In athletes with an acute ligamentous ankle injury a prevalence for (O)CLs of 14% was established using 3T MRI [38].

Ultrasound: 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 [154]. 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 [199]. 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 [205]. 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 [78]. Progressive and protected weight bearing is initiated as symptoms allow [78]. Physical therapy for balance, proprioception, and peroneal strengthening is associated with a decreased rate of reinjury [78]. Neuromuscular training paired with functional bracing reduces the risk of recurrence of low ankle sprains more than neuromuscular training alone [78]. Interventions based on improving self-efficacy might enhance and speed recovery from ankle injuries [150]. Ardèvol and colleagues favor non-operative functional treatment for complete ruptures of the ankle ligaments [61]. 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 144 patients with stable injuries [145].

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]. The operation for reconstruction of the lateral ligament of the ankle is suggested to be considered in all patients with chronic inversion instability 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 Approach / Technique: Arthroscopic repair of lateral ankle ligament when feasible produced similarly favorable outcomes compared with open lateral ankle repair [23]. Arthroscopic repair of lateral ankle ligament is likely to become the standard of care in the future, as it can produce favorable clinical outcomes in the short term [16]. 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 [42]. Ankle stability resumed with a high clinical success rate following a new arthroscopic Broström procedure for chronic lateral ankle instability [128]. Arthroscopic repair for chronic lateral instability of the ankle is a safe and successful procedure [69]. Endoscopic ligament reconstruction for chronic lateral ankle instability is a safe procedure that produces good clinical results with minimal complications [24]. 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 [15]. Ultrasound-guided ATFL repair with or without augmentation for chronic lateral ankle instability produced statistically significant improvements at two years [76]. 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 who are disabled by ankle instability due to unhealed or neglected tears of the lateral ligaments [46]. Symptomatic chronic lateral ankle instability could be successfully managed with a specific surgical reconstruction method described in the literature [133]. Both Ahlgren-Larsson and arthroscopic methods are safe and effective for chronic lateral ankle instability [156].

Implant Selection: 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 [14]. Synthetic suture is now commonly utilized to decrease the rate of recurrent instability in lateral ankle ligament repairs [78]. Nonanatomic peroneal tendon procedures (Evans procedure, Chrisman-Snook) or allograft procedures are reserved for recurrent instability after initial operative treatment [78].

Other Considerations: Surgeons should consider ligament quality when treating chronic lateral ankle instability, as anterior talofibular ligament remnant quality is important for achieving a stable ankle after arthroscopic repair [25]. Arthroscopic diagnosis and treatment of intra-articular lesions associated with chronic lateral ankle instability is a safe and effective method [151]. Simultaneous arthroscopic treatment of an osteochondral lesion of the talus (OLT) and open lateral ankle stabilization is a safe and effective procedure [153]. Outcomes indicated that medial collateral ligament reconstruction or resection of medial impingement lesions, performed in addition to lateral collateral ligament reconstruction, is effective for treating chronic combined medial and lateral collateral ligament injuries of the ankle [143]. The application of allogeneic tendons to treat malunited lateral malleolar avulsion fractures combined with chronic lateral ankle instability appeared safe and effective [70]. The success of lateral ankle instability surgery depends on proper phases of the rehabilitation period [71]. Postoperative treatment for chronic ankle instability is similar to the treatment advised after an acute ankle sprain [132]. 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 for not returning to sport [190]. Surgical treatment is sometimes indicated for ankle conditions, and good outcomes can be achieved with appropriate treatments [19].

Complications

Post-traumatic Osteoarthritis

Ligamentous posttraumatic ankle osteoarthritis is a predominant cause of end-stage joint disease, identified in 182 patients (185 ankles), representing 71% of 247 patients (261 ankles) referred to an ankle arthritis center for painful end-stage ankle arthritis [18]. Following acute ankle sprains, residual symptoms persist in 33% of patients [39], while persistent abnormal changes of the ankle are found in 60% [39]. Addressing chronic lateral ankle instability simultaneously with osteochondral lesion of the talus treatment may positively impact long-term joint health by protecting repaired cartilage and stopping the cascade of cartilage damage [80].

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].

Surgical Complications and Outcomes

Neurologic complications occur 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 occur in 4.2% of these patients, requiring surgical revision [170]. The rate of cutaneous complications in arthroscopic ligament repair or reconstruction is at least half that of open surgery [170]. Overall complication rates for arthroscopic repair or reconstruction of the lateral ankle ligament range between 11.5% and 18% [170]. Two-stage arthroscopy is associated with significantly higher complication rates compared with single-stage arthroscopy [170]. Higher complications are noted with suture anchor fixation (29%) compared with suture fixation (9%) in arthroscopic lateral ankle 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]. Anterior bony impingement is present in 12% of patients with chronic ankle instability [170]. Ankle arthroscopy performed with lateral ligament reconstruction is associated with a lower rate of ankle arthrodesis as a second procedure and lower complications compared to reconstruction without arthroscopy [170].

Other Considerations

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 [15]. This technique produced statistically significant improvements at two years [76]. Lateral ligament reconstruction with allograft in patients with severe chronic lateral ankle instability leads to satisfying outcomes and reduced joint morbidity [14]. Leaving the ruptured deltoid ligament unrepaired in ankle fracture-dislocation no longer gives acceptable results [44].

Recovery

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

Full activity (months): The evidence provided does not specify a month range for the return to manual work, sport, or full ROM/strength.

Complete recovery / outcome plateau (months): The evidence provided does not specify a month range for when pain, strength, and final functional outcomes stabilise.

Rehabilitation protocol: The literature identifies a clear deficiency in consistent, meaningful postoperative return to sport timelines following lateral ankle ligament repair [34]. Arthroscopic ankle stabilisation repair and reconstruction techniques require further evaluation to better determine the indications of repair versus reconstruction and to obtain information on long-term outcomes [42].

Functional milestones: Short-term AOFAS functional outcome scores were significantly improved with arthroscopic lateral ankle repair compared to open repair [77]. Arthroscopic repair of lateral ankle ligament produced similarly favorable outcomes when compared with open lateral ankle repair [23]. The AnkleGO score effectively tracks recovery following arthroscopic anatomic lateral ankle ligament reconstruction in the short term [81]. Ultrasound-guided ATFL repair with or without augmentation for chronic lateral ankle instability results in clinical improvement at 6 months [15]. 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 [203].

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]. Approximately one-quarter of children and adolescents treated with the modified Broström procedure experienced recurrent sprains at 5- to 10-year follow-up [214]. Nearly half of the cohort of children and adolescents treated with the modified Broström procedure was not able to achieve their previous sports performance at 5- to 10-year follow-up [214]. The inability to achieve previous sports performance after modified Broström procedure was particularly observed in athletes and those with calcaneofibular ligament injuries [214]. Recurrence rates of ankle sprains after the focal sprain did not differ between pediatric and adolescent patients treated surgically versus conservatively for anterior talofibular ligament injuries [211, 212]. Tenodeses result in restricted range of ankle motion compared to anatomical reconstructions [68]. Tenodeses result in reduced long-term stability compared to anatomical reconstructions [68]. Tenodeses result in an increased risk of medially located degenerative changes compared to anatomical reconstructions [68]. Tenodeses result in a larger number of reoperations compared to anatomical reconstructions [68]. Tenodeses result in less satisfactory overall results compared to anatomical reconstructions [68]. The Chrisman-Snook operation restores good long-term function in a high percentage of patients disabled by ankle instability due to unhealed or neglected tears of the lateral ligaments [46]. The prognosis for a simple inversion injury without visible instability is the same as that for a completely unstable ankle treated by primary ligament suture [62]. One year after the procedure, roentgenograms showed stable ankles with a full range of motion [84]. At follow-up, all patients except one reported that the affected ankle felt stable following a simple operation for correction of chronic lateral instability [83].

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)
• [L1] Reconstruction of the lateral ankle ligament is a relatively stable treatment for chronic ankle instability. [10] (10.1016/j.injury.2020.05.031)
• [L5] Syndesmotic injuries are rare, debilitating, and frequently misdiagnosed, often resulting in longer recovery times than lateral ankle sprains. [11] (10.2519/jospt.2006.2195)
• [L4] The current systematic review demonstrated that arthroscopic lateral ankle ligament repair yields favorable clinical outcomes in the short term. [13] (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. [14] (10.1007/s00402-013-1911-6)
• [L4] Ultrasound-guided ATFL repair with or without augmentation for chronic lateral ankle instability is safe and results in clinical improvement at 6 months. [15] (10.1016/j.jisako.2025.100386)
• [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. [16] (10.1016/j.arthro.2018.05.001)
• [L4] [18] (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. [21] (10.1177/0363546507302545)
• [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)
• [L2] Endoscopic ligament reconstruction for chronic lateral ankle instability is a safe procedure that produces good clinical results with minimal complications. [24] (10.1007/s00167-019-05793-9)
• [L4] Therefore, when treating chronic lateral ankle instability, surgeons should consider ligament quality. [25] (10.1007/s00167-022-07211-z)
• [L1] Ultrasound manifested high diagnostic accuracy in diagnosing chronic lateral ankle ligament injury. [26] (10.1186/s13018-018-0811-4)
• [L3] [27] (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. [32] (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. [33] (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. [34] (10.1136/jisakos-2016-000064)
• [L3] Two distinct ATFL fascicles may be identified in the majority of ankles on MRI. [36] (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. [38] (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. [39] (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. [40] (10.2106/00004623-194931020-00013)
• [L5] [41] (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. [42] (10.1016/j.otsr.2018.09.005)
• [L3] It can therefore no longer be claimed that in such an ankle fracture leaving the ruptured deltoid ligament unrepaired gives acceptable results. [44] (10.1016/0020-1383(88)90071-x)
• [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)
• [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] [53] (10.1302/2058-5241.1.000010)
• [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] Although it reflects a normal anatomical finding, it could lead to anterolateral impingement in cases with coexistent ankle instability. [60] (10.1177/0095399703258697)
• [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] The prognosis for a simple inversion injury without visible instability is the same as that for a completely unstable ankle treated by primary ligament suture. [62] (10.1007/bf00932312)
• [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)
• [L5] The findings suggest that isolated lateral ankle ligament injuries do not directly affect syndesmotic stability. [65] (10.1007/s00167-022-06985-6)
• [L3] Unlike anatomical reconstructions, tenodeses do not restore the normal anatomy of the lateral ankle ligaments, resulting in restricted range of ankle motion, reduced long-term stability, an increased risk of medially located degenerative changes, a larger number of reoperations, and less satisfactory overall results. [68] (10.1007/s001670050210)
• [L4] This study suggests that arthroscopic repair for chronic lateral instability of the ankle is a safe and successful procedure. [69] (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. [70] (10.1186/s12891-023-06390-1)
• [L5] The success of lateral ankle instability surgery also depends on proper phases of the rehabilitation period. [71] (10.1177/2325967124s00376)
• [L4] The literature would benefit greatly from the standardization of the definition of ankle instability treatment failure. [72] (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. [75] (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)
• [L5] Addressing chronic lateral ankle instability simultaneously with osteochondral lesion of the talus treatment may positively impact the long-term health of the ankle joint by protecting repaired cartilage and stopping the cascade of cartilage damage. [80] (10.1016/j.arthro.2025.02.005)
• [L2] This shortterm study confirmed that the AnkleGO score effectively tracks recovery following AALALR. [81] (10.1002/ksa.70296)
• [L4] At follow-up, all patients except one reported that the affected ankle felt stable. [83] (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. [88] (10.1186/s12891-025-09458-2)
• [L4] [95] (10.1186/s13018-020-01847-8)
• [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. [103] (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. [107] (10.1177/03635465010290050501)
• [L4] Plantar flexion of the ankle produces changes in radiographic measurements of the medial clear space. [109] (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. [110] (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. [112] (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. [115] (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. [116] (10.1177/2325967118786227)
• [L3] Patients with mechanical ankle instability have more of an internally rotated talus than a variation of fibular position. [118] (10.1055/s-0043-106741)
• [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. [125] (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. [126] (10.1136/jisakos-2020-000503)
• [L4] The ankle ligamentous injury resulted from a motion combining internal rotation and inversion on the ankle joint instead of plantar flexion and inversion, which were traditionally regarded as the typical injury mechanisms. [127] (10.1177/0363546511399384)
• [L4] Ankle stability resumed with a high clinical success rate. [128] (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. [129] (10.1007/s00167-016-4243-6)
• [L5] The number of mechanoreceptors was negatively correlated with ankle sensorimotor dysfunction. [130] (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. [131] (10.1016/j.jisako.2024.100361)
• [Paper] [132] (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. [133] (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. [135] (10.1177/23259671221139482)
• [L3] Abnormal internal rotation of the talus in patients with mechanical ankle instability was decreased after ankle lateral stabilization surgery. [138] (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. [143] (10.1177/0363546517700859)
• [L4] The study establishes a standardized technique for measuring talar tilt and demonstrates that normal ankles can exhibit tilts up to 25 degrees, challenging the use of bilateral symmetry or fixed degree thresholds as sole criteria for ankle instability. [144] (10.2106/00004623-196042020-00010)
• [L2] [145] (10.1016/0020-1383(86)90075-6)
• [L3] The presence of CAI negatively affected ankle function and HRQoL in adolescent athletes. [148] (10.1177/2325967119900962)
• [L5] Stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus. [149] (10.2106/00004623-199607000-00006)
• [L2] Interventions based on improving self-efficacy might enhance and speed recovery from ankle injuries. [150] (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. [151] (10.1177/0363546508319050)
• [L4] Simultaneous arthroscopic treatment of an OLT and open lateral ankle stabilization is a safe and effective procedure. [153] (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. [154] (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)
• [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. [199] (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. [201] (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. [202] (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. [203] (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. [205] (10.1177/0363546504270566)
• [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)
• [L4] Recurrence rates of ankle sprains after the focal sprain did not differ between treatment groups. [211] (10.1177/2325967126s00416)
• [L4] Recurrence rates of ankle sprains after the focal sprain did not differ between treatment groups. [212] (10.1177/2325967126s00162)
• [L4] However, approximately one-quarter experienced recurrent sprains, and nearly half of the cohort was not able to achieve their previous sports performance, particularly athletes and those with calcaneofibular ligament injuries. [214] (10.1177/03635465251354961)

See Also

• Lateral ligament reconstruction
• Ankle arthroscopy
• Chronic ankle instability
• Syndesmotic injury
• Talus fracture
• Ankle impingement
• Osteochondral lesion of the talus
• Ankle osteoarthritis
• Ankle arthrodesis
• Ankle fracture

References

[1] Campbell S Operative Orthopaedics 4 Volume Set. REPAIR OF ACUTE RUPTURE OF LATERAL LIGAMENTS > ACUTE ANKLE LIGAMENT INJURIES, CHRONIC ANKLE INSTABILITY.

[2] Treatment of acute ankle ligament injuries: a systematic review. Archives of Orthopaedic and Trauma Surgery. 2013. DOI: 10.1007/s00402-013-1742-5

[3] Management of acute lateral ankle ligament injury in the athlete. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2252-7

[4] Management of Chronic Lateral Ankle Instability in Military Service Members. Clinics in Sports Medicine. 2014. DOI: 10.1016/j.csm.2014.06.011

[5] OPERATIVE TREATMENT OF INJURY TO THE FIBULAR COLLATERAL LIGAMENT OF THE ANKLE. The Journal of Bone & Joint Surgery. 1954. DOI: 10.2106/00004623-195436040-00014

[6] Unrecognized injuries of the lateral ligaments associated with lateral malleolar fractures of the ankle.. The Journal of Bone & Joint Surgery. 1989. DOI: 10.2106/00004623-198971090-00018

[7] The Anatomic Pattern of Injuries in Acute Inversion Ankle Sprains. Orthopaedic Journal of Sports Medicine. 2013. DOI: 10.1177/2325967113517078

[8] Apley And Solomon S Concise System Of Orthopaedics And Trauma. INJURIES OF THE ANKLE.

[10] The effectiveness of lateral ankle ligament reconstruction when treating chronic ankle instability: A systematic review and meta-analysis. Injury. 2020. DOI: 10.1016/j.injury.2020.05.031

[11] Ankle Syndesmosis Injuries: Anatomy, Biomechanics, Mechanism of Injury, and Clinical Guidelines for Diagnosis and Intervention. Journal of Orthopaedic & Sports Physical Therapy. 2006. DOI: 10.2519/jospt.2006.2195

[13] Arthroscopic Repair of Lateral Ankle Ligament for Chronic Lateral Ankle Instability: A Systematic Review. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.02.034

[14] Lateral ligament reconstruction with allograft in patients with severe chronic ankle instability. Archives of Orthopaedic and Trauma Surgery. 2013. DOI: 10.1007/s00402-013-1911-6

[15] Ultrasound-guided repair of the anterior talofibular ligament with or without Gould augmentation is safe and improves clinical outcomes for chronic lateral ankle instability: A case series of 49 patients. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2025.100386

[16] Editorial Commentary: Repair of Lateral Ankle Ligament: Is Arthroscopic Technique the Next Station?. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.05.001

[18] Ligamentous Posttraumatic Ankle Osteoarthritis. The American Journal of Sports Medicine. 2006. DOI: 10.1177/0363546505281813

[19] Orthopaedic Knowledge Update Sports Medicine 6. Ankle and Foot Injuries and Other Disorders > Summary.

[21] Syndesmotic Ankle Sprains in Athletes. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546507302545

[22] Ankle Stability. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.21.00726

[23] Activity Level and Function 2 Years After Anterior Talofibular Ligament Repair: A Comparison Between Arthroscopic Repair and Open Repair Procedures. The American Journal of Sports Medicine. 2017. DOI: 10.1177/0363546517698675

[24] Endoscopic anatomic ligament reconstruction is a reliable option to treat chronic lateral ankle instability. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05793-9

[25] 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

[26] Imaging diagnosis for chronic lateral ankle ligament injury: a systemic review with meta-analysis. Journal of Orthopaedic Surgery and Research. 2018. DOI: 10.1186/s13018-018-0811-4

[27] Ligamentous Injuries and the Risk of Associated Tissue Damage in Acute Ankle Sprains in Athletes. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546514529643

[32] Acute clinical evaluation for the diagnosis of lateral ankle ligament injuries is useful: A comparison between the acute and delayed settings. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12079

[33] Clinical Association of Acute Lateral Ankle Sprain with Syndesmotic Involvement. The American Journal of Sports Medicine. 2002. DOI: 10.1177/03635465020300061101

[34] Return to sport following lateral ankle ligament repair is under-reported: a systematic review. Journal of ISAKOS. 2017. DOI: 10.1136/jisakos-2016-000064

[36] Individual fascicles of the ankle lateral ligaments and the lateral fibulotalocalcaneal ligament complex can be identified on 3D volumetric MRI. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-07275-x

[38] 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

[39] RESIDUAL DISABILITY FOLLOWING ACUTE ANKLE SPRAINS. The Journal of Bone & Joint Surgery. 1955. DOI: 10.2106/00004623-195537060-00011

[40] INJURIES OF THE LATERAL LIGAMENTS OF THE ANKLE. The Journal of Bone & Joint Surgery. 1949. DOI: 10.2106/00004623-194931020-00013

[41] Anatomy of the ankle ligaments: a pictorial essay. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1100-x

[42] Arthroscopic treatment of chronic ankle instability: Prospective study of outcomes in 286 patients. Orthopaedics & Traumatology: Surgery & Research. 2018. DOI: 10.1016/j.otsr.2018.09.005

[44] Fracture-dislocation of the ankle with rupture of the deltoid ligament. Injury. 1988. DOI: 10.1016/0020-1383(88)90071-x

[46] Long-term results of the Chrisman-Snook operation for reconstruction of the lateral ligaments of the ankle.. The Journal of Bone & Joint Surgery. 1985. DOI: 10.2106/00004623-198567010-00001

[50] Minor or occult ankle instability as a cause of anterolateral pain after ankle sprain. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3454-y

[51] Management of sports injuries of the foot and ankle. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b7.36588

[52] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Foot and Ankle Reconstruction > Chronic Ankle Instability.

[53] Acute ankle sprain: conservative or surgical approach?. EFORT Open Reviews. 2016. DOI: 10.1302/2058-5241.1.000010

[56] The contribution of the anterior talofibular ligament to ankle laxity.. The Journal of Bone & Joint Surgery. 1983. DOI: 10.2106/00004623-198365010-00011

[57] Orthopaedic Knowledge Update. Ankle Injuries* > Low Ankle Sprain.

[59] Persistence of long term isokinetic strength deficits in subjects with lateral ankle sprain as measured with a protocol including maximal preloading. Clinical Biomechanics. 2014. DOI: 10.1016/j.clinbiomech.2014.09.010

[60] The Accessory Anteroinferior Tibiofibular Ligament as a Cause of Talar Impingement. The American Journal of Sports Medicine. 2004. DOI: 10.1177/0095399703258697

[61] Treatment of lateral ankle sprains. Knee Surgery, Sports Traumatology, Arthroscopy. 2002. DOI: 10.1007/s00167-002-0327-6

[62] Inversion trauma of the ankle. Archives of Orthopaedic and Trauma Surgery. 1989. DOI: 10.1007/bf00932312

[63] The Surgical Treatment of Injuries of the Fibular Collateral Ligaments of the Ankle. The Journal of Bone & Joint Surgery. 1961. DOI: 10.2106/00004623-196143020-00011

[65] Isolated injuries to the lateral ankle ligaments have no direct effect on syndesmotic stability. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-06985-6

[68] Anatomical reconstruction versus tenodesis for the treatment of chronic anterolateral instability of the ankle joint: a 2‐ to 10‐year follow‐up, multicenter study. Knee Surgery, Sports Traumatology, Arthroscopy. 2000. DOI: 10.1007/s001670050210

[69] Ankle Syndesmotic Ligaments Injury: Total Arthroscopic Procedure Assisted With a New Anterosuperior Portal. Three‐Year First Results (SS‐62). Arthroscopy. 2008. DOI: 10.1016/j.arthro.2008.04.062

[70] Allogeneic tendons in the treatment of malunited lateral malleolar avulsion fractures with chronic lateral ankle instability. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06390-1

[71] Arthroscopic ankle lateral ligament instabilities repair. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00376

[72] Current Definitions of Failure in Lateral Ankle Instability Surgery: A Systematic Review. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465231153165

[75] Fair evidence consistently supports open surgical treatment for chronic ankle instability: a systematic review. Journal of ISAKOS. 2019. DOI: 10.1136/jisakos-2018-000265

[76] Two-year clinical outcome of ultrasound-guided repair of the anterior talofibular ligament with or without Gould augmentation: A case series. Journal of ISAKOS. 2026. DOI: 10.1016/j.jisako.2025.101043

[77] Arthroscopic versus open repair of lateral ankle ligament for chronic lateral ankle instability: a meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-5100-6

[78] Miller S Review Of Orthopaedics. ANKLE SPRAINS.

[80] Editorial Commentary: Concomitant Stabilization Is Recommended When Treating Osteochondral Lesions of the Talus in Patients With Chronic Lateral Ankle Instability. Arthroscopy. 2025. DOI: 10.1016/j.arthro.2025.02.005

[81] Evaluation of functional deficits using the Ankle‐GO™ score before and after arthroscopic anatomic lateral ankle ligament reconstruction among patients suffering from chronic ankle instability. Knee Surgery, Sports Traumatology, Arthroscopy. 2026. DOI: 10.1002/ksa.70296

[83] A simple operation for correction of chronic lateral instability of the ankle. Injury. 1983. DOI: 10.1016/0020-1383(83)90038-4

[84] WITH SPECIAL REFERENCE TO PERONEAL-NERVE BLOCK AS A DIAGNOSTIC ALD*. 1951.

[85] Miller S Review Of Orthopaedics. BIOMECHANICS OF THE FOOT AND ANKLE.

[88] Three-dimensional talar shape seems not a factor in chronic mechanical ankle instability. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-025-09458-2

[89] Campbell S Operative Orthopaedics 4 Volume Set. MULTIPLE Z-PLASTY RELEASE OF A CONGENITAL RING > ANKLE BLOCK.

[91] Orthopaedic Knowledge Update Sports Medicine 6. Ankle and Foot Injuries and Other Disorders > Ankle Sprains > Medial Ankle Injury.

[93] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Foot and Ankle Anatomy and Biomechanics > Annotated References.

[94] Rockwood And Green S Fractures In Adults. 59: Patellar Fractures and Dislocations and Extensor Mechanism Injuries > Imaging and Other Diagnostic Studies for Ankle Fractures > Radiography.

[95] Functional deficits in chronic mechanical ankle instability. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01847-8

[103] Kinematics and muscle activities of the lower limb during a side-cutting task in subjects with chronic ankle instability. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3745-y

[107] The Posteromedial Impingement Lesion of the Ankle. The American Journal of Sports Medicine. 2001. DOI: 10.1177/03635465010290050501

[109] Plantar Flexion Influences Radiographic Measurements of the Ankle Mortise. The Journal of Bone and Joint Surgery-American Volume. 2010. DOI: 10.2106/jbjs.i.00084

[110] The biomechanical influence of tibio‐talar containment on stability of the ankle joint. Knee Surgery, Sports Traumatology, Arthroscopy. 2007. DOI: 10.1007/s00167-007-0372-2

[112] Does antero-lateral ankle impingement exist?. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2017.09.004

[115] Dynamic balance deficits in individuals with chronic ankle instability compared to ankle sprain copers 1 year after a first-time lateral ankle sprain injury. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3744-z

[116] The Epidemiology of Ankle Injuries Identified at the National Football League Combine, 2009-2015. Orthopaedic Journal of Sports Medicine. 2018. DOI: 10.1177/2325967118786227

[118] MRI Identification of the Fibular and Talus Position in Patients with Mechanical Ankle Instability. International Journal of Sports Medicine. 2017. DOI: 10.1055/s-0043-106741

[125] Dynamic Ankle Control in Athletes With Ankle Instability During Sports Maneuvers. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546511406868

[126] Limited intrarater and interrater reliability of acute ligamentous ankle injuries on 3 T MRI. Journal of ISAKOS. 2021. DOI: 10.1136/jisakos-2020-000503

[127] Kinematics Analysis of Ankle Inversion Ligamentous Sprain Injuries in Sports. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546511399384

[128] Mid-term follow-up evaluation of a new arthroscopic Broström procedure for chronic lateral ankle instability. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03789-3

[129] Peroneal electromechanical delay and fatigue in patients with chronic ankle instability. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-4243-6

[130] Chronic Ankle Joint Instability Induces Ankle Sensorimotor Dysfunction: A Controlled Laboratory Study. The American Journal of Sports Medicine. 2024. DOI: 10.1177/03635465231217490

[131] Ligamentous ankle injuries in relation to the morphology of the incisura fibularis: A systematic review. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2024.100361

[132] Chronic Ankle Instability (Medial and Lateral). Clinics in Sports Medicine. 2015. DOI: 10.1016/j.csm.2015.06.004

[133] Surgical reconstruction for chronic lateral instability of the ankle. Injury. 2004. DOI: 10.1016/j.injury.2003.09.035

[135] Foot and Shank Coordination During Walking in Copers Compared With Patients With Chronic Ankle Instability and Controls. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221139482

[138] Decreasing the Abnormal Internally Rotated Talus After Lateral Ankle Stabilization Surgery. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/23259671211023447

[143] Simultaneous Reconstruction of the Medial and Lateral Collateral Ligaments for Chronic Combined Ligament Injuries of the Ankle. The American Journal of Sports Medicine. 2017. DOI: 10.1177/0363546517700859

[144] The Talar-Tilt Angle and the Fibular Collateral Ligaments. The Journal of Bone & Joint Surgery. 1960. DOI: 10.2106/00004623-196042020-00010

[145] A new treatment of stable lateral ligament injuries of the ankle joint. Injury. 1986. DOI: 10.1016/0020-1383(86)90075-6

[148] Prevalence and Impact of Chronic Ankle Instability in Adolescent Athletes. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967119900962

[149] Motion of the Ankle in a Simulated Supination-External Rotation Fracture Model. The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199607000-00006

[150] Factors associated with pain intensity and physical limitations after lateral ankle sprains. Injury. 2016. DOI: 10.1016/j.injury.2016.09.016

[151] Chronic Lateral Ankle Instability. The American Journal of Sports Medicine. 2008. DOI: 10.1177/0363546508319050

[153] Treatment of the Unstable Ankle with an Osteochondral Lesion. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546509351556

[154] The feasibility of point-of-care ankle ultrasound examination in patients with recurrent ankle sprain and chronic ankle instability: Comparison with magnetic resonance imaging. Injury. 2017. DOI: 10.1016/j.injury.2017.07.015

[156] Is arthroscopic surgery as successful as open approach in the treatment of lateral ankle instability?. Archives of Orthopaedic and Trauma Surgery. 2021. DOI: 10.1007/s00402-021-03799-y

[159] MRI for high ankle sprains with an unstable syndesmosis: posterior malleolus bone oedema is common and time to scan matters. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05581-5

[160] Reinjury after Acute Lateral Ankle Sprains in Elite Track and Field Athletes. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546509338107

[162] Reliability and Validity of Magnetic Resonance Imaging for the Evaluation of the Anterior Talofibular Ligament in Patients Undergoing Ankle Arthroscopy. Arthroscopy. 2015. DOI: 10.1016/j.arthro.2015.02.024

[164] Isolated syndesmotic injuries in acute ankle sprains: diagnostic significance of clinical examination and MRI. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3604-x

[167] A Prospective, Randomized Clinical Investigation of the Treatment of First-Time Ankle Sprains. The American Journal of Sports Medicine. 2006. DOI: 10.1177/0363546506288676

[170] Campbell S Operative Orthopaedics 4 Volume Set. ARTHROSCOPIC EXAMINATION AND DEBRIDEMENT OF THE ANKLE JOINT > ANKLE INSTABILITY.

[172] Distal insertion rupture of lateral ankle ligament as a predictor of weakened and delayed sports recovery after acute ligament repair: mid-term outcomes of 117 cases. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05260-6

[174] CORR Insights®: Apoptosis Occurs in the Anterior Talofibular Ligament of Patients With Chronic Lateral Ankle Instability: An In Vitro Study. Clinical Orthopaedics & Related Research. 2022. DOI: 10.1097/corr.0000000000002404

[179] Magnetic resonance imaging characterization of individual ankle syndesmosis structures in asymptomatic and surgically treated cohorts. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3399-1

[180] The ankle sprain and the domino effect. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12538

[182] The prevalence of posterior inferior tibiofibular ligament and inferior tibiofibular transverse ligament injuries in syndesmosis-injured ankles evaluated by oblique axial magnetic resonance imaging: a retrospective study. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05220-0

[184] Orthopaedic Knowledge Update. Ankle Injuries* > High Ankle Sprain.

[185] Diagnosis of avulsion fractures of the distal fibula after lateral ankle sprain in children: a diagnostic accuracy study comparing ultrasonography with radiography. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03287-1

[189] Reconstruction of the lateral ligament of the ankle. Injury. 1975. DOI: 10.1016/0020-1383(75)90065-0

[190] Analysis of Return to Play After Modified Broström Lateral Ankle Ligament Reconstruction. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671211068541

[191] Radiographic Measurements Do Not Predict Syndesmotic Injury in Ankle Fractures. Clinical Orthopaedics and Related Research. 2005. DOI: 10.1097/01.blo.0000161090.86162.19

[194] Searching for consensus in the approach to patients with chronic lateral ankle instability: ask the expert. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4556-0

[195] Reliability and Validity of Preoperative MRI for Surgical Decision Making in the Chronic Lateral Ankle Instability. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.04.066

[199] Agreement between arthroscopic and imaging study findings in chronic anterior talo-fibular ligament injuries. Orthopaedics & Traumatology: Surgery & Research. 2018. DOI: 10.1016/j.otsr.2018.09.008

[201] Arthroscopic Quantification of Syndesmotic Instability in a Cadaveric Model. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2016.11.008

[202] Reliability and validity of different ankle MRI scanning planes for the anterior talofibular ligament injury diagnosis: a cadaveric study. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1102-4

[203] The L‐shaped tunnel technique showed favourable outcomes similar to those of the Y‐graft technique in anatomic lateral ankle ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-06880-0

[205] Arthroscopic Assessment for Intra-articular Disorders in Residual Ankle Disability after Sprain. The American Journal of Sports Medicine. 2005. DOI: 10.1177/0363546504270566

[206] Arthroscopic Findings in Patients with Chronic Ankle Instability. The American Journal of Sports Medicine. 2002. DOI: 10.1177/03635465020300031601

[209] Recovery From a First-Time Lateral Ankle Sprain and the Predictors of Chronic Ankle Instability. The American Journal of Sports Medicine. 2016. DOI: 10.1177/0363546516628870

[211] Poster 112. Is There a Twist? Differences in Recurrence of Lateral Ankle Sprains Among Pediatric and Adolescent Patients Treated Surgically Versus Conservatively for Anterior Talofibular Ligament Injuries. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/2325967126s00416

[212] Is There a Twist? Differences In Recurrence of Lateral Ankle Sprains Among Pediatric and Adolescent Patients Treated Surgically Versus Conservatively for Anterior Talofibular Ligament Injuries?. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/2325967126s00162

[214] Clinical Outcomes and Sports Participation After the Modified Broström Procedure in Children and Adolescents With Chronic Lateral Ankle Instability: A 5- to 10-Year Follow-up of 111 Cases. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465251354961