Connor Stuart – 12051576 Assigned Condition #39 ATFL Strain

Anterior Talofibular Ligament (ATFL) Strain

Rehabilitation Protocol

Indications and Trauma History

The anterior talofibular ligament originates from the anterior edge of the lateral malleolus of the
fibula and inserts to the neck of the talus, anterior to the lateral malleolar facet.

To assess a possible ATFL injury, information must be found on the exact severity, mechanism and
velocity of trauma and any history of previous injuries and inadequate rehabilitation.

The mechanism for lateral injuries of the ATFL are from forces of inversion and plantarflexion and
severity of injury varies depending on the velocity of force during the movement. Makin gup
approximately two thirds of ankle injuries the anterior talofibular ligament is the weakest of the
lateral ligaments and hence often the first to be damaged. Its commonly injured with the
calcaneofibular and anterior tibiofibular ligaments, which is the inferior, anterior component of the
syndesmosis. Lateral ligament damage is unlikely to occur from a simple rolled ankle without prior
damage to those tissues. Common sporting mechanisms of injury are landing awkwardly on unstable
ground or an opponents foot or a slide tackle which contacts inside the opponents weight bearing
leg.

Swelling and bruising may appear within hours after injury and the degree of these signs will assist in
grading the injury. Patient reports of snapping or cracking may also help indicate the possibility of a
fracture or rupture from a partial strain.

Injury Descriptions and Healing Times

Grade 1 – Mild: Only ATFL Damaged

 Signs: minimal swelling, tenderness over damaged ligament, no bruising

 Damage: mild stretch, no instability, partial tear
 Function: no limp or walking changes, mild difficulty single leg hopping, full function return
expected in 2-14 days

Grade 2 – Moderate: Complete ATFL Rupture and Damage to Others

 Signs: bruising on injured side, mild-moderate swelling

 Damage: mild to moderate instability, full tear of ATFL and partial tear of other lateral
ligaments and/or the syndesmosis
 Function: Limping or impaired balance, inability to hop or run, full function return expected
in 14-40 days

Grade 3 – Severe: Complete Rupture of Multiple Ligaments (incl. ATFL) and Joint Capsule

 Signs: severe bruising, tenderness and swelling both sides of ankle, fracture must be ruled
out, Achilles tendon becomes difficult to see due to swelling
 Damage: noticeable instability with full rupture of ATFL, syndesmosis, joint capsule, other
lateral ankle ligaments or a combination of the above resulting in a severe complex injury
 Function: inability to weight-bear with poor balance, large loss in ROM, full function return
expected in 1-3 months but up to 6 if managed correctly
Connor Stuart – 12051576 Assigned Condition #39 ATFL Strain

Testing
Firstly beginning palpation and range of motion before commencing with activities with
weightbearing to see function such as walk, squat and hop. Orthopaedic test results may be
hindered by acute swelling so if results are initially negative but other signs remain then tests are to
be repeated after 3-5 days. Ensure to perform a neurovascular assessment before proceeding to
provocative testing and treatment.

Anterior Drawer Test:

 Sensitivity of 98% and Specificity of 84% for acute ATFL rupture with possible association of
CFL
 Performed with knee flexed to 90 degrees, increased laxity when ankle drawn anterior
compared to contralateral side

Lateral Talar Tilt Test:

 Sensitivity of 50% and specificity of 88% for lateral ankle sprains of ATFL but can be adjusted
to assess the posterior talofibular, calcaneofibular and deltoid ligaments
 Performed sitting with leg hanging off table; take ankle into plantar flexion and perform
inversion by moving the calcaneus; positive with pain and/or gapping greater than 15
degrees compared to contralateral side

Imaging
X-rays in weightbearing if a fracture is suspected, Ottawa ankle rules apply. CT and MRI will be more
effective at visualising lower grade injuries for the extent of ligament damage.

Anterior and posterior talofibular ligaments both usually seen via single axis MRI obtained slightly
distal to tibiofibular ligaments. Noticeable with increased intra-ligamentous signal intensity on fat
suppressed T2 weighted or with intermediate weight images as indicative of intrasubstance oedema
or haemorrhage. If suspected to be a chronic issue than ultrasound may be more efficient with high
sensitivity and specificity with increased chronicity.

Management
Immediately treat with RICE (rest, ice, compress, elevate) method when acute and keep joint stable
but mobile by progressing to METH (mobilisation, exercise, traction, heat) as pain decreases and
strength, function returns. Soft tissue therapy may assist with reduction of swelling and decrease
scar tissue with IASTM as pain limits permit. As the patient prepares to return to activity and
increased weight-bearing assess their footwear to prevent further inversion forces.

Grade 1/2:

 Early mobilisation and guided proprioception and strengthening activities, taping and
semirigid/laced supports if needed. Stable and controlled weightbearing activities as pain
allows early.

Grade 3:

 Immobilisation for a few days while initial response subsides with a cast or boot followed by
progressive strengthening and proprioception, as stability returns switch from cast to lace-
up or semirigid supports. MRI often recommended to view extent of and exact structures
damaged.
Connor Stuart – 12051576 Assigned Condition #39 ATFL Strain

Referral and Surgery

Sports physicians are trained in specific diagnosis and management in accordance with the patients
athletic goals. If fracture or unstable strain of the syndesmosis are suspected, then immediate
orthopaedic referral is required. Surgical repair of the ligament is not common but is an option for
full ruptures of the ligament.

Rehabilitation and Progression

Focussing on motion, strength building, proprioception and activity specific (if appropriate).
Minimum of 6 weeks for a mild injury before return to sport but may be different for degrees of
injury of athlete body types and activity demands. The following is a rough guideline of rehabilitation
for ATFL and other lateral ligament strains.

Week 1:

 RICE after activity, mobilising through pain free ranges, avoid unstable surfaces, weight
bearing on stable surfaces and increase stationary movements as pain permits

Week 2:

 Continue and increasing range of motion exercises, rocker board and light theraband work
for balance and strengthening, conscious walking normally keeping foot in neutral position
 Star excursion test to assess and monitor improvements in balance
 Strengthening should consist of both isometric and isotonic movements

Week 3:

 Continue the above and incorporate inversion/eversion movements but keep these lateral
movements slow and stable, progress walking to slow jog in straight lines, increase band
resistance if pain free

Week 4+:

 Progression depending on injury severity and patients progress; wobble board for
proprioception, begin activity specific movements for athletes, slow change of direction
movements
 Progress to light controlled drills and faster change of direction at pain free levels
 Return to activity only after two fully pain free exercise/training sessions

Injury Outcomes
Athletes with mild-moderate injuries are often able to return to activity; those with severe injuries
are also required to wear a semi-rigid ankle support along with continued management for best
likelihood of returning to sport. The prognosis for these injuries is drastically improved with early
mobilisation and rehab but it is common for more severe injuries to have limiting symptoms for 6-18
months. Adequately following rehabilitation can assist in preventing re-injury and chronicity.

References
Vizniak, N. (2020). Evidence Informed Orthopedic Conditions (3rd ed., pp. 270-271). Canada:
ProHealth.

Slimmon, D., & Brunker, P. (2010). Sports Ankle Injuries. Australian Family Physician, 39(2).
https://www.racgp.org.au/download/documents/AFP/2010/Jan-Feb/201001slimmon.pdf
Connor Stuart – 12051576 Assigned Condition #39 ATFL Strain

Anterior Talo-Fibular Ligament (ATFL). (2021). https://www.physio-pedia.com/Anterior_Talo-

Fibular_Ligament_(ATFL)

Ankle Injury. (2021). https://sma.org.au/resources-advice/injury-fact-sheets/ankle-injury/

Mattacola, C., & Dwyer, M. (2002). Rehabilitation of the Ankle After Acute Sprain or Chronic
Instability. Journal Of Athletic Training, 37(4), 413-429. https://pubmed.ncbi.nlm.nih.gov/12937563/

Weerakkody, Y., & Patel, M. (2021). Anterior talofibular ligament injury. Retrieved 28 January 2021,
from https://radiopaedia.org/articles/anterior-talofibular-ligament-injury

Hertel, J., Denegar, C., Monroe, M., & Stokes, W. (1999). Talocrural and subtalar joint instability after
lateral ankle sprain. Medicine & Science In Sports & Exercise, 31(11), 1501. doi: 10.1097/00005768-
199911000-00002

Video Clips
Physiotutors. (2016). The Talar Tilt Test. https://www.youtube.com/watch?v=UHNbm6Z3XK4

Physiotutors. (2017). Anterior Drawer Test of the Ankle. https://www.youtube.com/watch?

v=vAcBEYZKcto

University of Colorado, Anschutz Medical Campus. (2016). 4 Way Ankle Theraband.

https://www.youtube.com/watch?v=__Ms1xZFORw

DJO ANZ. (2018). Rehabilitate Sprained Ankles Using Procare Wobble Board.
https://www.youtube.com/watch?v=FHvP4_O2nhU