Knee Surgery, Sports Traumatology, Arthroscopy (2020) 28:34–39

https://doi.org/10.1007/s00167-019-05794-8

ANKLE

The lateral ankle ligaments are interconnected: the medial connecting

fibres between the anterior talofibular, calcaneofibular and posterior
talofibular ligaments
M. Dalmau‑Pastor1,2,3   · F. Malagelada1,4 · J. Calder5 · M. C. Manzanares1 · J. Vega1,2,6

Received: 30 September 2019 / Accepted: 6 November 2019 / Published online: 22 November 2019
© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Abstract
Purpose  A deep knowledge of lateral ankle ligaments is necessary to understand its function, pathophysiology and treat-
ment options. The ankle lateral collateral ligament is formed by the anterior talofibular ligament (ATFL), the calcaneofibular
(CFL) and the posterior talofibular ligament (PTFL). Although previous studies have reported connections between these
ligaments on its lateral side, no studies have specifically assessed connections on the medial side. The aim of this study was
to assess the morphology and consistency of the medial connections between the components of the lateral collateral liga-
ment complex of the ankle.
Methods  Forty fresh-frozen ankle specimens were dissected to look for connections between the three lateral ankle ligaments.
After visualization of the lateral ligaments was achieved, the fibula was amputated and ligament insertions were released at
the talar and calcaneal insertion points. Observation of the connections and video analysis of the dynamic relationships of
ligament connections were performed.
Results  Connections were found in all cases between the ATFL and PTFL, the ATFL and CFL, and the CFL and PTFL.
Connections between ATFL and PTFL were not homogeneous. Although connections between the ATFLif and PTFL were
noted in all cases (40), only 17 ankles (42.5%) had connections between the ATFLsf and PTFL. The amount of fibres of
connection was also variable.
Conclusion  Connections between the three components of the lateral collateral ligament of the ankle may be observed from
the medial aspect of the ankle, and this may have important implications for arthroscopic lateral ligament repair.

Keywords  Anatomy · Ankle · Anterior talofibular ligament · Calcaneofibular ligament · Posterior talofibular ligament ·
Ankle lateral ligaments

* M. Dalmau‑Pastor
mikeldalmau@ub.edu
1 the anterior talofibular ligament (ATFL), the calcaneofibu-
Department of Pathology and Experimental Therapeutics,
Human Anatomy and Embryology Unit, University
of Barcelona, Barcelona, Spain
2
GRECMIP, MIFAS (Groupe de Recherche et d’Etude en
Chirurgie Mini-Invasive du Pied, Minimally Invasive Foot
and Ankle Society), Merignac, France
3
Vilamèdic Medical Center, Santa Coloma de Gramanet,
Barcelona, Spain
4
Department of Trauma and Orthopaedic Surgery, Royal
London Hospital, Barts Health NHS Trust, London, UK
5
Trauma and Orthopaedics, Chelsea and Westminster
Hospital, London, UK
6
Foot and Ankle Unit, iMove Tres Torres, Barcelona, Spain
Introduction
The ankle lateral collateral ligament complex is formed by
lar (CFL) and the posterior talofibular ligament (PTFL).
These ligaments have been the subject of numerous studies
[2, 3, 6, 9, 10, 12, 15, 16, 18, 25]. However, new findings
of the relationship between the ATFL and CFL have been
recently published [25]. The ATFL was found to be a liga-
ment with two fascicles, its inferior one being connected
with CFL forming the lateral fibulotalocalcaneal ligament
(LFTCL) complex. This complex can be observed from the
lateral aspect of the ankle, where arciform fibres connect
the ATFL inferior fascicle (ATFLif) and the CFL. The pre-
vious study also showed that the LFTCL is an isometric
structure, while the ATFL superior fascicle (ATFLsf) is not.

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Knee Surgery, Sports Traumatology, Arthroscopy (2020) 28:34–39 35
In addition, ATFLsf was found to be an intra-articular liga-
ment, functionally and anatomically different from ATFLif
[4, 25]. This discovery challenges traditional concepts of
the lateral ligament complex that consider the ligaments as
anatomically separate structures which have then influenced
surgical reconstructive procedures.
Ankle arthroscopy is now the gold standard for the treat-
ment of many intra-articular pathologies, and arthroscopic
lateral ligament repair and reconstructive techniques are
gaining popularity [1, 7, 11, 17, 19–24, 26]. During ankle
arthroscopic procedures, a medial view of the lateral recess
is obtained, which includes a medial view of the lateral liga-
ments [4, 27] (Fig. 1). This change in the visualization of the
lateral ankle ligaments combined with recent advances in
understanding the anatomy [25] made necessary to specifi-
cally investigate the medial view of the lateral ligamentous
structures and in particular the LFTCL complex.
The aim of this study was to assess the morphology and
consistency of the medial connections between the compo-
nents of the lateral collateral ligament complex of the ankle.
Material and methods
Forty fresh-frozen ankle specimens were used for this study.
The specimens were provided by and dissected at the Human
Anatomy Unit (Bellvitge Campus) of the University of Bar-
celona (Spain). Specimens had a mean age of 61.3 years
(range 32–75 years). There were 27 male and 13 female
Fig. 1  Arthroscopic view of ATFLsf (3) obtained from the anterome-
dial portal. (1) Fibular malleolus. (2) Lateral talar articular surface.
(3) ATFLsf. (4) Anterior ankle joint capsule
specimens. The right ankle was dissected in 29 specimens
and the left ankle in the remaining 11.
Exclusion criteria for this study included: specimens with
any foot and ankle deformities; cutaneous incisions that sug-
gested any foot and ankle trauma; previous fracture or sur-
gery; ankle joint stiffness and ankle instability; and lateral
collateral ligament injury identified during dissection.
Each specimen was dissected in a standard manner. All
dissections were performed by an experienced anatomist
[5]. After thawing the specimens by submersion in room
temperature water, the specimens were dissected onto the
osteo-articular plane. ATFLsf, LFTCL complex and PTFL
were visualized and preserved. On completion of the dissec-
tion the fibula was transected. Firstly, the interosseous mem-
brane, tibio-fibular interosseous ligament, anterior tibio-fib-
ular ligament and posterior tibio-fibular ligament were cut
at its tibial insertion. Secondly, the ATFLsf, LFTCL and
PTFL were cut at the talar insertion for ATFL and PTFL and
calcaneal insertion for CFL. At this point, the distal half of
the fibula was separated from the ankle so that the lateral
ankle ligaments could be observed from both the lateral and
medial aspects. Synovium was carefully dissected off the
medial aspect of the ligaments when required.
The relationship and connections between the ligaments
were recorded including the number of ATFL fascicles and
the characteristics of the medial fibula facet. Video analy-
sis of ligamentous movements was performed to assess the
dynamic relationships of the ligament connections by apply-
ing tension individually to the ATFLsf, ATFLif, CFL and
PTFL.
Statistical analysis
SPSS version 19 (IBM, US) was used to perform statisti-
cal analysis. The presence or absence of connecting fibres
between ligaments was compared to the observed motion
of the same ligaments using the McNemar’s exact test for
a 2 × 2 contingency table. Results were coded into binary
variables (presence of fibres: yes or no and movement: yes
or no). A p value < 0.05 was considered significant.
Results
After dissection of the medial side of the lateral collateral
ankle ligament complex, connections were found in all
ankles between the ATFL and PTFL, the ATFL and CFL,
and the CFL and PTFL.
Connections between ATFL and PTFL were not homoge-
neous. Although connections between the ATFLif and PTFL
were noted in all ankles, only 17 ankles (42.5%) had connec-
tions between the ATFLsf and PTFL. The amount of fibres
of connection was also variable (Figs. 2, 3, 4).
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36 Knee Surgery, Sports Traumatology, Arthroscopy (2020) 28:34–39

Fig. 2  Lateral and medial view

of the fibular malleolus in a
specimen with ATFLsf, ATFLif,
CFL and PTFL connections. (1)
ATFLsf. (2) ATFLif. (3) CFL.
(4) PTFL

Fig. 3  Lateral and medial view

of the fibular malleolus in a
specimen with ATFLsf, ATFLif,
CFL and PTFL connections. In
this specimen, the connections
of ATFLsf and PTFL were par-
ticularly evident. (1) ATFLsf.
(2) ATFLif. (3) CFL. (4) PTFL

Connections between the ATFLif and CFL were always
observed by means of arciform (arc-shaped) fibres that
crossed the lateral part of the talocalcaneal joint (Figs. 2, 3, 5).
Connections between the CFL and PTFL were only
visible when observed from a medial view, because the
fibula prevented its visualization from a lateral view. These
connections were formed by arciform fibres and covered
by synovium on its medial part (Figs. 2, 3, 4).
The medial articular surface of the lateral malleolus
varied between specimens. Although it was always trian-
gular in shape, in some cases the vertex of the triangle was
found to be very acute. In these specimens, there were no

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Knee Surgery, Sports Traumatology, Arthroscopy (2020) 28:34–39 37

Fig. 4  a Posterior view of talus and fibula in its anatomical position. b and c The fibula is displaced laterally in order to show the connections
between ATFLsf and PTFL. (1) ATFLsf. (2) CFL. (3) PTFL

Fig. 5  Lateral and medial view

of the fibular malleolus in a
specimen with ATFLif, CFL
and PTFL connections. No
connections between ATFLsf
and PTFL were present in this
specimen. Observe the acute tri-
angular articular surface of the
lateral malleolus. (1). ATFLsf.
(2) ATFLif. (3) CFL. (4) PTFL

connections between the ATFLsf and PTFL because the of connections (ATFLsf-PTFL, ATFLif-PTFL and CFL-
space was occupied by the articular surface. PTFL) with consistent movement as those specimens with
connections showed movement and those without did not
Dynamic assessment of ligament connections (p < 0.01).

Movements of connections between the ATFLsf and PTFL

were not consistent (no movement in three specimens, move-
ment in 14). In these ankles, there was no significant differ-
ence in ligamentous movement between those specimens
with and those without connections (p = 0.49, n.s.).
On the other hand, there was a significant difference in
the amount of movement when comparing the various types
Discussion
The most important finding of this study is that intercon-
nections between the three components of the lateral col-
lateral ligament of the ankle may be observed from the
medial aspect. Connections were observed between ATFL

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38
and PTFL, ATFL and CFL, and CFL and PTFL in all ankles
studied. ATFLsf-PTFL connections were observed in 42.5%
of specimens, while ATFLif-PTFL connections were present
in all specimens.
A recent anatomical description of the lateral col-
lateral ligament complex has shown that extra-articular
connections between ATFLif and CFL exist, forming the
LFTCL complex, an isometric and extra-articular structure
anatomically separated from the ATFLsf, a non-isomet-
ric and intra-articular structure [25] The new finding of
medial connections between ligaments demonstrates some
similarities between the lateral collateral ligament and
the medial collateral ankle ligament (deltoid ligament).
The deltoid ligament is usually described as having up
to six fascicles divided into superficial and deep layers
(including the tibio-spring, tibio-navicular, superficial
and deep posterior tibio-talar, tibio-calcaneal and deep
anterior tibio-talar ligaments) [8]. Despite having dif-
ferent components, the deltoid ligament has always been
described as a unity formed by different fascicles which
are difficult to separate from each other [14], whereas the
three components of the lateral collateral ligament of the
ankle have been described as three independent ligaments
[16]. Now, in addition to the described connecting fibres
between ATFLif and CFL [25], the current study has
shown that both the superior and inferior fascicles of the
ATFL, the CFL and PTFL are also all connected medially.
This description changes the previous understanding of
the lateral ankle ligaments. Interconnection between the
three components of the lateral collateral ankle ligament
questions if an isolated injury of any of the lateral liga-
ments is possible, especially in those ankles where ATFLsf
is connected to PTFL. In addition, the finding of these
connections being covered by synovium made us describe
the ATFLsf (and some of the connecting fibres between
the lateral ankle ligaments) as intra-articular but probably
extrasynovial structures, similar to the cruciate ligaments
in the knee [13]. However, histological studies should con-
firm this, especially due to the clinical implications it may
have for the healing of ATFLsf and its connections.
The connections observed between ATFLsf-PTFL, ATF-
Lif-PTFL and CFL-PTFL represent a constant implication
in the movement of their fibres, whereas the less constant
connection observed between ATFLsf-PTFL is only occa-
sionally translating in movement and the dynamic effect is
less clear. Nevertheless, a biomechanical study is required
to understand the exact function of these connecting fibres,
both in the intact and in the unstable ankles.
Additionally, the presence of medial connecting fibres
between the ATFLsf and the PTFL could explain restricted
range of motion which has been observed in some cases of
arthroscopic all-inside ATFL repair [21, 22]. It is possible
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Knee Surgery, Sports Traumatology, Arthroscopy (2020) 28:34–39
that the increased tension on the connecting fibres when the
ligament is repaired could restrict ankle joint plantar flexion.
It is possible that releasing these medial connecting fibres
during ligament repair or avoiding their inclusion in the liga-
ment repair may prevent restricted ankle plantar flexion.
The shape of the medial articular surface of the lateral
malleolus influences the presence of medial connecting
fibres between ATFLsf and PTFL. When the articular sur-
face had an acute vertex, no medial connecting fibres were
observed, whereas they were always present when the vertex
was less acute. Documentation of the medial facet shape in
imaging studies could be helpful in determining whether
medial connecting fibres are present between the ATFLsf
and the PTFL.
Although all the dissections were performed by a highly
experienced anatomist, this study is limited by the intrinsic
difficulty of dissecting this anatomical area and the fact that
the medial connections are synovialized. Additionally, the
histological and mechanical characteristics of connecting
fibres were not studied in this study and this warrants fur-
ther investigation. Finally, ankles without laxity were used
for this study to describe the normal anatomy of the lateral
ligament complex which may differ slightly in pathological
cases.
The clinical implication of the study is that the lateral col-
lateral ligament complex of the ankle is an anatomical unit
with important medial connections between its ligamentous
components. This challenges the concept of isolated liga-
mentous injuries of the components of the lateral collateral
ligament complex of the ankle.
Conclusions
Interconnections between the three components of the lat-
eral collateral ligament of the ankle may be observed from
the medial aspect of the ankle, and this may have impor-
tant implications for arthroscopic lateral ligament repair
and reconstructive procedures. Connections were observed
between ATFL and PTFL, ATFL and CFL, and CFL and
PTFL in all ankles studied. ATFLsf-PTFL connections were
observed in 17 ankles (42.5%), while ATFLif-PTFL connec-
tions were present in all ankles studied.
Compliance with ethical standards 
Conflict of interest  The authors have no conflict of interest to declare.
Funding  No funding was received.
Ethical approval  Ethical approval was obtained with IRB number
IRB00003099.
Knee Surgery, Sports Traumatology, Arthroscopy (2020) 28:34–39 39

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