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EDUCATION ARTICLE

Sonography of the ankle: The lateral ankle and ankle sprains

Sharmaine McKiernan1 , Michelle Fenech2, Deborah Fox3, Ian Stewart4
1 University of Newcastle, Callaghan, Australia
2 Central Queensland University, Rockhampton, Australia
3 Citiscan Radiology, Brisbane, Australia
4 Pacific Radiology, Sunshine Coast, Australia

Keywords Abstract
sonography, lateral ankle, ankle sprain,
sporting injury.
Ankle sprains can be considered a relatively common injury particularly from sports
injuries. While a sprain is generally a benign injury, symptoms can persist and lead to
Correspondence long-term disability and instability. This article includes an overview of the lateral ankle
Sharmaine McKiernan, School of Health including ligament and tendon anatomy, scanning technique and information on the
Sciences, Medical Radiation Science, Hunter common sprains the sonographer may encounter. It is important that sonographers are
Building, The University of Newcastle,
familiar with the lateral ankle anatomy and potential injuries and how complicated an
University Drive, Callaghan 2308, Australia.
ankle sprain can be.
E-mail: sharmaine.mckiernan@newcastle.
edu.au

Received: 21 March 2017; revised 15 June

2017; accepted 18 July 2017

doi:10.1002/sono.12120

Introduction calcaneofibular ligament (CFL) and posterior talofibular

Ankle sprain occurs in 1:10 000 persons per day.1,2
Sprains are generally believed to be benign, with most
responding well to conservative management,3 although
symptoms can persist and may lead to ongoing disability
and instability. Ankle sprains occur frequently in sports;
some claim that these injuries account for up to 45% of
sports-related injuries.1,2,4 With such a high incidence, it
is important that the sonographer is aware of lateral ankle
anatomy, what structures to image and the different types
of ankle sprains.
Lateral ankle anatomy
Ligaments
Lateral ankle ligaments prevent joint damage in varus,
inward movement.5 Laterally, the ankle has three distinct
ligaments (Figure 1A) which form the lateral collateral
ligament: the anterior talofibular ligament (ATFL),
Funding: None.
Conflict of interest: None.
ligament (PTFL).5–7 Their origins and insertions can be
seen in Table 1.
• The ATFL originates from the anterior rim of the lat-
eral malleolus and inserts into the anterior part of
the talus. It is this ligament which is most often
strained when there is inversion of the ankle.6,8
The ATFL stretches across, running parallel to the
skin with the foot in plantar flexion. It is approxi-
mately 2 mm wide6 and should be tight between
the two insertions.6,7
• The CFL is the middle part of the lateral collateral
ligament and is long, strong and about 2 mm wide.6
It runs from the tip of the lateral malleolus to the
lateral aspect of the calcaneus. When the ankle is
flexed dorsally, this ligament will be stretched out.
CFL lies between the calcaneus and the peroneal
tendons and forms a hammock and fibrous pulley
for the tendons. This close relationship with the
peroneal tendons accounts for why there is often
a tendon sheath effusion when a CFL tear occurs.
Intraarticular fluid, which often occurs with ankle
sprains, is able to pass through the tear and collect
in the tendon sheath.6,7

146 Sonography 4 146–155 © 2017 Australasian Sonographers Association


Lateral ankle sonography
Figure 1 Normal ankle anatomy. (A) The lateral ligaments. (B) The lateral tendons.
Table 1 Lateral ankle ligaments5–7
Ligament Origin Insertion
ATFL Lateral malleolus Lateral aspect of the talar neck
CFL Tip of the malleolus The lateral face of the calcaneus
PTFL Posterior malleolus Posterior talus
AITFL Anterior part of the distal fibula Anterior part of the tibia
PITFL Posterior tibia Posterior malleolus
• The PTFL runs from the posterior part of the
malleolus to the posterior part of the talus. It is
the strongest of the lateral ligaments and limits
posterior and rotatory talar displacement and due
to its strength is not often torn although this may
occur if there is complete dislocation of
the talus.6,7
Laterally, there are two other ligaments: the anterior
inferior tibiofibular ligament (AITFL) and the posterior
inferior tibiofibular ligament (PITFL).6 Their origins and
insertions can also be seen in Table 1.
• The AITFL lies between the anterior distal fibula and
the anterior part of the tibia, and this provides
stability to the inferior tibiofibular joint. It usually
measures less than 2 mm wide.6
• The PITFL is a strong, thick, syndesmotic ligament
with twisting fibres and superficial and deep com-
ponents. The superficial component originates on
the posterior tubercle of the tibia and runs obliquely,
distally and laterally to the posterior lateral
malleolus. The deep component is often referred
to as the inferior transverse ligament. It passes from
the posterior tibial margin to the posterior, medial
and distal fibula. PITFL creates a posterior labrum,
which deepens the articular surface of the distal
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S. McKiernan et al.
Comments
Fibrous bundle, forms the lateral collateral ligament
Fibrous bundle, forms the lateral collateral ligament
Multiple thin bundles separated by fat; is hardly detectable
with ultrasound because of its deep location, forms the
lateral collateral ligament
Anterior reinforcement of the inferior tibiofibular joint
Has a superficial and deep component
tibia and stabilises the distal tibiofibular joint
preventing posterior translation of the talus.6
Tendons
The lateral group of tendons has a surrounding synovial
sheath made up of two laminae joined to form a
mesotendon. The visceral laminae is attached to the
tendon, and the parietal laminae lies adjacent to the
surrounding anatomy. This mesotendon contains the
nerves and vessels that supply the tendon.5 Grooves in
the posterior malleoli and talus form a tunnel for the
posterolateral tendons to lie in.
The peroneus longus (PL) and peroneus brevis (PB)
tendons arise from the respective muscles in the lateral
compartment of the lower leg (Figure 1A, Table 2). The
PL tendon lies lateral to the PB in the supramalleolar
region and posterior to it in the malleolar region. The
tendons are held in position by the peroneal superior
retinaculum. As the tendons course inferiorly they lie adja-
cent to the lateral aspect of the calcaneus; here, the PL is
superior to the PB, and there is a layer of fat separating
the bone and the tendons. The two tendons are held to
the calcaneal surface by a second retinaculum, the pero-
neal inferior retinaculum. The PB continues distally
inserting into the base of the fifth metatarsal. On the
anteroinferior aspect of the cuboid bone, the PL
147

S. McKiernan et al.
Table 2 Muscles of the lateral calf5,8
Muscle Origin
Peroneus longus Head of the fibula
Peroneus brevis Lower two-thirds of the
lateral surface of the fibula
continues to the foot’s plantar aspect where it inserts into
the base of the first and second metatarsals.5,9
Sonography of the lateral ankle
Those performing ultrasound of the lateral ankle tendons
and ligaments should be aware that tendons will show
signs of trauma, degenerative change and inflammatory
conditions, while the ligaments will mostly demonstrate
tears.5 It is also important to assess the bony structures
and the joints to assess if there is any other pathology
involved.5 The bony ligament and tendon origin and
insertion points should also be investigated for cortical
changes or joint displacement. This includes the lateral
malleolus, talus, calcaneus, anterior and posterior aspect
of the tibia and base of the first, second and fifth
metatarsals.
When using ultrasound to assess the lateral ankle,
moving the ankle into various positions will improve
visualisation of the ligaments. Having the foot in a
position of dorsal hyperextension will loosen the anterior
ligaments and stretch the posterior ligaments. The
ligaments are better seen when they are stretched out
with the ultrasound beam perpendicular to the
ligament fibres.6
Laterally, it is recommended that three ligaments and
two tendons are scanned. The ligaments include the
ATFL, AITFL and CFL, and the tendons include the PB
and PL. The PTFL is difficult to see and image on
ultrasound because it is either partially or completely
hidden by the malleolus.6,7 The patient should be
positioned on the bed in a supine position with their knee
Figure 2 Normal anterior talofibular ligament. (A) Red line indicates where to place the probe. (B) Arrows indicate an intact ligament.
148
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Lateral ankle sonography
Insertion Comments
Base of the first and Posterolateral, superficial muscle that acts to
second metatarsals evert and plantar flex the ankle
Base of the fifth metatarsal Posterolateral, short and small muscle that lies
under the peroneus longus
flexed and the plantar surface of the foot placed flat on
the bed.
ATFL
• Place the probe on the anterior aspect of the lateral
malleolus with the probe face parallel to the sole of
the foot (i.e. horizontal) (Figure 2A).
• Gentle inversion of the ankle can assist in
delineating the integrity of the ligament.
• Look for integrity of the ligament (Figure 2B)
avulsion fractures and effusions.
AITFL
• From the ATFL position, keep the posterior edge of
the probe on the lateral malleolus and rotate the
anterior edge of the probe until the tibia is located
with the thin AITFL ligament running between the
two bones (Figure 3A).
• Look for integrity of the ligament (Figure 3B) and for
any sign of effusion.
CFL
• Rotate the ankle medial, so the lateral ankle is
uppermost and neutrally flexed (Figure 4A).
• Place the probe distal to the posterior edge of the
lateral malleolus noting the transverse images of
the peroneal tendons.
• Slide the probe distally along the tendons until the
CFL becomes visible running along the surface of
the calcaneus (Figure 4B).
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Lateral ankle sonography S. McKiernan et al.

Figure 3 Normal anterior talofibular ligament. (A) Red line indicates where to place the probe. (B) Arrows indicate an intact ligament.

Figure 4 Normal calcaneofibular ligament. (A and B) Red line indicates where to place the probe. (B and D) Arrows indicate an intact ligament.
Note by dorsiflexing the foot as in image C, the anisotropy seen in image B is overcome and the calcaneofibular ligament at the fibular insertion
is demonstrated as in figure D.

• Dorsiflex the ankle to reduce anisotropy of the
proximal or fibula end of the ligament (Figure 4C).
• Look for ligament integrity.
Peroneus longus and peroneus brevis tendons
• View in both longitudinal and transverse planes
(Figure 5).
• Leave the leg in the CFL position.
• Start in the transverse plane, proximal to the lateral
malleolus at the musculotendinous junction.
• Follow the curved course of the longus and brevis
around the malleolus as they traverse the CFL.
• Continue distally to observe the PL directed under
the lateral plantar aspect of the foot, and the PB
inserting onto the base of the fifth metatarsal.
• Repeat the process with the probe in a longitudinal
orientation.
• Look for tendinopathy, sheath effusions,
retinaculum injuries and bony avulsion fractures of
the fifth metatarsal.
Ankle injuries
The ankle is reported to be the most frequently injured
joint in the body10 with ankle sprains commonly occurring

Sonography 4 146–155 © 2017 Australasian Sonographers Association 149


S. McKiernan et al.
Figure 5 Normal peroneal tendons. (A and D) Red and black lines indicate where to place the probe. (B) Longitudinal image of an intact peroneus
longus tendon. (C) Longitudinal image of a normal peroneus brevis insertion. (E) The tendons beside each other in the transverse plane.
in both the general population and in those playing
sports. Ultrasound imaging is reported to play a crucial
role in evaluation of ankle ligament thickness and
continuity as it is low cost, fast, available and does not
use ionising radiation.8,10–13 It can image normal
anatomy, evaluate ligament integrity and allow visualisa-
tion of dynamic manoeuvres which may increase visibility
of tears.10
A study investigating injury data from 15 college
sports over a 16-year period found that greater than
50% of all injuries were of the leg.9 The most common
injury was ankle ligament sprains,2,14–17 mostly involving
the lateral ankle ligaments.18 Pre-season practice injury
rates were 2.5 to 3 times higher than in-season practice
rates and 4.6 to 5.5 times higher than post-season
practice rates.14
A systematic review of ankle injuries sustained playing
sport found 277 studies covering 70 sports.15 Eighty-four
per cent of these injuries were ankle sprains.15 Authors
reported 77% of the sprains to involve the lateral
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Lateral ankle sonography
ankle,15,17 and 73% involved rupture or tear of the
ATFL.15,19
A strain occurs when the fibres of the ligament are
stretched. When high stresses are put on the ankle joint,
the fibres can be partially or completely disrupted.4
A study of 380 athletes with previous ankle sprains
reported that 48% were bilateral. If unilateral, 37% were
of the dominant leg.4 Ekstrand and Gillquist20 reported
that ankle sprains occurred more often in the dominant
leg. This was suggested as being due to the dominant
leg being more often used and therefore susceptible to
forced inversion during sport. Cox16 suggested that when
someone jumps, their foot falls into plantar flexion and
inversion making it more likely to be injured.
Most people are able to play sport again, after an ankle
sprain from 2 weeks to 18 months.2 There are often resid-
ual symptoms for many months or years. Symptoms can
include pain, instability, intermittent swelling and
stiffness. Degenerative change may occur due to an
accumulation of cartilage damage.2,4,18,21–25 A high
Sonography 4 146–155 © 2017 Australasian Sonographers Association

Lateral ankle sonography
recurrence rate of ankle sprains (up to 73%)4 has been
reported for athletes, with half of these reporting residual
problems.4,25–28 For ankles which have been sprained
one to four times, pain is the major residual problem
(24–28%), and for five or more times, instability problems
arise (38%).15 Studies have reported anywhere from 21 to
74% of patients with residual symptoms months to years
after the initial injury.2,4,17,22,29,30 Staples31 reported
58.7% of sprained ankles completely recovered after
10.4 years of follow-up. This group reported functional
instability as the major problem which existed over time
particularly in those patients who had multiple episodes
of ankle sprain.4,22,24,26,32,33
Inversion injury
Inversion ankle sprains have been reported as the most
common physical activity-related injury14,34,35 and
account for 10 to 34% of all sports-related injuries.34,36
Ankle sprains involve injuries to ligament substance and
are the most common type of ankle pathology seen on
imaging.37
Lateral ankle sprains happen when there is an inversion
injury which involves landing on a plantar flexed and
inverted foot. Often, this occurs running on uneven
ground or in sport stepping on another person’s foot.38
An increase in body mass index also correlates
significantly with an increase in severity of an ankle
sprain.39
The ATFL generally stretches first, and when a larger
force is involved in the injury, the forces can transfer to
further ligaments, usually the CFL and AITFL. These can
also be stretched or torn with associated small avulsion
fractures of which ultrasound is highly sensitive to
identifying.39
After a sprain, the fibrous structure of an ankle ligament
is disrupted. The sonographic appearance of a ligamen-
tous tear is hypoechoic thickening of the ligament in a
partial thickness tear and a hypoechoic gap extending
right across the ligament in a full thickness, complete
tear.2 As a partially torn ligament heals, fluid and swelling
around the injured ligament can be seen to resolve over
time, but the injured ligament may remain thickened; its
stabilising properties will be compromised, and it may
appear lax when stressed.40,41 The resultant ligament will
Table 3 Classification of low ankle sprains37
Ligament disruption
Grade I None
Grade II Stretch without tear
Grade III Complete tear
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S. McKiernan et al.
appear thick and will be weakened making it more likely
to tear.40
Ankle sprains can be categorised as low or high
ankle sprains. High ankle sprains are 1–10%42 of all
ankle sprains, and these are syndesmosis injuries
whereby there is tearing of the ligaments that connect
the tibia and fibula. High ankle injuries are more painful
and require longer rehabilitation time than low ankle
injury.43 Low ankle sprains account for the remaining
90%42 of ankle sprains and involve injury to the ATFL
and CFL.42–44
Low ankle injury
These occur when the ankle rolls inward and the
ligaments that connect the bones are stretched. Patients
present with pain on the lateral ankle with swelling and
bruising present. Whether a patient can weight bear
depends on the severity of the sprain. Stress testing
may show laxity with anterior drawing, inversion and
eversion stress.43,44
The decision to X-ray the ankle should follow the
Ottawa ankle rules.42 Imaging is indicted if there is inabil-
ity to weight bear, tenderness of the medial or lateral
malleolus, base of the fifth metatarsal or navicular. Further
imaging such as ultrasound and magnetic resonance
imaging (MRI) should be considered if pain persists for
8 weeks following the sprain.42,44
Low ankle sprains can be classified into three grades
as seen in Table 3.42 When ultrasound scanning, if the
ligaments appear normal and there is a small amount of
fluid seen, then the sprain is a grade I (Figure 6A). If there
is a laxity of the ligaments with fluid in the area, the sprain
is classified as grade II (Figure 6B). To be classified as a
grade III sprain (Figure 6C and D), the ligament must be
torn; there will be more fluid, and the patient will clinically
be in pain and have difficulty weightbearing.42
Case: Low ankle injury
A 28-year-old female presented for an ultrasound of her
ankle following a netball inversion injury 1 week prior.
Her ankle X-ray was reported as normal. She indicated
initial pain anterior to the lateral malleolus with
subsequent swelling and spreading of the pain over
Bruising and swelling Pain with weight bearing
Minimal Normal
Moderate Mild
Severe Severe
151

S. McKiernan et al.
Figure 6 Anterior talofibular ligament tear. (A) Grade I, ligament intact but superficial oedema present. (B) Grade II, ligament intact but lax and
oedematous. (C and D) Grade III, anterior talofibular ligament rupture with effusion.
the lateral ankle area. No medial pain was evident. A
grade III sprain of the ATFL at the fibular insertion was
demonstrated, with ligament laxity and only a few fibres
traversing the tear (Figure 7). The CFL also showed laxity
and inhomogeneity with excess fluid. The AITFL
was normal.
Treatment for low ankle sprain is generally
non-operative, employing the RICE principle: rest, ice,
compression and elevation. An elastic bandage may be
used to minimise swelling, and physiotherapy may be
helpful to improve muscle strength. If an operation is
required, the options are arthroscopy; to look for
impingement lesions and debris, anatomic reconstruc-
tion, shortening and reinsertion of the ATFL and CFL,
tendon transfer with tenodesis, correction of
malalignment and reconstruction using a diagnosis can result in instability, with a decreased
tendon transfer.42,43
High ankle sprain
Tibiofibular syndesmotic ankle sprains, or high ankle
sprains, present a challenge for the patient and the
treating physician. The distal tibiofibular joint is a
syndesmotic joint linked by the AITFL, PITFL and the
interosseous ligament.45–47 The deltoid ligament
provides a secondary stabiliser to the distal ankle
syndesmosis and may also be injured with the
syndesmotic connective tissue.
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Lateral ankle sonography
While the exact mechanisms of injury are not certain,
most of this type of injury occurs in contact sports where
the foot and ankle are forcefully externally rotated.46,47
High ankle sprains occur less frequently than isolated
lateral ankle sprains, with reported incidences ranging
from 1 to 20% of all ankle sprains.48,49 Any injury which
widens the mortise may damage the syndesmosis.
Isolated AITFL injury is rare, and complete distal
syndesmotic rupture generally occurs in combination with
injury to the anterior deltoid and/or tibiofibular ligament.48
This type of injury is often missed without the presence
of an associated fracture or frank diastasis. Syndesmotic
injuries often have a relatively rapid resolution of external
swelling and bruising; therefore, the athlete can often walk
almost immediately with little pain.48,50 Delayed or missed
response to surgery. Bone scans and computer tomogra-
phy are relatively reliable, and MRI is generally the
modality of choice for diagnosing syndesmotic injuries.50
Ultrasound has inherent advantages in diagnosis, having
real time and dynamic modes. A study by Mei-Danet al.48
compared ultrasound studies of athletes, with
syndesmotic injuries to athletes who sustained lateral
ankle sprains and a control group who were injury free.
Ultrasound was able to accurately diagnose syndesmotic
injuries where there was a high grade sprain. Milz et al.51
reported a sensitivity of 66% and specificity of AITFL of
91% for ultrasound when compared with MRI demon-
strated lateral ligament injuries and syndesmotic injuries.
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Lateral ankle sonography
Figure 7 Anterior talofibular ligament (ATFL) tear with calcaneofibular ligament injury. (A–C) Torn ATFL ligament, note the discontinuity of fibres
and the inhomogeneity under the arrows. (D) Calcaneofibular ligament, note its thickness and inhomogeneity. (E) Intact anterior inferior
tibiofibular ligament.
Figure 8 Anterior inferior tibiofibular ligament tear with bulging capsule.
Case: High ankle strain
A 26-year-old rugby player presented for an ultrasound of
his ankle following a tackle injury. His ankle was painful
and swollen laterally, and his X-ray was reported as nor-
mal. Ultrasound demonstrated that his AITFL was found
to be ruptured and the capsule bulging (Figure 8).
Conclusion
Ankle sprains can be considered a common injury,
particularly for those playing sports. While sprains may
be benign, some symptoms can persist and result in
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S. McKiernan et al.
long-term ankle instability. With inversion injuries, the
lateral ankle is affected, and the sonographer should
check the integrity of ATFL, AITFL, CFL and PB and PL
tendons. Complex sprains may require further imaging
and could even result in the need for surgery.
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