Anatomy of the ankle ligaments: a pictorial essay

Pau Golanó, Jordi Vega, Peter A J de Leeuw, Francesc Malagelada, M Cristina Manzanares, Víctor Götzens, C Niek van Dijk, Pau Golanó, Jordi Vega, Peter A J de Leeuw, Francesc Malagelada, M Cristina Manzanares, Víctor Götzens, C Niek van Dijk

Abstract

Understanding the anatomy of the ankle ligaments is important for correct diagnosis and treatment. Ankle ligament injury is the most frequent cause of acute ankle pain. Chronic ankle pain often finds its cause in laxity of one of the ankle ligaments. In this pictorial essay, the ligaments around the ankle are grouped, depending on their anatomic orientation, and each of the ankle ligaments is discussed in detail.

Figures

Fig. 1
Fig. 1
Anterolateral view of the ankle. Anatomic dissection. 1 Anterior talofibular ligament; 2 anterior tibiofibular ligament; 3 fibular insertion of the calcaneofibular ligament; 4 superior extensor retinaculum; 5 inferior extensor retinaculum; 6 peroneus tertius tendon; 7 extensor digitorum longus tendons; 8 superior peroneal retinaculum; 9 inferior peroneal retinaculum; 10 peroneus brevis tendon; 11 peroneus longus tendon; 12 extensor digitorum brevis muscle
Fig. 2
Fig. 2
Osteoarticular anatomic dissection of the lateral ligaments of the foot and ankle joint. The anterior talofibular ligament is typically composed of two separate bands. 1 Tip of the lateral malleolus; 2 tibia; 3 anterior tibiofibular ligament; 4 distal fascicle of the anterior tibiofibular ligament; 5 superior band of the anterior talofibular ligament; 6 inferior band of the anterior talofibular ligament; 7 lateral articular surface of the talus; 8 neck of the talus; 9 head of the talus; 10 calcaneofibular ligament; 11 talocalcaneal interosseous ligament; 12 cervical ligament; 13 talonavicular ligament; 14 navicular
Fig. 3
Fig. 3
Anatomic dissection of the lateral region of the foot and ankle showing the morphology and relationship of the anterior talofibular with the calcaneofibular ligaments. 1 Fibula and tip of the fibula; 2 tibia (anterior tubercle with arrows); 3 anterior tibiofibular ligament; 4 distal fascicle of the tibiofibular ligament; 5 interosseous membrane; 6 foramen for the perforating branch of the peroneal artery; 7 talus; 8 anterior talofibular ligament; 9 calcaneofibular ligament; 10 talocalcaneal interosseous ligament; 11 inferior extensor retinaculum (cut); 12 talonavicular ligament; 13 bifurcate ligament; 14 peroneal tubercle (arrows showing the peroneal tendons sulcus); 15 peroneus longus tendon; 16 peroneus brevis tendon; 17 calcaneal tendon
Fig. 4
Fig. 4
Anatomic dissection of the lateral ankle ligaments showing the relationship of the calcaneofibular and lateral talocalcaneal ligaments with the morphology of the anterior talofibular ligament. Some authors describe a third band of the anterior talofibular ligament. We have never found this third band in our dissections. In the presented dissection, the superior band of the anterior talofibular ligament is smaller than usually. 1 Tip of the fibula; 2 superior and inferior bands of the anterior talofibular ligament; 3 calcaneofibular ligament; 4 lateral talocalcaneal ligament; 5 anterior tibiofibular ligament; 6 distal fascicle of the anterior tibiofibular ligament; 7 triangular region of the talus; 8 lateral articular surface of the talus; 9 dorsal articular surface of the talus; 10 talocalcaneal interosseous ligament; 11 cervical ligament; 12 talonavicular ligament; 13 navicular; 14 lateral calcaneocuboid ligament; 15 bifurcate ligament (calcaneonavicular fascicle)
Fig. 5
Fig. 5
Osteoarticular dissection of the calcaneofibular ligament during ankle movements. a Neutral position. b Dorsal flexion. c Plantar flexion. Calcaneofibular ligament becomes horizontal during plantar flexion and vertical in dorsal flexion, remaining tensed throughout the entire arc of motion of the ankle. 1 Calcaneofibular ligament; 2 tip of the fibula; 3 calcaneus; 4 peroneal tubercle; 5 subtalar joint; 6 anterior talofibular ligament; 7 neck of the talus; 8 talocalcaneal interosseous ligament; 9 anterior tubercle of the tibia; 10 anterior tibiotalar ligament; 11 posterior tubercle of the tibia; 12 lateral talar process; 13 calcaneocuboid joint; 14 lateral calcaneocuboid ligament; 15 talonavicular ligament; 16 cervical ligament; 17 navicular; 18 bifurcate ligament (calcaneonavicular fascicle); 19 long plantar ligament
Fig. 6
Fig. 6
Anatomic dissection showing the relationship of the calcaneofibular ligament with peroneal tendons. 1 Calcaneofibular ligament; 2 peroneus longus tendon; 3 peroneus brevis tendon; 4 fibula; 5 talofibular ligament; 6 calcaneus; 7 subtalar joint; 8 septum in the peroneal tubercle; 9 superior extensor retinaculum; 10 inferior extensor retinaculum; 11 extensor digitorum longus tendons; 12 peroneus tertius tendon; 13 extensor digitorum brevis; 14 extensor digitorum brevis tendon; 15 calcaneal tendon; 16 Kager’s fat pad; 17 tuberosity of the fifth metatarsal bone; 18 lateral plantar fascia; 19 abductor digiti minimi
Fig. 7
Fig. 7
Osteoarticular dissection. Relationship of the calcaneofibular ligament with the lateral talocalcaneal ligament. 1 Calcaneofibular ligament; 2 lateral talocalcaneal ligament; 3 anterior talofibular ligament; 4 peroneal tubercle
Fig. 8
Fig. 8
Posterior view of the anatomic dissection of the ankle ligaments. 1 Tip of the fibula; 2 peroneal groove of the fibula; 3 tibia; 4 superficial component of the posterior tibiofibular ligament; 5 deep component of the posterior tibiofibular ligament or transverse ligament; 6 posterior calcaneofibular ligament; 7 lateral talar process; 8 medial talar process; 9 tunnel for flexor hallucis longus tendon; 10 flexor hallucis longus retinaculum; 11 calcaneofibular ligament; 12 subtalar joint; 13 posterior intermalleolar ligament; 14 flexor digitorum longus tendon (cut); 15 tibialis posterior tendon; 16 peroneal tendons
Fig. 9
Fig. 9
a Posterior view of the ankle ligaments showing the relationships of the posterior intermalleolar ligament, posterior talofibular ligament and transverse ligament. b T1-weighted spin-echo MR imaging showing the correlation between MRI and the saggital cuts in a. 1 Posterior intermalleolar ligament; 2 superficial component of the tibiofibular ligament; 3 deep component of the tibiofibular ligament or transverse ligament; 4 posterior talofibular ligament; 5 lateral talar process; 6 tunnel for flexor hallucis longus tendon
Fig. 10
Fig. 10
Posterior view of the anatomic dissection of the ankle ligaments showing the posterior intermalleolar ligament with its relation to the surrounding anatomy. 1 Fibula; 2 tip of the fibula; 3 peroneal groove of the fibula; 4 tibia; 5 posterior tubercle of the tibia; 6 superficial component of the posterior tibiofibular ligament; 7 deep component of the posterior tibiofibular ligament or transverse ligament; 8 interosseous membrane; 9 posterior talofibular ligament; 10 lateral talar process; 11 tunnel for flexor hallucis longus tendon; 12 flexor hallucis longus retinaculum; 13 calcaneofibular ligament; 14 subtalar joint; 15 flexor digitorum longus tendon (cut); 16 tibialis posterior tendon (cut); 17 posterior intermalleolar ligament: A Tibial insertion (tibial slip in arthroscopic view). B Talar insertion (lateral talar process). C Tibial malleolar insertion through the septum between the flexor digitorum longus and posterior tibial tendons. D Talar insertion (medial talar process) through the joint capsule
Fig. 11
Fig. 11
Anatomic view of the posterior intermalleolar ligament (arrows) showing its involvement in the posterior soft tissue impingement of the ankle. From dorsiflexion (a) to plantar flexion (d), to dorsiflexion (f). 1 Superficial component of the posterior tibiofibular ligament; 2 deep component of the posterior tibiofibular ligament or transverse ligament; 3 posterior talofibular ligament; 4 lateral talar process; 5 medial talar process; 6 tunnel for the flexor hallucis longus tendon; 7 deep layer of the medial collateral ligament (deep posterior tibiotalar ligament)
Fig. 12
Fig. 12
Schematic representation of the main components of the medial collateral ligament found as frequently observed in our dissections. The morphology of the medial malleolus is helpful to understand the origins of the medial collateral ligament. In the medial view, two areas or segments (culliculi) can be seen, separated by the intercollicular groove. 1 Tibionavicular ligament; 2 tibiospring ligament; 3 tibiocalcaneal ligament; 4 deep posterior tibiotalar ligament; 5 spring ligament complex (plantar and superomedial calcaneonavicular ligaments); 6 anterior culliculus; 7 posterior culliculus; 8 intercullicular groove; 9 sustentaculum tali; 10 medial talar process; 11 lateral talar process; 12 navicular; 13 navicular tuberosity
Fig. 13
Fig. 13
Medial view of the anatomic dissection of the main components of the medial collateral ligament. 1 Tibionavicular ligament; 2 tibiospring ligament; 3 tibiocalcaneal ligament; 4 deep posterior tibiotalar ligament; 5 spring ligament complex (superomedial calcaneonavicular ligament); 6 medial talar process; 7 sustentaculum tali; 8 medial talocalcaneal ligament; 9 tibialis posterior tendon
Fig. 14
Fig. 14
Medial view of the anatomic dissection of the medial collateral ligament. Most of the medial collateral ligament is covered by tendons (tibialis posterior and flexor digitorum longus tendons). In order to see the ligament, the tendon of flexor digitorum longus was removed. a Neutral position showing the relationship with the tibialis posterior tendon. b The posterior tibialis tendon was removed. c Plantar flexion. The components located anteriorly to the bimalleolar axis are tensed. d Dorsiflexion. The components located anteriorly to the bimalleolar axis are relaxed. 1 Medial malleolus; 2 lateral talar process; 3 sustentaculum tali; 4 navicular; 5 tibialis posterior tendon; 6 navicular tuberosity; 7 flexor hallucis longus (cut); 8 flexor hallucis longus retinaculum; 9 posterior talocalcaneal ligament; 10 calcaneal tendon (cut at the level of the insertion); 11 long plantar ligament; 12 spring ligament complex (superomedial calcaneonavicular ligament); 13 tibionavicular ligament; 14 tibiospring ligament; 15 tibiocalcaneal ligament; 16 deep posterior tibiotalar ligament
Fig. 15
Fig. 15
Medial view of the tibiofibular joint (os talus previously removed). 1 Articular surface of the lateral malleolus; 2 distal articular surface of the tibia; 3 anterior tibiofibular ligament (distal fascicle); 4 superficial component of the posterior tibiofibular ligament; 5 deep component of the posterior tibiofibular ligament or transverse ligament; 6 fatty synovial fringe; 7 anterior talofibular ligament; 8 calcaneofibular ligament; 9 posterior talofibular ligament; 10 fibulotalocalcaneal ligament or Rouvière and Canela ligament
Fig. 16
Fig. 16
Anterosuperior view of talocrural joint and dorsum of the foot. 1 Anterior tibiofibular ligament; 2 anterior tubercle of the tibia
Fig. 17
Fig. 17
Anatomic view of the anterolateral part of the ankle showing the relationship between the anterior tibiofibular ligament and the perforating branch of the peroneal artery (arteries are filled with black latex). 1 Anterior tibiofibular ligament; 2 distal fascicle of the anterior tibiofibular ligament; 3 anterior tubercle of the tibia; 4 perforating branch of peroneal artery; 5 triangular region of the talus; 6 anterior malleolar artery; 7 lateral articular surface of the talus; 8 dorsal articular surface of the talus; 9 anterior talofibular ligament
Fig. 18
Fig. 18
Anatomic view of the anterior ligaments of the ankle. 1 Anterior tibiofibular ligament; 2 distal fascicle of the anterior tibiofibular ligament; 3 tibia (anterior tubercle indicated with arrows); 4 anterior talofibular ligament; 5 beveled triangular region of the talus; 6 deep layer of the medial collateral ligament; 7 superficial layer of the medial collateral ligament; 8 notch of Harty
Fig. 19
Fig. 19
Osteoarticular anatomic dissection of the ligaments of the foot and ankle joint. 1 Tip of the lateral malleolus; 2 tibia (anterior tubercle indicated with arrows); 3 anterior tibiofibular ligament; 4 distal fascicle of the anterior tibiofibular ligament; 5 imaging showing a calcification in the tibial insertion of the distal fascicle of the anterior tibiofibular ligament; 6 abrasion of the joint cartilage in the region where the anterior tibiofibular ligament came into contact with the talus; 7 beveled triangular region of the talus; 8 anterior talofibular ligament; 9 calcaneofibular ligament; 10 lateral talocalcaneal ligament; 11 cartilaginous rim; 12 talonavicular ligament; 13 lateral calcaneocuboid ligament; 14 navicular; 15 cervical ligament; 16 lateral cuneiform; 17 dorsal cuboideonavicular ligament; 18 dorsal cuneonavicular ligament; 19 calcaneus (peroneal tubercle); 20 anterior tibialis tendon
Fig. 20
Fig. 20
Anatomic dissection of the posterior ligaments of the ankle. 1 Lateral malleolus; 2 tip of the lateral malleolus; 3 peroneal groove; 4 tibia; 5 posterior tubercle of the tibia; 6 posterior tibiofibular ligament, superficial component; 7 posterior tibiofibular ligament, deep component or transverse ligament; 8 subtalar joint; 9 posterior talofibular ligament; 10 posterior intermalleolar ligament; 11 lateral talar process; 12 tunnel for flexor hallucis longus tendon (tendon was removed); 13 medial talar process; 14 calcaneofibular ligament; 15 flexor digitorum longus
Fig. 21
Fig. 21
Sagittal section of the ankle (lateral view). 1 Tibia; 2 talus; 3 calcaneus; 4 posterior tibiofibular ligament; 5 superficial component of the posterior tibiofibular ligament; 6 deep component of the posterior tibiofibular ligament or transverse ligament; 7 posterior talofibular ligament; 8 posterior intermalleolar ligament; 9 subtalar joint; 10 talocrural joint; 11 posterior capsular recess of the subtalar joint; 12 flexor hallucis longus muscle

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