Anterior Talofibular Ligament (ATFL)

Where is it painful for a client with an ATFL injury?

Classical patient features for an ATFL injury

Age: Most common between 15-24 years of age,

Gender: Females show a higher risk for an ATFL sprain compared to males

Sport: Netball, AFL, soccer, Basketball, Volleyball, ultimate frisbee, tennis, badminton, squash

Area of symptoms for an ATFL injury

– Lateral ankle // slightly anterior to the lateral malleolus

– Will commonly notice pain in the inferior section of the malleolus

– Localised and easily palpable

– Common to have an increase in generalised pain if acute and large inflammatory reaction (bruising, swelling ect)

Characteristics of symptoms for a client with an ATFL injury

– Pop may be heard at the onset.

– Pain, swelling and tenderness on the lateral ankle.

– If it is an acute incident the patient will report the symptoms very localised // will be able to touch it with their finger.

– chronic presentations will be more general over the anterolateral aspect of the ankle

– Bruising at the site of injury

– Neural signs if present will be at the sural, superficial or deep fibular nerve distribution

Typical activity capability/restriction for an ATFL injury

– Progressive with restriction with activities that require high spring loads of the lower limb

– Limitations in running,

– Difficulty weight-bearing and walking

– Decreased ankle function and range of motion

– Instability (Grade 2/3)

– Proprioception deficits may present as difficulty performing single-leg tasks

– reduced sporting performance

– inability to perform tasks with high levels of variability // especially if loaded

jumping, hopping, change of direction and acceleration

– Inhibit or reduced performance in sport

Behaviour of symptoms for a client with an ATFL injury

Agg: change of direction, inversion, uneven surfaces, landing

Ease: taping/bracing, rest, compression, ice, elevation,

24 hour pattern: Nil as mechanical

Typical history for a client with an ATFL injury

– Constitutes 10% of all acute injury presentations

– ATFL is frequently the first ligament to be compromised // ankle inversion cases have a 97% likelihood of rupture compared to 3% CFL

– Can occur in conjunction with medial ankle injuries // rare

– Swelling usually occurs immediately, although occasionally it may be delayed over several hours following the injury

Pathobiological mechanisms underlying a an ATFL injury

– Nociceptive pain mechanism

– Often compounded by a large inflammatory response

– Will have observable pro-inflammatory signs at the location of the injury

Proposed pathology for a an ATFL injury

– The most common mechanism of an ATFL injury is plantarflexion and inversion of the ankle

– This may occur with rapid change in direction, especially on uneven surfaces (grass fields etc).

– Also may occur when jumping, landing awkwardly or the ankle giving way

– An audible snap, crack, or tear may also be present

The ATFL is the weakest of the lateral ankle ligaments and is the most likely to be injured.

Grade 1 – partial tear, no laxity and mild swelling

Grade 2 – partial tear, mild laxity, moderate effusion, instability and tenderness on palpation.

Grade 3 – full tear or rupture, massive swelling, severe pain and laxity and instability of the ankle joint.

Physical impairments & associated structure/tissue sources (ie P/E findings)


– Observation – Swelling observed distal to the lateral malleolus, which may also extend to the foot. Bruising will also be present depending on the severity

– AROM – Limited in all directions secondary to pain and swelling // inversion will be the most affected and reproduce pain

Palpation – Tenderness over ATFL // common to also find tenderness in syndesmotic area and on the medial deltoid ligament

– boney assessment required to rule out fracture // Ottawa rules (high-level evidence)

Proprioception – Compare bilateral single-leg stance

Special tests

Positive – Anterior drawer test (Sensitivity 96%, Specificity 84%)

Positive – Talar tilt test (ATFL bias) (Sensitivity 50%, Specificity 88%) // note percentages based on CFL not ATFL so anterior draw will hold more value

Typical contributing factors for an ATFL injury


– Increased BMI

– Reduced dorsiflexion

– Reduced eccentric strength of supinators/inverters

– Low PSR (Pronator supinator ratio)

– Reduced hip extensor strength

– Previous ankle sprains

– Reduced proprioception


– Grass / unstable surface

– Non-use of ankle braces

– Non-use of high top shoes (Basketball)

Relevant precautions/ contraindications to P/E and treatment

– Depending on irritability/severity – limiting tests and going to P1

– Need to rule out a fracture with boney assessment or send for imaging

– If significant instability tape will not be sufficient for return to play

Relevant diagnostic imaging for an ATFL injury

Ottawa rules indicate if radiographs are indicated: (high-level evidence)

  • Tenderness over the medial malleolus, lateral malleolus, navicular, and/or base of the fifth metatarsal upon palpation;
  • An inability to weight bear immediately following injury or during the clinical evaluation;
  • The tenderness that extends 6 cm superiorly from either malleolus”

Grade 1: don’t typically require imaging

Grade 2: consider imaging (US or MRI)

Grade 3: consider imaging (US or MRI)

Indications for an MRI or CT scan

– If symptoms present for more than a week and previous radiographs inconclusive

Typical prognosis for an ATFL injury

Grade 1: Return to sports at 1 to 4 weeks. Taping is used as a means of protection and increasing proprioception

Grade 2: Return to sports at 2 to 6 weeks.

Grade 3: Return to sports at 6 to 12 weeks.

Management/treatment selection for an ATFL injury

Goals of Early management

– Manage symptoms (pain and swelling)

– Optimize ROM

– Recondition muscles (especially into inversion and eversion )

– proprioceptive

– functional exercises

– Return to sport

– After sustaining an ATFL injury compromised individuals are at increased risk of recurrence for 6-12 months

Immobilisation/restriction (high level evidence)

– Taping or bracing are common interventions for protection in the early phase

– Need to make sure no allergies or precautions for the use of tape

– Thought that tape increases proprioception at the ankle more so than reducing the range of motion

– Taping is NOT a form of rehabilitation // rationale for use during the high-risk period however rehabilitation is preferred to optimize long term management

High levels of evidence to support rehabilitation in grade 3 ATFL sprains

– compared to surgical control group there was a faster return to play times, equal stiffness and equal reinjury rates

– Due to these findings a minimum of 6-12week of conservative management is indicated

– If patient is still having instability or persistent pain after this trial surgical referral may be warranted

Differential diagnosis for an ATFL injury

– CFL // talar tilt in neutral and palpation

– PTFL //posterior draw and palpation

– Syndesmosis // compression, DF +OP, DF + eversion + OP

– Fractures // Tib/Fib/5th met/ calcaneus/ talus/greenstick

– Dislocation // history and laxity

– Chronic ligamentous instability // history and laxity

Dynamic assessment and tendon signs

– Peroneal Tendinopathy

– Tib post Tendinopathy

– Tib ant Tendinopathy

– CRPS // history, examination and exclusion

– Tarsal Coalition // imaging

– Chronic ligamentous instability

– synovitis

– Sinus tarsi syndrome


Bahr R. The IOC manual of sports injuries. 1st ed. Sweden: International Olympic Commitee; 2012.

Balduini, F.C., Vegso, J.J., Torg, J.S. and Torg, E., 1987. Management and rehabilitation of ligamentous injuries to the ankle. Sports medicine, 4(5), pp.364-380.

Brukner P, Khan K. Clinical sports medicine (volume 1 injuries). 5th ed. Australia: McGraw-Hill Education; 2017.

Chen, E.T., McInnis, K.C. and Borg-Stein, J., 2019. Ankle sprains: evaluation, rehabilitation, and prevention. Current sports medicine reports, 18(6), pp.217-223.

Fong, D.T., Chan, Y.Y., Mok, K.M., Yung, P.S. and Chan, K.M., 2009. Understanding acute ankle ligamentous sprain injury in sports. BMC Sports Science, Medicine and Rehabilitation, 1(1), pp.1-14.

Krabak B, 2019, ‘Ankle Sprain’ in Walter F, Julie K.S, Thomas D.R (eds) Essentials of Physical Medicine and Rehabilitation Musculoskeletal Disorders, Pain and Rehabilitation, Elsevier, Philadelphia PA, pp – 460-465

Petersen, W., Rembitzki, I.V., Koppenburg, A.G., Ellermann, A., Liebau, C., Brüggemann, G.P. and Best, R., 2013. Treatment of acute ankle ligament injuries: a systematic review. Archives of orthopaedic and trauma surgery, 133(8), pp.1129-1141.

Wang, D.Y., Jiao, C., Ao, Y.F., Yu, J.K., Guo, Q.W., Xie, X., Chen, L.X., Zhao, F., Pi, Y.B., Li, N. and Hu, Y.L., 2020. Risk factors for osteochondral lesions and osteophytes in chronic lateral ankle instability: a case series of 1169 patients. Orthopaedic Journal of Sports Medicine, 8(5), p.2325967120922821.