Straight Form of Calcaneofibular Ligament as a Three-Dimensional Magnetic Resonance Imaging Sign in Diagnosis of Calcaneofibular Ligament and Anterior Talofibular Ligament Inferior Fascicle Injury

Published:September 08, 2021DOI:


      The present study was performed to investigate the morphological characteristics of the calcaneofibular ligament (CFL) and evaluate its relationship to the anterior talofibular ligament (ATFL) in patients with lateral ankle ligament injury using 3-dimensional magnetic resonance imaging (3D-MRI). This retrospective study involved 35 patients with lateral ankle ligament injury and 24 patients without a history of ankle trauma and a bone abnormality as controls. Reconstructed 3D-MRI was used to classify the form of the CFL as curved, wavy, or straight. The presence/absence of continuity between the fibula and CFL was evaluated in the 35 patients with injury, who were divided into 2 groups (continuity and discontinuity groups). The number of fascicles in the ATFL and the continuity between the distal end of the fibula and the proximal end of the ATFL were then evaluated. Among the patients with injury, 54.3% had the curve type of CFL, 34.3% had the wave type, and 11.4% had the straight type. In the control group, 62.5% had the curve type, 37.5% had the wave type, and none had the straight type. Continuity between the fibula and CFL was seen in 88.6%, and discontinuity was seen in 11.4%. Additionally, 85.7% had double fascicles in the ATFL. Inferior fascicle discontinuity between the ATFL and fibula was found in 13.3% with a double-fascicle ATFL; in all of these patients, the form of the CFL was straight and exhibited inferior fascicle discontinuity. The straight form of CFL could be a 3D-MRI sign in the diagnosis of CFL and ATFL inferior fascicle injury.

      Level of Clinical Evidence


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Foot and Ankle Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Broström L.
        Sprained ankles. V. Treatment and prognosis in recent ligament ruptures.
        Acta Chir Scand. 1966; 132: 537-550
        • Garrick JG
        • Requa RK.
        The epidemiology of foot and ankle injuries in sports.
        Clin Podiatr Med Surg. 1989; 6: 629-637
        • Maffulli N
        • Ferran NA.
        Management of acute and chronic ankle instability.
        J Am Acad Orthop Surg. 2008; 16: 608-615
        • Lynch SA
        • Renström PA.
        Treatment of acute lateral ankle ligament rupture in the athlete. Conservative versus surgical treatment.
        Sports Med. 1999; 27: 61-71
        • Kakegawa A
        • Fukushima N
        • Sumitomo N
        • Nagira A
        • Moriizumi T
        • Mori Y.
        Continuous and connective fibers of the lateral ankle ligament complex.
        J Foot Ankle Surg. 2020; 59: 679-684
        • Kakegawa A
        • Mori Y
        • Tsuchiya A
        • Sumitomo N
        • Fukushima N
        • Moriizumi T.
        Independent attachment of lateral ankle ligaments: anterior talofibular and calcaneofibular ligaments - a cadaveric study.
        J Foot Ankle Surg. 2019; 58: 717-722
        • Ziaei Ziabari E
        • Lubberts B
        • Chiou D
        • Razi M
        • Haghpanahi M
        • Ashkani-Esfahani S
        • DiGiovanni CW
        Biomechanics following anatomic lateral ligament repair of chronic ankle instability: a systematic review.
        J Foot Ankle Surg. 2020; 60: 762-769
        • Hunt KJ
        • Pereira H
        • Kelley J
        • Anderson N
        • Fuld R
        • Baldini T
        • Kumparatana P
        • D‘Hooghe P
        The role of calcaneofibular ligament injury in ankle instability: implications for surgical management.
        Am J Sports Med. 2019; 47: 431-437
        • Broström L.
        Sprained ankles. VI. Surgical treatment of “chronic” ligament ruptures.
        Acta Chir Scand. 1966; 132: 551-565
        • Ferkel RD
        • Chams RN.
        Chronic lateral instability: arthroscopic findings and long-term results.
        Foot Ankle Int. 2007; 28: 24-31
        • Hamilton WG
        • Thompson FM
        • Snow SW.
        The modified Brostrom procedure for lateral ankle instability.
        Foot Ankle. 1993; 14: 1-7
        • Buerer Y
        • Winkler M
        • Burn A
        • Chopra S
        • Crevoisier X.
        Evaluation of a modified Broström-Gould procedure for treatment of chronic lateral ankle instability: a retrospective study with critical analysis of outcome scoring.
        Foot Ankle Surg. 2013; 19: 36-41
        • Molloy AP
        • Ajis A
        • Kazi H.
        The modified Broström-Gould procedure–early results using a newly described surgical technique.
        Foot Ankle Surg. 2014; 20: 224-228
        • Acevedo JI
        • Mangone P.
        Arthroscopic brostrom technique.
        Foot Ankle Int. 2015; 36: 465-473
        • Takao M
        • Matsui K
        • Stone JW
        • Glazebrook MA
        • Kennedy JG
        • Guillo S
        • Calder JD
        • Karlsson J
        Arthroscopic anterior talofibular ligament repair for lateral instability of the ankle.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 1003-1006
        • Yoshimura I
        • Hagio T
        • Noda M
        • Kanazawa K
        • Minokawa S
        • Yamamoto T.
        Optimal suture anchor direction in arthroscopic lateral ankle ligament repair.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 2110-2115
        • Vega J
        • Malagelada F
        • Manzanares Céspedes MC
        • Dalmau-Pastor M
        The lateral fibulotalocalcaneal ligament complex: an ankle stabilizing isometric structure.
        Knee Surg Sports Traumatol Arthrosc. 2020; 28: 8-17
        • Alves T
        • Dong Q
        • Jacobson J
        • Yablon C
        • Gandikota G.
        Normal and injured ankle ligaments on ultrasonography with magnetic resonance imaging correlation.
        J Ultrasound Med. 2019; 38: 513-528
        • Lee SH
        • Yun SJ.
        The feasibility of point-of-care ankle ultrasound examination in patients with recurrent ankle sprain and chronic ankle instability: comparison with magnetic resonance imaging.
        Injury. 2017; 48: 2323-2328
        • Margetic P
        • Salaj M
        • Lubina IZ.
        The value of ultrasound in acute ankle injury: comparison with MR.
        Eur J Trauma Emerg Surg. 2009; 35: 141-146
        • Oae K
        • Takao M
        • Uchio Y
        • Ochi M.
        Evaluation of anterior talofibular ligament injury with stress radiography, ultrasonography and MR imaging.
        Skelet Radiol. 2010; 39: 41-47
        • Golanó P
        • Vega J
        • de Leeuw PA
        • Malagelada F
        • Manzanares MC
        • Götzens V
        • van Dijk CN
        Anatomy of the ankle ligaments: a pictorial essay.
        Knee Surg Sports Traumatol Arthrosc. 2010; 18: 557-569
        • Park HJ
        • Lee SY
        • Choi YJ
        • Hong HP
        • Park SJ
        • Park JH
        • Kim E
        3D isotropic T2-weighted fast spin echo (VISTA) versus 2D T2-weighted fast spin echo in evaluation of the calcaneofibular ligament in the oblique coronal plane.
        Clin Radiol. 2017; 72: 176.e171-176.e177
        • Choo HJ
        • Lee SJ
        • Kim DW
        • Jeong HW
        • Gwak H.
        Multibanded anterior talofibular ligaments in normal ankles and sprained ankles using 3D isotropic proton density-weighted fast spin-echo MRI sequence.
        AJR Am J Roentgenol. 2014; 202: W87-W94
        • Ulbrich EJ
        • Zubler V
        • Sutter R
        • Espinosa N
        • Pfirrmann CW
        • Zanetti M.
        Ligaments of the Lisfranc joint in MRI: 3D-SPACE (sampling perfection with application optimized contrasts using different flip-angle evolution) sequence compared to three orthogonal proton-density fat-saturated (PD fs) sequences.
        Skelet Radiol. 2013; 42: 399-409
        • Park HJ
        • Lee SY
        • Park NH
        • Rho MH
        • Chung EC
        • Park JH
        • Park SJ
        Three-dimensional isotropic T2-weighted fast spin-echo (VISTA) ankle MRI versus two-dimensional fast spin-echo T2-weighted sequences for the evaluation of anterior talofibular ligament injury.
        Clin Radiol. 2016; 71: 349-355
        • Teramoto A
        • Akatsuka Y
        • Takashima H
        • Shoji H
        • Sakakibara Y
        • Watanabe K
        • Yamashita T
        3D MRI evaluation of morphological characteristics of lateral ankle ligaments in injured patients and uninjured controls.
        J Orthop Sci. 2020; 25: 183-187
        • Dalmau-Pastor M
        • Malagelada F
        • Calder J
        • Manzanares MC
        • Vega J.
        The lateral ankle ligaments are interconnected: the medial connecting fibres between the anterior talofibular, calcaneofibular and posterior talofibular ligaments.
        Knee Surg Sports Traumatol Arthrosc. 2020; 28: 34-39
        • Boonthathip M
        • Chen L
        • Trudell D
        • Resnick D.
        Lateral ankle ligaments: MR arthrography with anatomic correlation in cadavers.
        Clin Imaging. 2011; 35: 42-48
        • Milner CE
        • Soames RW.
        Anatomical variations of the anterior talofibular ligament of the human ankle joint.
        J Anat. 1997; 191: 457-458
        • Taser F
        • Shafiq Q
        • Ebraheim NA.
        Anatomy of lateral ankle ligaments and their relationship to bony landmarks.
        Surg Radiol Anat. 2006; 28: 391-397
        • Burks RT
        • Morgan J.
        Anatomy of the lateral ankle ligaments.
        Am J Sports Med. 1994; 22: 72-77
        • Milner CE
        • Soames RW.
        Anatomy of the collateral ligaments of the human ankle joint.
        Foot Ankle Int. 1998; 19: 757-760
        • Sindel M
        • demir S
        • Ye Ucar
        Anatomy of the lateral ankle ligaments.
        Tr J Med Sci. 1998; 28: 53-56
        • Ruth CJ.
        The surgical treatment of injuries of the fibular collateral ligaments of the ankle.
        J Bone Joint Surg Am. 1961; 43A: 229-239
        • Matsui K
        • Oliva XM
        • Takao M
        • Pereira BS
        • Gomes TM
        • Lozano JM
        • Glazebrook M
        Bony landmarks available for minimally invasive lateral ankle stabilization surgery: a cadaveric anatomical study.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 1916-1924
        • Beynnon BD
        • Vacek PM
        • Murphy D
        • Alosa D
        • Paller D.
        First-time inversion ankle ligament trauma: the effects of sex, level of competition, and sport on the incidence of injury.
        Am J Sports Med. 2005; 33: 1485-1491