Knee Surg Sports Traumatol Arthrosc (2007) 15:465–471

DOI 10.1007/s00167-006-0275-7

A N KL E

The distal fascicle of the anterior inferior tibiofibular ligament

as a cause of tibiotalar impingement syndrome: a current
concepts review
Michel P. J. van den Bekerom Æ Eric E. J. Raven

Received: 12 August 2006 / Accepted: 11 December 2006 / Published online: 20 January 2007
Ó Springer-Verlag 2007

Abstract Impingement syndromes of the ankle in- of the distal fascicle. The presence of the AITFL
volve either osseous or soft tissue impingement and and the contact with the talus is a normal finding. An
can be anterior, anterolateral, or posterior. Ankle impingement of the AITFL can result from an ana-
impingement syndromes are painful conditions caused tomical variant or anteroposterior instability of the
by the friction of joint tissues, which are both the cause ankle. The diagnosis of ligamentous impingement in
and the effect of altered joint biomechanics. The distal the anterior aspect of the ankle should be considered in
fascicle of the anterior inferior tibiofibular ligament patients who have chronic ankle pain in the antero-
(AITFL) is possible cause of anterior impingement. lateral aspect of the ankle after an inversion injury and
The objective of this article was to review the literature have a stable ankle, normal plain radiographs, and
concerning the anatomy, pathogenesis, symptoms and isolated point tenderness on the anterolateral aspect of
treatment of the AITFL impingement and finally to the talar dome and in the anteroinferior tibiofibular
formulate treatment recommendations. The AITFL ligament. The impingement syndrome can be treated
starts from the distal tibia, 5 mm in average above the arthroscopically.
articular surface, and descends obliquely between the
adjacent margins of the tibia and fibula, anterior to Keywords Ankle
Impingement syndrome

the syndesmosis to the anterior aspect of the lateral Anterior inferior tibiofibular ligament

malleolus. The incidence of the accessory fascicle Accessory fascicle
differs very widely in the several studies. The presence
of the distal fascicle of the AITFL and also the contact
with the anterolateral talus is probably a normal find- Introduction
ing. It may become pathological, due to anatomical
variations and/or anterolateral instability of the ankle Impingement syndromes of the ankle involve either
resulting from an anterior talofibular ligament injury. osseous or soft tissue impingement and can be anterior,
When observed during an ankle arthroscopy, the sur- anterolateral, or posterior [5, 25]. Ankle impingement
geon should look for the criteria described to decide syndromes are painful conditions caused by the friction
whether it is pathological and considering resection of joint tissues, which are both the cause and the
effect of altered joint biomechanics [14]. The leading
causes of impingement lesions are post-traumatic ankle
M. P. J. van den Bekerom
E. E. J. Raven
injuries, usually ankle sprains, resulting in chronic
Department of Orthopaedic Surgery, Gelre Hospitals,
Apeldoorn, The Netherlands ankle pain [33]. According to the ISAKOS definition,
anterior ankle impingement is a pain syndrome char-
M. P. J. van den Bekerom (&) acterised by anterior ankle pain on activity. Recurrent
Department of Surgery and Traumatology,
dorsiflexion is often the cause. On investigation, there
Gelre Hospitals, Location Lukas, P.O. Box 9014,
7300 Apeldoorn, The Netherlands is pain on palpation at the antero/medial and/or ante-
e-mail: Bekerom@gmail.com rolateral aspect of the ankle joint. Some swelling and/

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or limitations of dorsiflexion are present [32]. The first and treatment of the AITFL impingement and finally
reported impingement syndromes about the ankle have to formulate treatment recommendations.
evolved osseous impingement and generally have been
noted in athletes whose sports necessitated sudden
acceleration, jumping, and extremes of dorsiflexion or Anatomy of the anterior inferior tibiofibular ligament
plantar flexion. Impingement of the ankle was first
described in the English language literature by Morris The distal tibiofibular joint was classically described
[20], in 1943, in five patients who had what he called as a syndesmosis between the rough, triangular surface
the athlete’s ankle. This was later called footballer’s on the medial and distal aspect of the fibular shaft and
ankle in the report of McMurray [18]. the fibular notch of the distal end of the tibia. The
Soft tissue impingement of the ankle is a common tibiofibular syndesmosis is established by three liga-
cause of chronic ankle pain that usually arises at the ments: the interosseous ligament, the posterior inferior
lateral and/or anterolateral compartment of the ankle tibiofibular ligament, and the AITFL [7, 10, 15, 24, 26].
joint following an inversion injury [8]. It is estimated The AITFL is a flat band becoming thicker from
that approximately 3% of ankle sprains may lead to superior to inferior [24]. The ligament starts from the
anterolateral impingement [32]. Three types of intra- distal tibia, 5 mm in average above the articular sur-
articular soft tissue lesions that lead to these com- face, and descends obliquely between the adjacent
plaints have been described: the meniscoid lesion, margins of the tibia and fibula, anterior to the syn-
synovitis, and the distal fascicle of the anterior inferior desmosis to the anterior aspect of the lateral malleolus
tibiofibular ligament (AITFL) [4, 6, 8, 9, 12, 16, 19, 28]. [7, 22]. Its length ranges from 12 to 20 mm [4, 22]; its
The formation of tibiotalar spurs due to repetitive thickness, from 1 to 3 mm [4, 22]; and its width ranges
capsule traction therefore does not seem plausible from 7 to 12 mm at the fibular insertion and 9 to
reason for anterior ankle impingement [29]. 22 mm at the tibial insertion [22]. This ligament is the
Impinging soft tissue pathology in the ankle was first weakest of the syndesmotic ligaments and is the first
described by Wolin et al. as a ‘‘meniscoid mass or le- to yield to forces that promote an external rotation
sion’’ [34]. They described the lesion as a membrane of the fibula around its longitudinal axis [15]. Resection
shaped hyalinised scar tissue obstructing the lateral of the accessory ligament did not disturb the stability of
talofibular articulation in nine patients with persistent the syndesmosis, a finding that was in accordance with
symptoms over the anterolateral corner of the ankle the results reported by Rasmussen et al. which suggests
after an inversion trauma [34]. Some authors thought that mobility is minimally influenced by isolated cut-
this lesion was formed from the torn ends of the ting of the AITFL [23].
anterior tibiofibular ligament [3, 27]. However there Nikolopoulos et al. studied 24 cadaveric ankles to
was no ligamentous tissue found on histologic exami- describe the anatomy of the AITFL [22]. In five ankles
nation of this lesion [9]. Guhl thought the lesion was of the AITFL appeared to consist of two layers, one
synovial origin [11]. Irritation of the joint by bleeding superficial and one deep, which were separated by a
and a torn capsule or a torn anterior tibiofibular liga- thin fibrofatty septum [22, 24]. However, the total
ment are thought to be the underlying factors for thickness of these two layers did not exceed the aver-
developing post-traumatic synovitis in the ankle [17] age thickness of the AITFL in the rest of the specimens
which in unstable ankles may lead to formation of [22]. In five ankles, the articulated surfaces of the distal
fibrosis and granulation tissue. Although synovitis and tibia and fibula that formed the syndesmosis were
the meniscoid lesion have been referred frequently, covered by articular cartilage and were surrounded by
impingement by a separated fascicle of the AITFL is a synovial bursa [22]. A completely separate accessory
relatively new and unknown pathology. Bassett et al. anteroinferior tibiofibular ligament was present in 22
[4] were the first who reported a ligamentous etiology ankles (Fig. 1). Nikolopoulos was the first to describe
of impingement of the anterior aspect of the ankle. The this accessory ligament [21]. However the results of his
presence of the so-called accessory AITFL, as de- study were never published in English literature [26].
scribed by Nikolopoulos was confirmed by them [21]. Nikolopoulos believed that this anatomical structure
However they called this accessory ligament, the distal represents a separate ligament rather than a distal
fascicle of the normal AITFL [4]. The distal part of the component of the AITFL [21]. The fact that there was
fascicle rubs against the talus, and that this causes pain clearly a fibrofatty septum that separates the AITFL
at the ankle [1, 2, 4, 8, 12, 22]. from the accessory fascicle, similar to the one that
The objective of this article was to review the liter- covered the intermediate space between the interos-
ature concerning the anatomy, pathogenesis, symptoms seous and the anterior or the interosseous and the

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the superior lateral margin of the ankle joint. The

accessory ligament was separated from the AITFL by a
distinct fibrofatty septum. The ligament could even be
divided in two, three, or more fascicles, increasing in
length from superior to inferior [24].
The incidence of the accessory fascicle differs very
widely in the several studies (21–92%) [2, 4, 22, 24].
The discrepancies in the incidence between the several
studies were probably due to the different definitions
of a separate fascicle. Ray and Kriz did not consider it
a separate fascicle if any digitations were present be-
tween the fascicle and the main body of the AITFL
[24]. The incidence was up to 92%, which implied that
the ligament may be considered as a normal finding.
Vessels from the anterior peroneal artery penetrate
through the interlaminar spaces [26]. It is not uncom-
mon to have branches from the anterior tibial artery or
peroneal artery or a branch arising from the anasto-
mosis between these two arteries pass between these
fascicles [11]. The most inferior fibres of the ligament
Fig. 1 The distal fascicle in relation to the anterior inferior merged at their fibular attachment with the origin of
tibiofibular ligament
the ATFL [24].
Ray and Kriz [24] studied 23 cadaveric ankles.
posterior tibiofibular ligaments, suggested that this A classification scheme was designed to categorise
fascicle could probably be considered an independent the anatomical variations observed in the AITFL
accessory ligament [22]. Some other authors described (Table 2).
this accessory ligament as a complete separate distal
fascicle of the AITFL [4, 15, 26].
Ray and Kriz [24] founded in 10 of the 46 specimens Pathomechanism of the impingement syndrome
an accessory ligament. This ligament was parallel and
distal to the AITFL. The fibres of the accessory liga- It should be stressed that most studies were carried out
ment descended obliquely from the lateral, anterior, in vitro and do not take muscular tonus and the effects
and distal borders of the tibia to the anteromedial as- of weightbearing into consideration, we performed a
pect of the lateral malleolus, approximating the fibular review of the pathomechanism of the impingement
insertion of the anterior talofibular ligament (ATFL). syndrome caused by the distal fascicle of the AITFL.
Its length ranges from 17 to 22 mm, its thickness Bassett et al. correlated the presence of this acces-
from 1 to 2 mm, and its width from 3 to 5 mm. The sory ligament with pain from impingement in the an-
maximum, minimum, mean, and standard deviation for terolateral aspect of the ankle in patients with a history
the length, width, gap, and angle of declination for the of inversion sprains [4]. They postulated that the post-
inferior fibre bundle are provided in Table 1. The lig- traumatic anterolateral hyperlaxity, due to an injured
ament was not covered by synovial tissue, ran deeper ATFL, resulted in anterior extrusion of the talar dome
than the AITFL and was described as being intra- with dorsiflexion, which now contacted the inferior
articular, although how this was determined was not fascicle of the AITFL with more pressure and friction
stated by the authors. The accessory ligament crossed [4]. This in turn might set up an environment favouring
ligamentous impingement of the anterior aspect of the
ankle [4].
Table 1 Characteristics of the inferior fascicle of the AITFL [24] Akseki et al. stated that the variations in width,
length, and obliquity of the fascicle may be related to
Maximum Minimum Mean
the pathological behaviour of the fascicle [2]. Mean
Ligament length (cm) 3.4 2.1 2.6 ± 0.3 width and length of the fascicle with bending during
Ligament width (cm) 1.3 0.2 0.4 ± 0.2 dorsiflexion and dorsiflexion-eversion were significantly
Gap (cm) 0.5 0.1 0.2 ± 0.1 higher than the fascicle without bending. Therefore
Declination angle (deg) 155.0 121.5 136.3 ± 7.4
this wider and longer fascicles had more potential to

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Table 2 AITFL classification system [24]

Type 1 Multiple fascicles (more than three) with or without small gaps between adjacent fascicles
1A The inferior fascicle is separated from the rest of the ligament by a gap and possesses its own distinct proximal
and distal attachments
1B The inferior fascicle is not completely separated from the rest of the ligament by a gap. Either its proximal
or its distal attachment is continuous with the rest of the ligament
1C Multiple fascicles without gaps intervening between them
Type 2 Three fascicles or less. A distinct inferior fascicle with both its proximal and distal attachments separate from
the rest of the ligament. The inferior fascicle is separated completely from the main portion of the ligament by a gap
Type 3 Three fascicles or less. A distinct inferior fascicle with either its proximal or its distal attachment continuous with the rest
of the ligament. A gap does not completely separate the inferior fascicle from the rest of the ligament
Type 4 Three fascicles or less. The lower portion of the ligament possesses an inferior fascicle with both its proximal
and distal attachments for the rest of the ligament
Type 5 Three fascicles or less. A ligament with no separations or gaps within its structure. It may or may not possess
a fascicular arrangement

become pathological than thinner ones. They also dorsiflexion-eversion position [22]. No interaction of
conclude that if the fibular insertion point is far from the the accessory ligament with the talus was noted during
joint level, the fascicle has more potential to become ankle plantar flexion [22].
pathological. These findings might be useful during In 82.9% of the cases with AITFL impingement Ray
arthroscopic procedures of the ankle. and Kriz [24] found an anterior abraded articular re-
During dorsiflexion of the ankle the posterior shift gion of the talus. Akseki et al. [2] found this in 17% of
of the anterior talus below the tibial plafond in ATFL the cases. In the study of Basset et al. [4] 71% of the
intact cases was observed. Following incision of the patients, had an area of abraded articular cartilage on
ATFL this posterior shift of the talus was not observed; the anterolateral surface of the talar dome. There is no
the talus remained in an anterior position and thus in clarity if this abraded cartilage region is an anatomical
contact with the fascicle [2]. Lesion of the ATFL led to variant of the talus or a pathological remodelling of the
bending of the fascicle with dorsiflexion and dorsi- bone due to true ligamentous impingement [4].
flexion-inversion in the specimens which the bending On base of these studies we conclude that antero-
sign was negative. Lesion of the ATFL led also to lateral hyperlaxity results in anterior extrusion of the
contact between the talus and the fascicle in the ankles talar dome with dorsiflexion, which contacts the infe-
which showed no contact previously [2]. After sec- rior fascicle of the AITFL with more pressure and
tioning the ATFL the anteroposterior laxity of the friction. This hyperlaxity was most likely due to an
ankle increases especially in dorsiflexion [4, 13]. injured ATFL. Wider and longer fascicles and a fibular
In 89.3% of the cases contact was observed between insertion point far from the joint level have more po-
the ATFL and the anterolateral corner of the talus [2]. tential to become pathological. Often contact between
This contact may be normal in some of the cases. the AITFL and the superolateral corner of the talus
Contact was observed at an average of 12° of dorsi- and an abraded region of the cartilage of the talus can
flexion of the ankle [4]. Bending of the accessory lig- be observed during arthroscopy.
ament, indicating further tensioning of its ligamentous
bands caused by impingement of the talus, this was
noted in an extent of dorsiflexion that varied from 5° to Diagnosis
10° (average 7°) [22]. Maximum dorsiflexion of the foot
relieved the contact between the ligament and the su- The diagnosis of ligamentous impingement in the
perolateral corner of the talus [22]. In other studies the anterior aspect of the ankle should be considered in
contact was also observed in neutral position [2, 24]. patients who have chronic ankle pain in the antero-
In one study the contact between the fascicle and lateral aspect of the ankle after an inversion sprain and
talar dome was observed throughout the whole range who have a stable ankle, normal plain radiographs, and
of motion of the ankle [1]. They called this the isolated point tenderness on the anterolateral aspect of
‘‘arthroscopic impingement test,’’ and it was positive in the talar dome and in the anteroinferior tibiofibular
all of the cases with AITFL impingement they have ligament [4]. A popping sensation and aggravation of
studied [1]. Contact between the accessory fascicle and pain with dorsiflexion and eversion were noted [2, 4].
the talus was also observed during eversion of the foot, This audible popping is usually not seen in other causes
being more prominent when the foot was placed in a of impingement of the anterior aspect of the ankle [4].

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Fig. 2 There is contact

between the distal fascicle
of AITFL and the talus in
dorsiflexion with bending
of this fascicle

Pain in the beginning of plantarflexion-inversion may Not every patient with chronic ankle instability
alert the physician for an impinging AITFL [2]. needs a reconstructive procedure [1]. If the history,
It is usually impossible to distinguish the source of physical examination, and other diagnostic tests sug-
pain in patients with both instability and impingement. gest impingement in addition to instability, arthro-
So if the patient complains of giving way and frequent scopic debridement of the soft tissue lesion may be all
sprains, the surgeon may choose a reconstructive pro- that is needed [1. In cases with an area of abraded
cedure [1]. But it should be noted that a painful lesion articular cartilage on the anterolateral surface of the
in the joint (synovitis, meniscoid lesion, or an imping- talar dome, further debridement of this region was
ing fascicle of the AITFL) may cause reflex sprains [1]. required [4]. At long-term follow-up arthroscopic
This process may confuse decision making in this type excision of soft tissue overgrowth and osteophytes
of combined pathology. The differential diagnosis for proved to be an effective way of treating anterior
pain in the lateral aspect of the ankle after an inversion impingement of the ankle in patients who had no
sprain includes osteochondral fracture, instability narrowing of the joint space [30]. Patients with less
of the lateral aspect of the ankle, synovitis or rupture than 2 years of ankle pain before surgery for anterior
of the peroneal tendon, and ligamentous impingement ankle impingement showed significant better scores
in the anterior aspect of the ankle, with the latter being in pain, swelling, ability to work, and engagement in
the least common [4]. sports [31].
The decision to perform an arthroscopy of the ankle
is typically based on the patient’s history and physical
Treatment examination [9, 19, 28]. Arthroscopically resection of
the distal fascicle of the AITFL should be considered
Patients should be treated conservatively after an when there (Fig. 2): (1) is contact between the AITFL
inversion sprain of the ankle for at least 6 months before and the talus was prominent also in the beginning of
operative intervention is considered [5]. This is with the plantarflexion-inversion of the ankle, (2) is increased
exception of patients with an osteochondral fracture. contact between the talus and the ligament and this
Akseki et al. observed that conservative management continued until maximum dorsiflexion with abrasion of
with physical therapy, NSAIDs and bracing in patients the articular cartilage (the surgeon should remember
with instability symptoms, for a period of 3 months, that this finding may be normal), (3) bending of the
failed in all 21 patients [1]. fascicle on the anterolateral edge of the talus with

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dorsiflexion and dorsiflexion-inversion, (4) is a distally The decision to perform an arthroscopy of the ankle
inserting fascicle on the fibula, close to the origin of the is typically based on the patient’s history and physical
ATFL on the fibula. This finding may be missed if examination. When an impinging distal fascicle of
the distraction is preserved throughout the procedure the AITFL and an abraded anterolateral region of the
[2, 24]. For this reason, temporarily relieving distrac- talus were observed during an ankle arthroscopy, the
tion is advised, when a distal fascicle is seen during surgeon should look for the criteria described above
arthroscopy [2, 22]. to decide whether it is pathological and needs to be
Only three studies reported on the results of the resected.
treatment of AITFL impingement [1, 4, 12]. Akseki
et al. [1] arthroscopically resected the distal fascicle of
the AITFL in 21 patients with chronic ankle pain after an Conclusion
ankle sprain. During the procedure an impinging distal
fascicle of the AITFL was found in all cases. Following Because of the lack of evidence only preliminary
anterolateral synovectomie, the fascicle was excised. At conclusions can be drawn. The AITFL started from the
an average follow-up of 3 years good to excellent results distal tibia, 5 mm in average above the articular sur-
were obtained in 17 patients. Nineteen patients were face, and descended obliquely between the adjacent
satisfied with the procedure and 17 patients returned to margins of the tibia and fibula, anterior to the syn-
previous level of activity. Two patients who had mild desmosis to the anterior aspect of the lateral malleolus.
laxity were graded as poor because neuromas of the The incidence of the accessory fascicle differs very
terminal branches of the superficial peroneal nerve. widely in the several studies. The presence of the distal
These patients became asymptomatic after an injection fascicle of the AITFL and also the contact with the
of steroids. anterolateral talus is probably a normal finding. It may
Bassett et al. [4] treated seven patients who had become pathological, however, due to anatomical
talar impingement by an AITFL and they were variations and/or anterolateral instability of the ankle
followed for a mean of 39 months. Two patients had resulting from an ATFL injury. When observed during
arthroscopy and five had an arthrotomy. In all patients, an ankle arthroscopy, the surgeon should look for the
a thickened distal fascicle of the AITFL was resected. criteria described to decide whether it is pathological
Five patients also needed debridement of an area of and considering resection of the distal fascicle.
abraded hyaline cartilage on the anterolateral aspect of
the talar dome at the point where the distal fascicle
made contact. Post-operative management consisted of References
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