The distal fascicle of the anterior inferior tibiofibular ligament as a cause of tibiotalar impingement syndrome: a current concepts review

Impingement syndromes of the ankle involve either osseous or soft tissue impingement and can be anterior, anterolateral, or posterior. Ankle impingement syndromes are painful conditions caused by the friction of joint tissues, which are both the cause and the effect of altered joint biomechanics. The distal fascicle of the anterior inferior tibiofibular ligament (AITFL) is possible cause of anterior impingement. The objective of this article was to review the literature concerning the anatomy, pathogenesis, symptoms and treatment of the AITFL impingement and finally to formulate treatment recommendations. The AITFL starts from the distal tibia, 5 mm in average above the articular surface, and descends obliquely between the adjacent margins of the tibia and fibula, anterior to the syndesmosis to the anterior aspect of the lateral malleolus. The incidence of the 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 finding. It may become pathological, due to anatomical variations and/or anterolateral instability of the ankle resulting from an anterior talofibular ligament injury. When observed during an ankle arthroscopy, the surgeon should look for the criteria described to decide whether it is pathological and considering resection of the distal fascicle. The presence of the AITFL and the contact with the talus is a normal finding. An impingement of the AITFL can result from an anatomical variant or anteroposterior instability of the ankle. The diagnosis of ligamentous impingement in the anterior aspect of the ankle should be considered in patients who have chronic ankle pain in the anterolateral aspect of the ankle after an inversion injury and have a stable ankle, normal plain radiographs, and isolated point tenderness on the anterolateral aspect of the talar dome and in the anteroinferior tibiofibular ligament. The impingement syndrome can be treated arthroscopically

Anatomy of the ankle ligaments: a pictorial essay

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

KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY

Impingement by the distal fascicle of the anterior inferior tibiofibular ligament (AITFL) is a relatively new entity among the known causes of anterolateral impingement syndromes of the ankle. This study investigated the anatomy of the anterior inferior tibiofibular ligament and its possible role in talar impingement in 47 ankles of 27 cadavers. The length, width, insertion point to the fibula and the interactions with talus were noted, as was the relationship of the fascicle and talus during different ankle movements before and after incision of the lateral ligaments. A distal fascicle of the AITFL was found in 39 of the 47 ankles (83%) and appeared as a single-complete ligament in the remaining 8 ankles (17%). The fascicle averaged 16.1 +/- 2.94 mm in length (range 10-21) and 4.2 +/- 1.00 mm in width (range, 3-7). The insertion point of the fascicle on the fibula averaged 10.3 +/- 2.27 mm (5-13) distal to the joint level. Contact between the ligament and the lateral dome of the talus was observed in 42 specimens (89.3%). Bending of the fascicle was observed in 8 of these 42 ankles with forced dorsiflexion. These 8 specimens were significantly wider and longer than the specimens without bending of the fascicle. Incision of the anterior talofibular ligament led to bending in dorsiflexion in additional 11 ankles. The total 19 fascicles with bending after incision of the anterior talofibular ligament were significantly longer and inserted more distally than the remaining 20 fascisles without bending. Manual traction simulating distraction during arthroscopic procedures relieved the contact. These findings show that the presence of the distal fascicle of the AITFL and its contact with the talus is a normal finding. However, it may become pathological due to anatomical variations and/or instability of the ankle resulting from torn lateral ligaments. When observed during an ankle arthroscopy, the surgeon should look for the criteria described in the present study to decide whether it is pathological and needs to be resected

ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY

Purpose: The purpose of this study was to describe a new weight-bearing McMurray's test (Ege's test) and to compare its diagnostic value with McMurray's test and joint line tenderness (JLT). We also aimed to determine if associated lesions had any effect on the diagnostic values of the 3 tests. Type of Study: Prospective controlled trial, clinical study. Methods: The study group consisted of 150 consecutive patients who had had symptoms related to intra-articular knee pathology, and arthroscopic diagnoses were used as the gold standard. Results: There were a total of 211 diagnoses on arthroscopy. A meniscus tear was found in 127 of the 150 patients; 90 had medial, 28 had lateral, and 9 had tears of both menisci. There were no statistically significant differences between the 3 tests in detecting a meniscal tear (P > .05). However, better accuracy, sensitivity, and specificity rates were obtained with Ege's test for medial meniscal lesions (71%, 67%, and 81%, respectively). JLT also gave superior accuracy rates (71%), but the specificity of Ege's test was apparently higher than JLT (81% v 44%). The highest positive predictive value was also obtained with Ege's test (86%), whereas a superior negative predictive value was obtained with JLT (67%) in medial meniscal tears. Lateral meniscal tears were diagnosed more accurately than medial meniscal tears, and Ege's test gave results superior to the others (84%, 64%, 90% for accuracy, sensitivity, and specificity, respectively). Higher positive predictive values were obtained with McMurray's and Ege's tests than with JLT, but similar negative predictive values were achieved in all. A torn anterior cruciate ligament did not decrease the diagnostic values of the 3 tests, whereas the number of associated lesions in the knee negatively affected the diagnostic capabilities of the tests. Conclusions: Accuracies of traditional clinical meniscus tests may be improved by including Ege's test in the clinical examination. Level of Evidence: Level II, diagnostic

ACTA ORTHOPAEDICA SCANDINAVICA

We arthroscopically resected the impinged distal fascicle of the anterior inferior tibiofibular ligament: (AIT-FL) in 21 patients (mean age 31 (11-88) years, 14 women) with chronic ankle pain after an ankle sprain. Clinical tests revealed moderate laxity in 2 and severe laxity in another 2, the remaining 17 ankles showing only mild laxity. During arthroscopy, an impinging distal fascicle of the AITFL was found in all cases. Following anterolateral synovectomy, the fascicle was excised. At the follow-up after mean 3 (2-4) years, good-to-excellent results were obtained in 17 patients. 19 patients were satisfied with the procedure and 17 patients returned to their previous level of activity. 2 patients who had mild laxity were graded as poor because of neuromas of the terminal branches of the superficial peroneal nerve. These patients became asymptomatic after an injection of steroids

Acta Orthopaedica et Traumatologica Turcica

Objectives: The importance of proprioception in the etiology, treatment, and prevention of sports injuries and joint diseases has become increasingly clear. The purpose of this study was to investigate knee proprioception in patients with patellofemoral pain syndrome (PFPS). Methods: The study included 28 patients (18 females, 10 males mean age 28 years: range 16 to 48 years) with a clinical diagnosis of unilateral PFPS and 27 normal volunteers (13 females, 14 males: mean age 26 years; range 19 to 32 years) without any complaint related to the knee. The mean duration of complaints was 35.8 weeks (range 2 weeks to 3 years). In both patient and control groups, proprioception of the knee was measured by means of active joint position sense at four different target angles (15 degrees, 30 degrees, 45 degrees, 60 degrees) with the use of a digital geniometer and the results were compared target angles Results: Proprioceptive errors were greater at all tar in the affected knees compared to those measured in the contralateral knees and both knees of the controls. Differences between affected knees and contralateral knees ranged from 1.01 +/- 0.250 to 1.65 +/- 0.43 degrees and were significant at three target angles (15 degrees, 30 degrees, 60 degrees; p<0.05). Comparisons between the affected knees and both knees of the controls also showed significant differences at all target angles ranging from 2.48 +/- 0.92 degrees to 3.87 +/- 2.46 degrees (p<0.001). Errors obtained in the normal knees of the patients were also significantly greater compared to those seen in both knees of the controls, exceeding, 2.7 degrees at some target angles (P<0.001). Conclusion: Our results show that patients with PFPS have impaired proprioception in the affected knee accompanied by significant losses in the proprioception of the contralateral normal knee. Based on these findings, proprioceptive rehabilitation techniques should be incorporated into the treatment of PFPS

The anterior inferior tibiofibular ligament and talar impingement: a cadaveric study.

Impingement by the distal fascicle of the anterior inferior tibiofibular ligament (AITFL) is a relatively new entity among the known causes of anterolateral impingement syndromes of the ankle. This study investigated the anatomy of the anterior inferior tibiofibular ligament and its possible role in talar impingement in 47 ankles of 27 cadavers. The length, width, insertion point to the fibula and the interactions with talus were noted, as was the relationship of the fascicle and talus during different ankle movements before and after incision of the lateral ligaments. A distal fascicle of the AITFL was found in 39 of the 47 ankles (83%) and appeared as a single-complete ligament in the remaining 8 ankles (17%). The fascicle averaged 16.1 +/- 2.94 mm in length (range 10-21) and 4.2 +/- 1.00 mm in width (range, 3-7). The insertion point of the fascicle on the fibula averaged 10.3 +/- 2.27 mm (5-13) distal to the joint level. Contact between the ligament and the lateral dome of the talus was observed in 42 specimens (89.3%). Bending of the fascicle was observed in 8 of these 42 ankles with forced dorsiflexion. These 8 specimens were significantly wider and longer than the specimens without bending of the fascicle. Incision of the anterior talofibular ligament led to bending in dorsiflexion in additional 11 ankles. The total 19 fascicles with bending after incision of the anterior talofibular ligament were significantly longer and inserted more distally than the remaining 20 fascisles without bending. Manual traction simulating distraction during arthroscopic procedures relieved the contact. These findings show that the presence of the distal fascicle of the AITFL and its contact with the talus is a normal finding. However, it may become pathological due to anatomical variations and/or instability of the ankle resulting from torn lateral ligaments. When observed during an ankle arthroscopy, the surgeon should look for the criteria described in the present study to decide whether it is pathological and needs to be resected

Dislocating anterior horn of the medial meniscus.

Dislocating anterior horn of the medial meniscus was found in 15 knees of 13 patients during arthroscopic examinations done between 1992 and 1995. All of them were available for follow-up evaluation (4 by telephone). There were 11 men and 2 women (average age, 28 years; range, 17 to 49 years). Nine knees had a history of trauma. Only 1 knee had had trauma in two bilateral cases. Duration of symptoms was an average of 3.3 years (range, 3 months to 10 years). The knees were stable clinically. Arthroscopy revealed associated lesions in 13 knees; hypertrophic medial plicae, meniscal, chondral and anterior cruciate ligament (ACL) lesions predominated. Three knees had unusually hypertrophic ligamentum mucosum. Eleven of 13 knees had more than one associated lesions. Only 2 knees (2 patients) had isolated dislocating anterior horn of the medial meniscus. Only the associated lesions were treated (except for ACL lesions) and dislocating anterior horns of the medial menisci were left alone. Follow-up averaged 21 months (7 to 40 months). At follow-up, 11 knees were graded as excellent, 3 as good, and 1 as fair according to the Lysholm scale. Eight knees had minor symptoms and 6 were asymptomatic; no improvement was noted in 1 knee. Overall, 12 patients (14 knees) were satisfied with their treatment. Dislocating anterior horn of the medial meniscus is a normal anatomic variant with little or no clinical significance. When seen during arthroscopy, a significant lesion should be looked for. It is an incidental finding and should be left alone

A new weight-bearing meniscal test and a comparison with McMurray's test and joint line tenderness.

Purpose: The purpose of this study was to describe a new weight-bearing McMurray's test (Ege's test) and to compare its diagnostic value with McMurray's test and joint line tenderness (JLT). We also aimed to determine if associated lesions had any effect on the diagnostic values of the 3 tests. Type of Study: Prospective controlled trial, clinical study. Methods: The study group consisted of 150 consecutive patients who had had symptoms related to intra-articular knee pathology, and arthroscopic diagnoses were used as the gold standard. Results: There were a total of 211 diagnoses on arthroscopy. A meniscus tear was found in 127 of the 150 patients; 90 had medial, 28 had lateral, and 9 had tears of both menisci. There were no statistically significant differences between the 3 tests in detecting a meniscal tear (P > .05). However, better accuracy, sensitivity, and specificity rates were obtained with Ege's test for medial meniscal lesions (71%, 67%, and 81%, respectively). JLT also gave superior accuracy rates (71%), but the specificity of Ege's test was apparently higher than JLT (81% v 44%). The highest positive predictive value was also obtained with Ege's test (86%), whereas a superior negative predictive value was obtained with JLT (67%) in medial meniscal tears. Lateral meniscal tears were diagnosed more accurately than medial meniscal tears, and Ege's test gave results superior to the others (84%, 64%, 90% for accuracy, sensitivity, and specificity, respectively). Higher positive predictive values were obtained with McMurray's and Ege's tests than with JLT, but similar negative predictive values were achieved in all. A torn anterior cruciate ligament did not decrease the diagnostic values of the 3 tests, whereas the number of associated lesions in the knee negatively affected the diagnostic capabilities of the tests. Conclusions: Accuracies of traditional clinical meniscus tests may be improved by including Ege's test in the clinical examination. Level of Evidence: Level II, diagnostic

Traumatic prepatellar neuroma: an unusual cause of anterior knee pain.

Although the patellar (infrapatellar) branch of the saphenous nerve is vulnerable to direct trauma, traumatic prepatellar neuroma has rarely been reported in the literature. It should be considered in the differential diagnosis of disorders causing anterior knee pain. Point tenderness, a palpable fusiform nodule and a positive Tinel's sign are the diagnostic features. Simple excision is curative