Anterior Talofibular Pain Syndrome – The Clinical Syndrome
Talofibular pain syndrome is being encountered more frequently in clinical practice with the increased interest in jogging and marathon running. The talofibular ligament, which passes from the anterior margin of the fibular malleolus, forward and medially, to the talus bone, in front of its lateral articular facet, is susceptible to strain from acute injury from sudden inversion of the ankle or from repetitive microtrauma to the ligament from overuse or misuse, such as long-distance running on soft or uneven surfaces. Patients with strain of the talofibular ligament report pain just below the lateral malleolus. Activities that require inversion of the ankle joint exacerbate the pain.
Signs and Symptoms
On physical examination, point tenderness is felt just below the lateral malleolus. With acute trauma, ecchymosis over the ligament may be noted. Passive inversion of the ankle joint exacerbates the pain. Coexistent bursitis and arthritis of the ankle and subtalar joint may be present and confuse the clinical picture. Stress fractures of the foot occur with increased frequency in runners, and this must be considered in all patients thought to have talofibular pain syndrome.
How is Anterior Talofibular Pain Syndrome diagnosed?
Plain radiographs are indicated in all patients with ankle pain. Based on the patient’s clinical presentation, additional tests, including complete blood cell count, erythrocyte sedimentation rate, and antinuclear antibody testing, may be indicated. Magnetic resonance imaging (MRI) and ultrasound imaging of the ankle is indicated if disruption of the talofibular ligament or joint instability, occult mass, or tumor is suspected
Avulsion fractures of the calcaneus, talus, lateral malleolus, and base of the fifth metatarsal can mimic the pain of injury to the talofibular ligament. Bursitis, tendinitis, and gout of the midtarsal joints may coexist with ligament strain and may confuse the diagnosis. Tarsal tunnel syndrome may occur after ankle trauma and may further confuse the clinical picture.
Initial treatment of the pain and functional disability associated with talofibular pain syndrome should include a combination of nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors and physical therapy. Local application of heat and cold may be beneficial. Avoidance of repetitive activities that aggravate the patient’s symptoms and short-term immobilization of the ankle joint also may provide relief. For patients who do not respond to these treatment modalities, the injection of the talofibular ligament may be a reasonable next step. Ultrasound guidance may improve the accuracy of needle placement and decrease the incidence of needle-related complications.
Complications and Pitfalls
Failure to identify occult fractures of the ankle and foot may result in significant morbidity. Radionucleotide bone scanning and MRI of the ankle should be performed on all patients experiencing unexplained ankle and foot pain, especially if trauma is present. The major complication of the previously mentioned injection technique is infection. This complication should be exceedingly rare if strict aseptic technique is followed. Approximately 25% of patients report a transient increase in pain after injection of the talofibular ligament, and patients should be warned of this possibility. Injection around strained ligaments always should be done gently to avoid further damage to the already compromised ligament.
It is estimated that approximately 25,000 individuals sprain their ankle every day. Although viewed as benign by the lay public, ankle sprains can result in significant permanent pain and disability. The major ligaments of the ankle joint include the deltoid, anterior talofibular, calcaneofibular, and posterior talofibular ligaments, which provide most of the strength to the ankle joint. The talofibular ligament is not as strong as the deltoid ligament and is susceptible to strain. The talofibular ligament runs from the anterior border of the lateral malleolus to the lateral surface of the talus.
The injection technique described here is extremely effective in the treatment of pain secondary to the talofibular ligament strain. Coexistent arthritis, bursitis, and tendinitis may contribute to medial ankle pain and may require additional treatment with more localized injection of a local anesthetic and depot steroid. The use of physical modalities, including local heat and gentle range-of-motion exercises, should be introduced several days after the patient undergoes this injection technique for ankle pain. Vigorous exercises should be avoided because they would exacerbate the symptoms. Simple analgesics and NSAIDs may be used concurrently with this injection technique.