Korean J Radiol.  2015 Oct;16(5):1096-1103. 10.3348/kjr.2015.16.5.1096.

Deltoid Ligament and Tibiofibular Syndesmosis Injury in Chronic Lateral Ankle Instability: Magnetic Resonance Imaging Evaluation at 3T and Comparison with Arthroscopy

  • 1Department of Radiology, Eulji Hospital, Eulji University, Seoul 01830, Korea. mdcys0128@hanmail.net
  • 2Department of Orthopedic Surgery, Eulji Hospital, Eulji University, Seoul 01830, Korea.


To evaluate the prevalence of deltoid ligament and distal tibiofibular syndesmosis injury on 3T magnetic resonance imaging (MRI) in patients with chronic lateral ankle instability (CLAI).
Fifty patients (mean age, 35 years) who had undergone preoperative 3T MRI and surgical treatment for CLAI were enrolled. The prevalence of deltoid ligament and syndesmosis injury were assessed. The complexity of lateral collateral ligament complex (LCLC) injury was correlated with prevalence of deltoid or syndesmosis injuries. The diagnostic accuracy of ankle ligament imaging at 3T MRI was analyzed using arthroscopy as a reference standard.
On MRI, deltoid ligament injury was identified in 18 (36%) patients as follows: superficial ligament alone, 9 (50%); deep ligament alone 2 (11%); and both ligaments 7 (39%). Syndesmosis abnormality was found in 21 (42%) patients as follows: anterior inferior tibiofibular ligament (AITFL) alone, 19 (90%); and AITFL and interosseous ligament, 2 (10%). There was no correlation between LCLC injury complexity and the prevalence of an accompanying deltoid or syndesmosis injury on both MRI and arthroscopic findings. MRI sensitivity and specificity for detection of deltoid ligament injury were 84% and 93.5%, and those for detection of syndesmosis injury were 91% and 100%, respectively.
Deltoid ligament or syndesmosis injuries were common in patients undergoing surgery for CLAI, regardless of the LCLC injury complexity. 3T MRI is helpful for the detection of all types of ankle ligament injury. Therefore, careful interpretation of pre-operative MRI is essential.


Chronic ankle instability; Lateral collateral ligament; Deltoid ligament; Syndesmosis; Magnetic resonance imaging; 3T

MeSH Terms

Ankle Injuries/pathology/*radiography
Ankle Joint/*radiography
Chronic Disease
Joint Instability/pathology/radiography/*surgery
Ligaments, Articular/pathology/radiography
*Magnetic Resonance Imaging
Middle Aged
Young Adult


  • Fig. 1 21-year-old man with chronic tear of anterior talofibular ligament (ATFL) and deltoid ligament. A. Axial proton-weighted turbo spin echo (TSE) magnetic resonance (MR) image showing torn ATFL (arrows). B. Oblique coronal proton-weighted TSE MR image showing loose, thin superficial deltoid ligament (arrow). Deep posterior tibiotalar ligament is thickened with loss of striation. C. On arthroscopy, injury of superficial (not visible on this figure) and deep deltoid ligament (arrow) with widening of medial mortise (double arrow) were seen. Patient underwent modified Broström operation and repair of superficial deltoid ligament. MM = medial malleolus, Ta = medial talus

  • Fig. 2 27-year-old man with chronic injuries of anterior talofibular ligament (ATFL) and anterior inferior tibiofibular ligament (AITFL). A. Axial fat suppression T2-weighted turbo spin echo (TSE) magnetic resonance (MR) image shows very loose and irregular ATFL (arrows). B. Axial oblique proton-weighted TSE MR image shows irregular and loose AITFL (arrow). C. On arthroscopic image, there are obturator insertion and widening of distal tibiofibular joint (> 4 mm). Patient underwent modified Broström operation and reconstruction of AITFL using anchors. F = distal fibula, T = distal tibia

  • Fig. 3 48-year-old man with chronic injuries to anterior talofibular ligament (ATFL), superficial deltoid ligament, and anterior inferior tibiofibular ligament (AITFL). A. Axial T2-weighted fat-suppression turbo spin echo (TSE) magnetic resonance (MR) image shows hyperintensity of ATFL, with partial discontinuity (arrow). B. Coronal oblique proton-weighted TSE MR image shows hyperintensity of superficial deltoid ligament, with partial discontinuity (arrow). C. Axial proton-weighted TSE MR image shows thickened AITFL (arrow). D, E. Arthroscopic images show loose and partially torn superficial deltoid ligament, with widening of medial mortise (double arrow, D), and widening of distal tibiofibular joint (double arrow, E). Patient underwent modified Broström operation, repair of superficial deltoid ligament, and reconstruction of AITFL using anchors. F = distal fibula, MM = medial malleolus, T = distal tibia, Ta = medial talus


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