Sonographic visibility of the main posterior ankle ligaments and para-ligamentous structures in 15 healthy subjects

  • Salvatore Massimo StellaEmail author
  • Barbara Ciampi
  • Andrea Del Chiaro
  • Gianfranco Vallone
  • Mario Miccoli
  • Massimo Gulisano
  • Eugenio Orsitto
  • Stefano Galletti
Original Paper


The present article describes the ultrasound (US) appearance of ligaments and paraligamentous structures which are not included in standard US imaging of the ankle: the posterior inferior tibiofibular ligament (PITFL), the transverse tibiofibular ligament (TTFL), the posterior talofibular ligament (PTFL), the posterior intermalleolar ligament (PIL), the synovial recess (SR) of the posterior joint and the os trigonum (OT). Two skilled operators examined 15 ankles in 15 healthy volunteers. Correlation between thickness of the main ligaments and body mass index (BMI) was also analyzed. Compound and tissue harmonic imaging (THI) were carried out using 12-, 6–15- and 9-MHz linear probes. Exploration of the posterior ankle ligament complex is accurately described including correct ankle position, echogenicity, shape, direction and thickness. Both operators identified and measured the main ligaments (PITFL, TTFL and PTFL) in all volunteers (Intraclass Correlation Coefficient ranged from 0.8 to 1); both operators also detected SR and OT in 2/15 ankles and posterior intermalleolar ligament (PIL) in 5/15 ankles. Pearson’s test showed a significant correlation (< 0.05) between TTFL thickness and BMI. Also, a dynamic study was carried out showing tension of the PTFL during dorsiflexion in 7/15 subjects. Our results highlight the potential role of accurate US imaging in detecting posterior ankle ligament involvement in acute and chronic traumas. To our knowledge, there are no previous articles in the literature dealing with this topic providing an accurate description of the US procedure, and in particular, no study has been carried out to identify OT.


Ankle ligaments Musculoskeletal ultrasound Posterior tibiofibular ligament Posterior talofibular ligament 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Human and animal rights

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material (11.5 mb)
Attached Video: US progressive transverse section of the back of the ankle from the proximal to the distal portion using a 12 MHz probe set at 12 MHz frequency. The first frames show a long axis of a thin PITFL; proceeding downwards the second ligament that clearly appears is the deep and thick TTFL (long axis). Immediately below, the long axis of PTFL is easily identified containing an os trigonum (in the distal part). (MOV 11740 kb)


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Copyright information

© Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB) 2020

Authors and Affiliations

  • Salvatore Massimo Stella
    • 1
    • 2
    • 7
    Email author
  • Barbara Ciampi
    • 2
    • 7
  • Andrea Del Chiaro
    • 2
    • 3
  • Gianfranco Vallone
    • 4
  • Mario Miccoli
    • 5
  • Massimo Gulisano
    • 6
  • Eugenio Orsitto
    • 1
    • 2
  • Stefano Galletti
    • 2
    • 7
  1. 1.Emergency Radiology, Emergency Department of Cisanello (Pisa) University HospitalPisaItaly
  2. 2.Advanced Musculoskeletal Ultrasound SIUMB School of PisaPisaItaly
  3. 3.Orthopedic and Traumatology Operating UnitUniversity of PisaPisaItaly
  4. 4.Department of Advanced Biomedical SciencesUniversity Federico IINaplesItaly
  5. 5.Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
  6. 6.Department of Clinical and Experimental MedicineUniversity of FlorenceFlorenceItaly
  7. 7.Advanced Musculoskeletal Ultrasound SIUMB School of BolognaMaggiore HospitalBolognaItaly

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