Alterated ligamento-muscular reflex pattern after stimulation of the anterior talofibular ligament in functional ankle instability



Ligamento-muscular reflex pattern following stimulation of the anterior talofibular ligament (ATFL) was examined.


The peroneus longus (PL), the tibialis anterior (TA), and tibialis posterior (TP) muscles were investigated in sixteen patients with functional ankle instability (FAI) and 16 age- and gender-matched controls. The ATFL was stimulated with a fine wire electrode while electromyographic (EMG) activities were recorded during isometric foot contraction of 20% maximal force in plantarflexion, dorsiflexion, supination and pronation. The complete measurement was repeated after a peroneal block anesthesia.


Statistically significant changes in post-stimulus EMG activity were observed in all three muscles and all four tested foot positions. In supination, the PL showed no reactions in both groups before and after anesthesia. The post-stimulus inhibition of the TA seen after 80 and 180 ms disappeared in controls after anesthesia. The TP had similar inhibitory responses in both groups.


Ligamento-muscular reflex pattern is alterated in FAI. While early reactions are essential in protecting the ankle joint in sudden movements, the later responses indicate a supraspinal control of neuromuscular stability of the ankle joint. Proprioceptive rehabilitation of the PL, TA, and TP is crucial in FAI to compensate for post-traumatic ligamentomuscular reflex deficiencies.

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Fig. 1
Fig. 2
Fig. 3



Anterior talofibular ligament


Calcaneofibular ligament




Functional ankle instability


Peroneus longus muscle


Tibialis anterior muscle


Tibialis posterior muscle


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We thank Ursula Range (Institute for Medical Informatics and Biometry, University Hospital ‘‘Carl Gustav Carus’’, Dresden, Germany) for statistical support, Jonas K. E. Persson, MD, PhD (Department of Clinical Neuroscience, Section of Neurophysiology, Stockholm, Sweden), Thomas Albrecht and Heiko Lange (Center for Orthopedics and Trauma Surgery, University Hospital ‘‘Carl Gustav Carus), and Christian Retschke (Leipzig) for logistic support as well as Jochen Schäfer, MD, and Martin Pette, MD, PhD (Department of Neurology, University Hospital „Carl Gustav Carus“, Dresden, Germany). Furthermore, we thank Axel Kalpen (novel biomechanic laboratory,, Ismaninger Straße 51, 81675 Munich, Germany) for technical support.


This study has been financially supported by Bauerfeind AG, Zeulenroda-Triebes, Germany (Grant no.: 100_3380). The authors disclose any financial conflicts of interest that may influence the interpretation of this study and/or results.

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All authors made substantive intellectual contributions to this study, in conception and design (SR, EH, TSH), acquisition of data (SR, TSH), analysis and interpretation of data (SR, EH, TSH), drafting and revising the manuscript (SR, EH, TSH), as well as final approval of the version to be submitted (SR, EH, TSH). All authors have read and approved the final submitted manuscript.

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Correspondence to Susanne Rein.

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The local ethical committee of the Medical Faculty of the Technical University Dresden approved this study under the processing number: EK34022012.

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Rein, S., Hagert, E. & Sterling-Hauf, T. Alterated ligamento-muscular reflex pattern after stimulation of the anterior talofibular ligament in functional ankle instability. Knee Surg Sports Traumatol Arthrosc 29, 1544–1553 (2021).

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  • Ankle joint
  • Electromyography
  • Ligament
  • Proprioception