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Deltoid Ligament Injuries

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Deltoid Ligament Injuries

Comprehensive review of deltoid ligament injuries including acute sprains, chronic insufficiency, grading systems, associated fractures, and evidence-based management strategies

complete
Updated: 2025-01-15

Deltoid Ligament Injuries

High Yield Overview

DELTOID LIGAMENT INJURIES

Medial Ankle Stability | PER Mechanism | Rare Isolated Injury

3-5%Of ankle sprains (isolated)
2-3xStronger than ATFL
4mmMedial clear space threshold
70-80%Conservative success rate

Deltoid Injury Grading

Critical Must-Knows

  • Deltoid complex 2-3x stronger than ATFL - isolated injury rare
  • PER mechanism most common - associated with SER-4 fractures
  • Medial clear space greater than 4mm indicates instability
  • MRI gold standard for soft tissue assessment
  • Conservative treatment 4-6 weeks for isolated injuries

Examiner's Pearls

  • "
    Deep layer critical for rotational and translational control
  • "
    Superficial layer for valgus and eversion restraint
  • "
    Always suspect associated syndesmosis injury or fractures
  • "
    Surgery for fracture/syndesmosis fixation or chronic instability

Clinical Imaging

Imaging Gallery

The external rotation of the supinated foot stopped before medial injury occurred. The deltoid ligament becomes taut because the deep part of this ligament limits external rotation of the talus with t
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The external rotation of the supinated foot stopped before medial injury occurred. The deltoid ligament becomes taut because the deep part of this ligCredit: van den Bekerom MP et al. via Clin. Orthop. Relat. Res. via Open-i (NIH) (Open Access (CC BY))
Acute deltoid ligament injury. Patients usually present with ecchymosis, swelling, and tenderness along the medial part of the ankle joint. Weight bearing may be impossible due to pain and instability
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Acute deltoid ligament injury. Patients usually present with ecchymosis, swelling, and tenderness along the medial part of the ankle joint. Weight beaCredit: Lötscher P et al. via Eur J Trauma Emerg Surg via Open-i (NIH) (Open Access (CC BY))
SER-4 fracture: combination of a spiral fracture of the fibula and a deltoid ligament injury (a). After anatomical fracture reduction of the fibula, the medial clear space remains wide in the talar ti
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SER-4 fracture: combination of a spiral fracture of the fibula and a deltoid ligament injury (a). After anatomical fracture reduction of the fibula, tCredit: Lötscher P et al. via Eur J Trauma Emerg Surg via Open-i (NIH) (Open Access (CC BY))
X-ray of ankle joint anteroposterior view showing example of supination external rotation (SE4) injuries with fibular fracture and medial space widening indicating a deltoid ligament disruption and un
Click to expand
X-ray of ankle joint anteroposterior view showing example of supination external rotation (SE4) injuries with fibular fracture and medial space wideniCredit: Tejwani NC et al. via Indian J Orthop via Open-i (NIH) (Open Access (CC BY))

Exam Warning

High-Yield Mechanisms

Focus on PER vs PAB mechanics. Isolated deltoid injury is rare (3-5%)—always suspect associated syndesmosis injury or fractures.

Key Concepts

Master Medial Clear Space interpretation (greater than 4mm) and defend Surgical vs Conservative indications (fracture/instability vs isolated).

Anatomic Foundation

Deltoid Ligament Complex Structure

The deltoid ligament is a multifascicular triangular structure extending from the medial malleolus to the tarsal bones, providing primary medial ankle stability.

Superficial Deltoid Components

Tibionavicular ligament: Anterior colliculus to navicular tuberosity Tibiocalcaneal ligament (superficial): Anterior colliculus to sustentaculum tali Tibiospring ligament: Anterior colliculus to superomedial calcaneonavicular (spring) ligament Posterior superficial tibiotalar: Posterior colliculus to medial talus Collective function: Primary restraint to hindfoot valgus and eversion Width: Fan-shaped, broad insertion covering medial hindfoot Thickness: Thinner than deep layer (1-2mm average)

Deep Deltoid Components

Anterior tibiotalar ligament: Intercollicular groove to medial talus anterior Posterior tibiotalar ligament (deep): Posterior intercollicular region to medial talar tubercle Tibiocalcaneal ligament (deep): Intercollicular groove to calcaneal medial wall Collective function: Critical restraint to external rotation, prevents lateral talar translation Configuration: Thick cord-like bands (3-5mm thickness) Strongest component: Posterior tibiotalar (deep) with tensile strength 800-1200N Critical for stability: Deep layer injury indicates severe force and high risk associated injuries

Neurovascular Relationships

Posterior tibial neurovascular bundle: 1-1.5cm posterior to medial malleolus, deep to flexor retinaculum Medial plantar nerve branch: Emerges at sustentaculum level, innervates FHB Saphenous nerve: Anterior to deltoid, accompanies great saphenous vein Arterial supply: Medial malleolar branches from posterior tibial artery Venous drainage: Great saphenous vein system medially Surgical relevance: Structures at risk during surgical approaches to medial ankle

Biomechanical Function and Load Distribution

At a Glance

Deltoid ligament injuries are uncommon (3-5% of ankle sprains) because the deltoid complex is 2-3 times stronger than the ATFL (tensile strength 800-1200N). Injuries are graded I-III based on fiber disruption and typically occur with pronation-external rotation mechanisms, often associated with lateral malleolar fractures (SER-4) or syndesmotic disruption. The deltoid has superficial (resists hindfoot valgus/eversion) and deep (resists external rotation and lateral talar translation) components. Diagnosis requires clinical suspicion, positive external rotation stress test, and medial clear space over 4mm on weight-bearing radiographs. MRI is gold standard for soft tissue assessment. Isolated injuries are treated conservatively (4-6 weeks immobilisation, 70-80% success); surgical repair is reserved for injuries requiring fracture/syndesmosis fixation or chronic instability.

Mnemonic

Memory Hook:REVEL

The deltoid complex contributes 40-50% of total ankle stability with intact osseous anatomy, increasing to 70-80% when bony congruity compromised. Tensile strength of intact deltoid is 2-3 times greater than ATFL (deltoid 800-1200N vs ATFL 300-400N), explaining rarity of isolated injuries.

Load distribution varies with ankle position. In neutral position, deep posterior tibiotalar bears maximum load. In dorsiflexion, anterior tibiotalar and superficial components engage. In plantarflexion, posterior components maximally stressed. This position-dependent loading explains injury patterns based on mechanism.

Injury Classification and Mechanisms

Grading System

Deltoid ligament injuries are graded based on extent of fiber disruption and functional impairment, assessed clinically and with advanced imaging.

Deltoid Ligament Injury Grading Classification

featureclinicalFindingsimagingFindingsfunctionalImpacttreatmentprognosis
Grade 1 (Sprain/Strain)Mild medial ankle tenderness, minimal swelling, no instability on stress testingMRI: Ligament intact with surrounding edema, no fiber disruption. Radiographs normalAble to weight-bear with discomfort, normal ROM with pain at extremesConservative: protection 2-3 weeks, early ROMExcellent, 90% full recovery 4-6 weeks
Grade 2 (Partial Tear)Moderate-severe tenderness, ecchymosis, mild instability on external rotation stressMRI: Partial thickness tear with some fiber continuity. May show slight medial clear space widening (less than 4mm)Difficulty weight-bearing, painful ROM, subjective instabilityConservative: CAM boot immobilization 4-6 weeks, protected weight-bearingGood, 70-80% full recovery 8-12 weeks, 20% chronic symptoms
Grade 3 (Complete Rupture)Severe tenderness, extensive ecchymosis to hindfoot, positive instability tests, often associated injuriesMRI: Complete ligament discontinuity, fluid in ligament gap. Radiographs: medial clear space greater than 4mm, possible fractureUnable to weight-bear, gross instability on examination, significant functional limitationVariable: Conservative if isolated, surgical if associated syndesmosis/fractureFair-good, 60-70% recovery conservative, 80-85% with appropriate surgical treatment

Injury Mechanisms and Force Patterns

Pronation-External Rotation (PER): Most common mechanism for deltoid injury. Sequential failure pattern:

  1. Deltoid ligament rupture (medial structure fails first)
  2. Anterior syndesmosis disruption (AITFL tear)
  3. Posterior syndesmosis disruption or posterior malleolus fracture
  4. Fibula fracture at level of syndesmosis (Weber B or C)

This represents SER-4 pattern in Lauge-Hansen classification. Deltoid injury indicates high energy and mandates syndesmotic assessment.

Pronation-Abduction (PAB): Less common but classic fracture pattern:

  1. Deltoid rupture OR transverse medial malleolus fracture
  2. Lateral malleolus fracture (transverse or comminuted, at level of plafond)
  3. Usually syndesmosis intact

Medial malleolus fracture may occur instead of deltoid rupture depending on bone quality (osteoporotic bone fractures rather than ligament tears).

Direct Valgus Trauma: Rare isolated deltoid injury from pure valgus force without rotation. More common in sports with lateral impact (soccer, rugby). Usually partial tears of superficial layer, deep layer remains intact.

Clinical Evaluation

History Taking and Index of Suspicion

Mnemonic

Memory Hook:MEDIAL Pain

Specific mechanism questions help predict injury pattern and associated pathology. "Did your foot twist outward while ankle bent inward?" suggests PER mechanism with high syndesmotic injury risk. "Was there direct impact to outside of ankle?" suggests PAB pattern. Previous ankle injuries and pre-existing instability relevant for chronic presentations.

Physical Examination Sequence

Inspection: Observe swelling pattern (isolated medial vs circumferential suggesting syndesmotic injury), ecchymosis distribution (extensive hindfoot ecchymosis indicates grade 2-3 injury), and weight-bearing status. Compare hindfoot alignment to contralateral (valgus suggests chronic deltoid insufficiency or acute deformity).

Palpation Sequence:

  1. Medial malleolus tip and anterior border (fracture assessment)
  2. Deltoid course from anterior colliculus inferiorly (ligament disruption creates palpable gap)
  3. Sustentaculum tali and spring ligament (associated spring ligament injury)
  4. PTT course posterior to medial malleolus (concurrent PTT pathology)
  5. Syndesmosis anteriorly (squeeze test, palpation 2-3cm above ankle)

Stress Testing:

  • External rotation stress test: Patient seated, knee flexed 90 degrees. Stabilize tibia, apply external rotation force to foot. Compare degree of rotation and pain reproduction to contralateral. Positive if increased rotation and medial pain (indicates deltoid injury, possibly syndesmotic)
  • Eversion stress test: Apply eversion force to hindfoot with ankle neutral. Assess medial joint opening. Positive if visible or palpable medial clear space widening
  • Cotton test: Lateral translation of talus within mortise. Grasp heel, apply lateral force. Positive if excessive lateral shift compared to contralateral (indicates deltoid AND syndesmotic injury)
  • Squeeze test: Compress tibia and fibula at mid-calf. Positive if pain at syndesmosis level (associated syndesmotic injury)

Exam Pearl

Positive external rotation stress test with medial ankle pain indicates deltoid injury BUT does not differentiate isolated deltoid from combined deltoid-syndesmotic injury. Must assess syndesmosis specifically with squeeze test, external rotation radiograph, and/or MRI. Failure to identify syndesmotic component leads to inadequate treatment and poor outcomes.

Advanced Clinical Tests

Single heel raise test: Assesses PTT function and deltoid competency. Patient stands on affected leg, rises onto toes. Normal response shows hindfoot inversion and heel rise. Inability to perform or lack of hindfoot inversion suggests PTT dysfunction or severe deltoid insufficiency (chronic cases).

Kleiger test: External rotation stress with ankle dorsiflexed and tibia stabilized. Pain localization determines pathology - medial malleolus (deltoid), anterolateral ankle (syndesmosis), or both (combined injury).

Range of motion assessment: Measure dorsiflexion and plantarflexion, compare to contralateral. Reduced dorsiflexion may indicate syndesmotic injury or anterior impingement. Increased eversion suggests deltoid insufficiency.

Imaging Evaluation

Radiographic Assessment

Standard Radiographic Views

AP view: Assess medial clear space (normal less than 4mm, should equal superior clear space). Tibiofibular clear space (normal less than 6mm). Tibiofibular overlap (normal greater than 6mm on AP, greater than 1mm on mortise) Lateral view: Tibiofibular overlap (normal greater than 10mm). Assess for posterior malleolus fracture Mortise view: True AP of ankle joint. Best view for medial clear space assessment and syndesmotic measurements Weight-bearing requirement: Essential for accurate medial clear space measurement. Non-weight-bearing may miss subtle instability Comparison views: Contralateral ankle useful for borderline measurements

Stress Radiography

External rotation stress: Manual or mechanical external rotation of foot with ankle neutral. Assess for medial clear space widening (greater than 2mm difference from contralateral indicates deltoid injury) Gravity stress: Affected leg hangs off table with knee flexed, weight of leg creates stress. Less reproducible than mechanical devices Indications: Suspected deltoid injury with normal standard radiographs, equivocal clinical findings Limitations: Painful, requires patient cooperation, some centers lack mechanical devices Interpretation: Medial clear space widening greater than 4mm absolute or greater than 2mm compared to contralateral is pathologic

Advanced Imaging - MRI

Gold standard: Soft tissue characterization, injury grading, associated pathology identification Protocol: T1, T2, STIR sequences in all three planes. Coronal images best for deltoid assessment Grading on MRI: Grade 1 (intact with edema), Grade 2 (partial thickness tear), Grade 3 (complete disruption with gap) Associated injuries: Syndesmotic ligaments (AITFL, PITFL, IOL), spring ligament, PTT, osteochondral lesions, bone bruising patterns Chronic findings: Ligament thickening, scarring, fatty infiltration, attenuation Indications: Grade 2-3 clinical injury, syndesmotic injury suspected, chronic symptoms, pre-operative planning

Medial clear space greater than 4mm on weight-bearing radiographs indicates deltoid insufficiency UNTIL PROVEN OTHERWISE. This finding mandates assessment for syndesmotic injury (examine tibiofibular clear space, overlap measurements) and consideration of advanced imaging. Isolated deltoid injury rare - look for fractures and syndesmotic disruption.

Bone Bruising Patterns

MRI bone marrow edema patterns predict injury mechanism and associated soft tissue injuries. Kissing bone bruises on medial talus and medial malleolus indicate compression from valgus impact, supporting deltoid injury diagnosis. Anterolateral tibial bruising suggests syndesmotic component. Posterior malleolar bruising indicates posterior translation force and potential posterior malleolus fracture.

MRI and Arthroscopic Correlation

MRI and arthroscopic correlation of deltoid ligament tear
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MRI-arthroscopy correlation in a 21-year-old male with chronic ATFL and deltoid ligament tears. (A) Axial proton-weighted MRI showing torn ATFL (arrows). (B) Coronal MRI demonstrating ligamentous pathology. (C) Arthroscopic view from the medial gutter showing deltoid ligament tear (arrow) between medial malleolus (MM) and talus (Ta). This case demonstrates the value of arthroscopic confirmation of MRI findings for surgical planning.Credit: Chun KY et al., Korean J Radiol (PMC4559781) - CC BY
MRI and arthroscopic correlation of syndesmosis injury
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Syndesmosis injury correlation in a 27-year-old male. (A) Axial fat-suppressed T2 MRI showing ATFL and AITFL pathology (arrows). (B) Coronal MRI demonstrating syndesmotic widening (arrowhead). (C) Arthroscopic view of the syndesmosis showing widening between tibia (T) and fibula (F). Combined deltoid and syndesmotic injuries require comprehensive imaging assessment and often warrant surgical stabilization.Credit: Chun KY et al., Korean J Radiol (PMC4559781) - CC BY

Conservative Management

Treatment Protocol by Grade

Mild Deltoid Sprain Management

Grade 1 injuries represent ligament strain without macroscopic fiber disruption, managed successfully with brief protection and early mobilization.

Acute Phase (0-7 days):

  • PRICE protocol: Protection, Rest, Ice, Compression, Elevation
  • CAM boot or ankle brace for comfort, weight-bearing as tolerated
  • NSAIDs for pain management (ibuprofen 400-600mg TID or naproxen 500mg BID) if no contraindications
  • Compression stocking or wrap to control edema
  • Cryotherapy 20 minutes every 2-3 hours while awake

Recovery Phase (1-3 weeks):

  • Progressive weight-bearing to normal gait pattern
  • Active ROM exercises: Ankle alphabet, towel stretches, resistance band exercises
  • Begin gentle strengthening: Tibialis posterior activation, toe raises
  • Wean from boot/brace as symptoms improve
  • Return to normal shoe wear by week 2-3

Return to Activity (3-4 weeks):

  • Progressive loading: Walking to jogging progression
  • Sport-specific drills without cutting or pivoting
  • Proprioceptive training: Single leg balance, balance board
  • External ankle support (brace or tape) for high-risk activities
  • Full return to sports typically 4-6 weeks

Success rate: 90% complete resolution with conservative management. Chronic symptoms uncommon unless unrecognized associated injury present.

Partial Tear Management

Grade 2 injuries involve partial thickness ligament disruption requiring longer immobilization and structured rehabilitation to prevent progression to chronic instability.

Immobilization Phase (0-3 weeks):

  • CAM boot immobilization, non-weight-bearing first week, then progress to 50% weight-bearing week 2-3
  • Consider short leg cast if patient compliance questionable or significant pain
  • Cryotherapy and elevation to control swelling
  • Pain management with NSAIDs or acetaminophen
  • Weekly clinical assessment for improvement

Protected Mobilization (3-6 weeks):

  • Transition to weight-bearing as tolerated in CAM boot
  • Begin active ROM exercises (avoid forced eversion initially)
  • Isometric strengthening of ankle dorsiflexors and invertors
  • Pool therapy for unloaded range of motion
  • Continue until pain-free with daily activities

Strengthening Phase (6-12 weeks):

  • Progressive resistance exercises with theraband
  • Focus on tibialis posterior strengthening (critical for medial stability)
  • Proprioceptive training: Single leg stance, perturbation exercises, sport-specific balance
  • Transition to lace-up brace or ankle taping
  • Graduated return to impact activities

Return to Sport (10-14 weeks):

  • Criteria: Full strength, normal ROM, negative stress tests, functional hop testing passed
  • Progressive sport-specific training
  • External ankle support recommended for 6-12 months post-injury
  • Education regarding injury mechanism avoidance

Outcomes: 70-80% achieve full recovery and return to pre-injury activity level. 20-30% have persistent symptoms requiring extended therapy or occasional surgical consideration.

Complete Rupture Conservative Management

Complete deltoid rupture WITHOUT fracture or syndesmotic injury is rare. Conservative management remains first-line if truly isolated, but requires close monitoring.

Decision Making: Must confirm isolated injury through comprehensive imaging (MRI demonstrating isolated deltoid rupture, normal syndesmosis, no fracture). Weight-bearing radiographs showing medial clear space less than 4mm despite complete deltoid tear on MRI supports conservative approach.

Immobilization Protocol (0-6 weeks):

  • Short leg cast or CAM boot, strict non-weight-bearing first 2-3 weeks
  • Progress to partial weight-bearing (25-50%) weeks 3-4
  • Full weight-bearing in boot weeks 5-6
  • Cast preferable to boot for improved immobilization and patient compliance
  • Serial radiographs at weeks 2, 4, 6 to assess for delayed medial clear space widening

Rehabilitation Phase (6-12 weeks):

  • Structured physical therapy program emphasizing tibialis posterior strengthening
  • Progressive ROM exercises avoiding forced eversion
  • Proprioceptive training critical for restoring protective reflexes
  • Transition to hinged ankle brace or Arizona brace
  • Functional progression: Walking, elliptical, stationary bike, pool jogging

Extended Recovery (3-6 months):

  • Continued strengthening and proprioceptive work
  • Gradual return to cutting and pivoting activities
  • May require permanent external support for high-level athletics
  • Serial clinical examination assessing for instability development
  • MRI at 4-6 months if persistent symptoms to assess healing

Outcomes: Success rate 60-70% with conservative management. 30-40% develop chronic symptoms or instability requiring surgical intervention. Higher failure rates in athletes and heavy laborers.

Indications to convert to surgery: Progressive medial clear space widening on serial radiographs, development of clinical instability despite immobilization, persistent pain limiting function after 6 months, patient occupation/activity level incompatible with chronic instability.

Surgical Management

Acute Surgical Repair Indications

Surgery for acute deltoid injuries is typically performed as part of treatment for associated fractures or syndesmotic injuries rather than isolated ligament repair.

Mnemonic

Memory Hook:FLAIR

Surgical timing depends on injury pattern. Acute fractures with deltoid rupture require surgery within 7-10 days of injury before soft tissue swelling precludes safe approach. Syndesmotic injuries with deltoid rupture treated within first week for optimal reduction. Isolated deltoid ruptures (rare) can undergo delayed repair within first 4 weeks if conservative management failing.

Repair Techniques and Technical Considerations

Approach and Exposure: Curvilinear incision centered over medial malleolus, 6-8cm length. Identify and protect saphenous vein and nerve anteriorly. Create full-thickness flaps exposing medial malleolus and deltoid. Assess level of ligament disruption (tibial avulsion, midsubstance tear, or tarsal insertion avulsion).

Suture Anchor Repair (preferred modern technique):

  • Place suture anchors at anatomic origin on medial malleolus based on component injured
  • Anterior colliculus for superficial deltoid components
  • Intercollicular groove for deep deltoid components
  • Use 3.0-3.5mm anchors with high-strength suture (2-0 FiberWire or equivalent)
  • Pass sutures through ligament tissue, repair with ankle in neutral dorsiflexion and 5 degrees hindfoot inversion
  • Mattress or modified Mason-Allen configuration for optimal strength
  • Repair deep layer first (critical for stability), then superficial layer

Bone Tunnel Repair (alternative technique):

  • Drill 2.5-3.0mm tunnels through medial malleolus at anatomic origins
  • Pass heavy nonabsorbable suture through ligament tissue
  • Thread sutures through bone tunnels, tie over bony bridge on medial malleolus
  • More time-consuming than anchors but comparable outcomes

Augmentation Options:

  • Internal brace (suture tape) can augment repair in high-demand athletes
  • Placed from medial malleolus to sustentaculum/medial talus in anatomic deltoid orientation
  • Acts as temporary "internal splint" during healing
  • Limited evidence but biomechanically sound concept

Concurrent Procedures: Address associated injuries in same setting. Syndesmotic fixation performed first, then assess medial clear space before deltoid repair. Spring ligament repair if identified intraoperatively. Medial malleolus ORIF if fracture pattern present.

Chronic Reconstruction

Chronic deltoid insufficiency with poor tissue quality or failed previous treatment requires reconstruction rather than repair. See medial-ankle-instability topic for detailed reconstruction techniques using autograft or allograft to recreate anatomic ligament complex.

Outcomes and Prognosis

Natural History of Isolated Deltoid Injuries

2
Am J Sports Med (2016)
Clinical Implication: This evidence guides current practice.

Deltoid Repair in SER-4 Ankle Fractures

2
J Bone Joint Surg Am (2018)
Clinical Implication: This evidence guides current practice.

MRI Correlation with Clinical Outcomes

3
Foot Ankle Int (2017)
Clinical Implication: This evidence guides current practice.

Long-Term Outcomes Untreated Deltoid Injuries

4
Foot Ankle Surg (2015)
Clinical Implication: This evidence guides current practice.

Prognostic Factors

Favorable prognostic indicators: Isolated grade 1-2 injury, no associated syndesmotic injury, age less than 40 years, normal BMI, sedentary occupation, good rehabilitation compliance, superficial component injury only.

Unfavorable prognostic indicators: Grade 3 complete rupture, deep component injury, associated syndesmotic disruption, age greater than 50, BMI greater than 30, manual labor or competitive athletics, poor rehabilitation access/compliance, delayed diagnosis (greater than 4 weeks).

Return to activity timelines: Grade 1 injuries return to full activity 4-6 weeks. Grade 2 injuries 10-14 weeks. Grade 3 injuries treated conservatively 16-20 weeks. Grade 3 injuries requiring surgery 4-6 months. High-level athletics may require 6-9 months regardless of treatment for complete ruptures.

Complications and Sequelae

Acute Complications

Compartment syndrome: Rare but catastrophic. High-energy deltoid injuries with associated fractures have 2-5% incidence. Presents with pain out of proportion, pain with passive toe extension, tense swelling, paresthesias. Requires immediate fasciotomy of all four compartments. Prevention through careful monitoring and low threshold for compartment pressure measurement.

Vascular injury: Posterior tibial artery injury extremely rare with isolated deltoid injury but possible with high-energy trauma. Assess distal pulses, capillary refill, and Doppler signals. Urgent vascular surgery consultation if compromised perfusion.

Nerve injury: Tibial nerve or plantar branch injury presents with plantar foot numbness, toe flexion weakness. Usually from direct trauma rather than iatrogenic. Document neurovascular status pre-operatively for medicolegal protection.

Chronic Sequelae

Chronic medial ankle pain: Affects 20-30% of inadequately treated injuries. Differential includes deltoid scarring/fibrosis, spring ligament insufficiency, medial ankle impingement, PTT tendinopathy, subtalar arthritis. Requires thorough re-evaluation with MRI and targeted injections for diagnosis.

Medial ankle instability: Develops in 10-15% of grade 3 injuries treated conservatively. Presents with recurrent giving way, difficulty with uneven ground, activity limitation. Objective instability demonstrated on stress radiographs or examination. Treatment requires reconstruction (see medial-ankle-instability topic).

Post-traumatic arthritis: Long-term consequence affecting 15-25% at 10-year follow-up, higher with associated fractures (30-40%). Results from initial cartilage damage, chronic instability causing abnormal joint mechanics, or malreduction of associated fractures. Prevention requires anatomic fracture reduction, addressing instability, and optimizing initial treatment.

Valgus hindfoot deformity: Progressive deformity from untreated chronic deltoid insufficiency combined with spring ligament attenuation. Leads to stage 4 PTTD-type presentation. Prevention requires early identification and reconstruction of chronic instability before fixed deformity develops.

Missed syndesmotic injury is most common and consequential complication of deltoid injury management. Approximately 40-60% of deltoid injuries have associated syndesmotic disruption. Failure to identify and treat syndesmotic component leads to chronic pain, instability, and accelerated arthritis. Mandatory syndesmotic assessment with every deltoid injury using clinical examination, radiographic measurements, and low threshold for MRI.

Viva Scenarios

Viva Revision - Overview

Core Concepts

Deltoid ligament injuries involve damage to the primary medial stabilizer of the ankle joint.

Key Points:

  • Represent 3-5% of all ankle sprains
  • Deltoid is 2-3 times stronger than lateral ligaments (ATFL)
  • Isolated injuries are rare - suspect associated pathology
  • Most common mechanism: pronation-external rotation

Injury Spectrum

GradeDescriptionStability
Grade 1Strain/stretch, intact fibersStable
Grade 2Partial thickness tearMild instability
Grade 3Complete ruptureUnstable

Biomechanical Importance

Deltoid Complex Functions:

  • 40-50% total ankle stability with intact bone
  • Primary restraint to external rotation
  • Prevents lateral talar translation
  • Resists hindfoot valgus and eversion

Exam Viva Point

Isolated deltoid injury is rare - always assess syndesmosis:

  • 40-60% have associated syndesmotic injury
  • Pronation-external rotation = high syndesmotic risk
  • MCS widening mandates full workup

Anatomy

Deltoid Ligament Components

Superficial Layer:

  • Tibionavicular ligament
  • Tibiocalcaneal ligament (superficial)
  • Tibiospring ligament
  • Posterior superficial tibiotalar
  • Function: Resists valgus and eversion

Deep Layer:

  • Anterior tibiotalar ligament
  • Posterior tibiotalar ligament (strongest)
  • Tibiocalcaneal ligament (deep)
  • Function: Resists external rotation, lateral translation

Layer Comparison

FeatureSuperficialDeep
Thickness1-2 mm3-5 mm
Primary FunctionValgus/eversion restraintRotation/translation
Strongest ComponentTibiocalcanealPosterior tibiotalar

At-Risk Structures

Neurovascular Relations:

  • Posterior tibial artery: 1-1.5 cm posterior to medial malleolus
  • Tibial nerve: Deep to flexor retinaculum
  • Saphenous nerve/vein: Anterior to deltoid

Exam Viva Point

Deep posterior tibiotalar is the strongest component:

  • Tensile strength: 800-1200N
  • Deep injury = high-energy mechanism
  • Always assess for associated injuries

Viva Revision - Grading

Grading System

Three-Grade Classification:

Deltoid Injury Grades

GradePathologyMRI FindingPrognosis
Grade 1Strain, intact fibersEdema, no discontinuity90% recovery 4-6 weeks
Grade 2Partial tearPartial thickness tear70-80% recovery 8-12 weeks
Grade 3Complete ruptureFull discontinuity, gap60-70% conservative success

Advanced Classification

By Component Involved:

  • Superficial only: Better prognosis (89% success)
  • Deep component: Worse prognosis (72% success)
  • Combined: Worst prognosis

By Associated Injury:

  • Isolated deltoid: Rare, conservative management
  • With syndesmosis: Requires fixation
  • With fracture (SER-4): ORIF approach

Exam Viva Point

Deep component injury indicates:

  • High-energy mechanism
  • Higher risk of associated injuries
  • May require surgical intervention

Clinical Assessment

Examination Findings

Inspection:

  • Medial ankle swelling
  • Ecchymosis extending to hindfoot (Grade 2-3)
  • Hindfoot alignment (valgus suggests chronic)

Palpation:

  • Medial malleolus and anterior border
  • Deltoid course (palpable gap indicates complete tear)
  • Syndesmosis (anterolateral ankle)

Key Clinical Tests

TestTechniquePositive Finding
External rotation stressRotate foot externallyIncreased rotation + medial pain
Eversion stressEvert hindfootMedial joint opening
Squeeze testCompress mid-calfSyndesmotic pain

Special Tests

Cotton Test:

  • Lateral translation of talus
  • Positive: Combined deltoid + syndesmotic injury

Kleiger Test:

  • External rotation with ankle dorsiflexed
  • Pain location differentiates pathology

Exam Viva Point

Positive external rotation stress does NOT differentiate:

  • Isolated deltoid from deltoid + syndesmosis
  • Must specifically assess syndesmosis
  • Low threshold for MRI

Investigations

Imaging Approach

Radiographs (Essential):

  • Weight-bearing AP, lateral, mortise views
  • Medial clear space: Normal less than 4 mm
  • Tibiofibular measurements for syndesmosis

MRI (Gold Standard):

  • Defines injury grade
  • Assesses associated pathology
  • Guides surgical planning

Key Radiographic Measurements

MeasurementNormalPathological
Medial clear spaceLess than 4 mmGreater than 4 mm
Tibiofibular clear spaceLess than 6 mmGreater than 6 mm
Tibiofibular overlapGreater than 6 mm (AP)Less than 6 mm

Stress Radiographs

External Rotation Stress:

  • Pathological: Greater than 2 mm difference from contralateral
  • Or absolute MCS greater than 4 mm

MRI Features:

  • Grade 1: Intact with edema
  • Grade 2: Partial thickness tear
  • Grade 3: Complete discontinuity with gap
Five-panel MRI and arthroscopic correlation of deltoid ligament and syndesmosis injuries
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MRI and arthroscopic correlation in chronic ankle ligament injuries: (A) Axial fat-suppressed T2 MRI showing high signal in the superficial deltoid ligament region (arrow) indicating chronic injury. (B) Coronal MRI demonstrating deltoid ligament pathology (arrows). (C) Axial MRI showing associated AITFL injury (arrows). (D) Arthroscopic view from anteromedial portal showing medial malleolus (MM) and talus (Ta) with deltoid ligament between. (E) Arthroscopic view of syndesmosis showing tibia (T) and fibula (F) with AITFL disruption (arrows). MRI-arthroscopic correlation is essential for surgical planning.Credit: Chun KY et al., Korean J Radiol - CC BY 4.0

Exam Viva Point

MCS greater than 4 mm on weight-bearing radiographs:

  • Indicates deltoid insufficiency
  • Mandates syndesmosis assessment
  • Advanced imaging indicated

Decision Flowchart

📊 Management Algorithm
Deltoid Ligament Injuries Management Algorithm
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Treatment Approach

Conservative (Majority):

  • Grade 1: CAM boot 2-3 weeks, early ROM
  • Grade 2: CAM boot 4-6 weeks, structured PT
  • Grade 3 isolated: NWB cast 2-3 weeks, then progress

Surgical Indications:

  • Associated fracture requiring ORIF
  • Syndesmotic injury needing fixation
  • Persistent MCS greater than 4 mm after fixation
  • Chronic instability

Treatment by Grade

GradeTreatmentDuration
Grade 1Brace/boot, early ROM2-3 weeks protection
Grade 2CAM boot, structured PT4-6 weeks immobilization
Grade 3Cast/surgery as indicated6+ weeks, surgery if needed

Surgical Decision Making

When to Repair Deltoid:

  • MCS widening persists after lateral fixation
  • Deltoid interposition blocking reduction
  • Grossly unstable medial ankle

Key Principle:

  • Most ankle fractures: Anatomic fibular reduction restores medial stability
  • Direct deltoid repair rarely needed

Exam Viva Point

Deltoid repair in SER-4 fractures:

  • Usually NOT required
  • Fibular fixation typically restores stability
  • Repair only if MCS remains widened

Surgical Technique

Repair Principles

Approach:

  • Curvilinear incision over medial malleolus (6-8 cm)
  • Protect saphenous vein and nerve anteriorly
  • Full-thickness flaps to expose deltoid

Suture Anchor Technique:

  • 3.0-3.5 mm anchors at anatomic origin
  • Anterior colliculus: Superficial components
  • Intercollicular groove: Deep components
  • High-strength suture (2-0 FiberWire)

Repair Techniques

TechniqueMethodIndication
Suture anchorsAnchors at malleolusPreferred, modern
Bone tunnelsSuture through tunnelsAlternative
Internal braceSuture tape augmentationHigh-demand athletes

Technical Pearls

Position During Repair:

  • Ankle neutral dorsiflexion
  • 5 degrees hindfoot inversion
  • Repair deep layer first (critical for stability)

Concurrent Procedures:

  • Syndesmotic fixation first
  • Assess MCS before deltoid repair
  • Spring ligament if injured

Exam Viva Point

Order of repair:

  1. Syndesmotic fixation first
  2. Reassess medial clear space
  3. Deltoid repair only if MCS remains widened

Viva Revision - Potential Problems

Potential Problems

Acute:

  • Missed syndesmotic injury (most common)
  • Nerve injury (saphenous, tibial)
  • Wound complications

Chronic:

  • Persistent medial pain (20-30%)
  • Medial instability (10-15%)
  • Post-traumatic arthritis (15-25%)

Complication Overview

ComplicationIncidencePrevention
Missed syndesmosis40-60% of deltoid injuriesComplete assessment, MRI
Chronic pain20-30%Adequate treatment, PT
Instability10-15%Identify, treat appropriately

Long-Term Sequelae

Post-Traumatic Arthritis:

  • 15-25% at 10-year follow-up
  • Higher with associated fractures (30-40%)
  • Prevention: Anatomic reduction, address instability

Valgus Hindfoot:

  • Progressive deformity from chronic insufficiency
  • Combined with spring ligament attenuation
  • Prevention: Early reconstruction

Exam Viva Point

Missed syndesmotic injury is the most consequential complication:

  • Leads to chronic pain, instability
  • Accelerated arthritis
  • Mandatory syndesmotic assessment with every deltoid injury

Postoperative Care

Rehabilitation Protocol

Phase 1 (0-2 weeks):

  • Non-weight-bearing in splint/cast
  • Elevation, ice for swelling
  • Wound care

Phase 2 (2-6 weeks):

  • Progressive weight-bearing in CAM boot
  • Active ROM exercises
  • Avoid forced eversion

Progression Timeline

PhaseWeight-BearingActivity
0-2 weeksNon-weight-bearingSplint, wound care
2-6 weeksProgressive in bootROM exercises
6-12 weeksFull weight-bearingStrengthening, proprioception

Return to Activity

Phase 3 (6-12 weeks):

  • Full weight-bearing
  • Progressive resistance exercises
  • Proprioceptive training

Phase 4 (3-6 months):

  • Sport-specific training
  • External support for activities
  • Gradual return to cutting/pivoting

Exam Viva Point

Return to Sport Criteria:

  • Full strength (less than 10% deficit)
  • Normal ROM
  • Negative stress tests
  • Functional hop testing passed

Outcomes

Results by Grade

Conservative Outcomes:

  • Grade 1: 90% excellent recovery
  • Grade 2: 70-80% good-excellent
  • Grade 3: 60-70% conservative success

Surgical Outcomes:

  • SER-4 with deltoid repair: 80-85% good-excellent
  • Chronic reconstruction: 70-75%

Outcome Summary

Injury TypeTreatmentSuccess Rate
Grade 1Conservative90% excellent
Grade 2Conservative70-80% good-excellent
Grade 3 isolatedConservative60-70% success
With fractureORIF ± repair80-85% success

Prognostic Factors

Favorable:

  • Grade 1-2 injury
  • Superficial component only
  • Age less than 40, normal BMI
  • Good rehabilitation compliance

Unfavorable:

  • Grade 3, deep component
  • Associated syndesmosis injury
  • BMI greater than 30, manual labor
  • Delayed diagnosis (greater than 4 weeks)

Exam Viva Point

Deep component injury predicts worse outcomes:

  • 72% vs 89% success rate
  • Higher rates of chronic symptoms
  • May require surgical intervention

Evidence Base

Key Studies

Natural History (Hintermann 2016):

  • 114 patients with isolated deltoid injury
  • Grade 1-2: 82% good-excellent at 1 year
  • Grade 3: 63% conservative success

Deltoid Repair in SER-4 (Dabash 2018):

  • RCT: Syndesmotic fixation ± deltoid repair
  • No difference in AOFAS scores at 2 years
  • Faster weight-bearing with repair

Evidence Summary

StudyFindingImplication
Hintermann 2016Grade 3: 37% need surgeryRisk factors for failure
Dabash 2018Repair may speed recoveryNot mandatory in fractures
Massri-Pugin 2017Deep injury worse outcomeMRI has prognostic value

Critical Appraisal

MRI Prognostic Value (Massri-Pugin 2017):

  • MRI grade correlates with outcomes
  • Deep component injury: 72% vs 89% success

Long-Term Consequences (Savage-Elliott 2015):

  • Inadequate treatment: Higher chronic pain (44% vs 8%)
  • Higher arthritis rates (29% vs 9%)
  • AOFAS scores: 78 vs 94

Exam Viva Point

Evidence supports:

  • Conservative management for isolated injuries
  • Deltoid repair not mandatory in SER-4 fractures
  • Deep component injury indicates worse prognosis

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Acute Deltoid Injury with Equivocal Syndesmotic Injury

EXAMINER

"A 26-year-old recreational footballer presents to emergency department 2 hours after twisting injury. Mechanism was landing from jump with foot pronated and externally rotated. Examination shows medial ankle swelling, tenderness over deltoid and anterolateral ankle joint line. External rotation stress test is painful medially and anteriorly. Weight-bearing radiographs show medial clear space of 4.5mm. Tibiofibular clear space is 5.5mm (borderline). MRI not immediately available. How do you proceed?"

EXCEPTIONAL ANSWER
This case represents a diagnostic challenge with clear deltoid injury but equivocal syndesmotic involvement requiring systematic assessment. The mechanism (pronation-external rotation) is classic for combined injury. Clinical findings of tenderness at both medial ankle and anterolateral joint line, positive external rotation stress test, and borderline radiographic measurements all suggest possible combined pathology. The medial clear space widening to 4.5mm is pathologic and indicates at minimum grade 2-3 deltoid injury. Given it's after hours and MRI unavailable, I would admit patient for observation, elevate leg, apply posterior splint non-weight-bearing, and arrange urgent MRI within 24 hours. MRI will definitively characterize deltoid injury grade, assess syndesmotic ligaments (AITFL, PITFL, IOL), and identify any occult fractures or associated pathology. If MRI confirms isolated deltoid injury with intact syndesmosis, conservative management with CAM boot immobilization 6 weeks. If MRI shows syndesmotic disruption, requires surgical fixation of syndesmosis with intra-operative assessment of deltoid (may require repair if medial clear space remains wide after syndesmotic reduction). Key is not rushing to treatment decision with incomplete information given the potential for missed syndesmotic injury.
KEY POINTS TO SCORE
Mechanism and examination findings highly suspicious for combined deltoid-syndesmotic injury
Medial clear space 4.5mm is pathologic, indicating minimum grade 2-3 deltoid injury
Borderline tibiofibular measurements and anterolateral tenderness suggest syndesmotic component
MRI is gold standard for definitive characterization when clinical/radiographic findings equivocal
Temporary immobilization and observation while awaiting advanced imaging is appropriate
Treatment algorithm differs significantly for isolated deltoid vs combined injury
COMMON TRAPS
✗Discharging patient with ankle sprain diagnosis without investigation for syndesmotic injury
✗Proceeding with isolated deltoid injury treatment without definitively excluding syndesmosis
✗Rushing to surgery without adequate soft tissue characterization and surgical planning
✗Assuming normal tibiofibular measurements exclude syndesmotic injury (MRI more sensitive)
✗Not recognizing that pronation-external rotation mechanism has high syndesmotic injury rate
LIKELY FOLLOW-UPS
"Q: What if MRI shows grade 3 deltoid rupture but intact syndesmosis - would you operate? A: Controversial. If truly isolated on MRI with medial clear space less than 4mm and young patient willing to accept 3-month recovery, trial conservative management with CAM boot non-weight-bearing 6 weeks, then rehabilitation. Close follow-up with serial radiographs. Surgery if develops instability or persistent symptoms. However, elite athlete might consider early repair to optimize outcomes."
"Q: How do you measure medial clear space accurately? A: On mortise view weight-bearing radiograph, measure shortest distance between medial border of talus and medial malleolus at level of talar dome. Should be less than 4mm and equal to superior clear space. Compare to contralateral ankle if borderline. Must be weight-bearing or may miss dynamic instability."
"Q: What findings on MRI would make you convert to surgical management? A: Complete AITFL disruption, grade 3 deltoid with poor tissue quality (retracted, degenerated), medial clear space greater than 6mm suggesting complete medial instability, displaced posterior malleolus fracture greater than 25% of joint surface, extensive bone bruising suggesting high-energy injury with likely instability."
"Q: If you proceed with surgery, what is your fixation construct for the syndesmosis? A: Preference is anatomic reduction confirmed under fluoroscopy followed by suture button device (TightRope or equivalent). Allows physiologic tibiofibular motion during healing, doesn't require removal, lower malreduction rates than screws in some studies. Alternative is two 3.5mm screws engaging 3 cortices, placed parallel from fibula to tibia 2-3cm above joint. Remove at 12 weeks if symptomatic."
VIVA SCENARIOStandard

Chronic Deltoid Injury with Persistent Pain

EXAMINER

"A 42-year-old presents 18 months following ankle sprain initially treated conservatively with 4 weeks CAM boot. She has persistent medial ankle pain with walking and inability to return to running. Examination shows medial ankle tenderness, mild valgus hindfoot alignment, positive but not severe external rotation stress test. Weight-bearing radiographs show medial clear space of 4.8mm. MRI demonstrates chronic deltoid thickening with partial thickness tears of superficial components, intact deep components, and grade 2 spring ligament injury. Failed 6 months physical therapy. What is your management approach?"

EXCEPTIONAL ANSWER
This represents chronic medial ankle pain syndrome following inadequately healed deltoid injury with associated spring ligament pathology. The presentation is complex because she has borderline instability (medial clear space 4.8mm, mild positive stress testing) but not profound instability, making surgical decision-making nuanced. Initial step is confirming the deltoid and spring ligament as primary pain generators using diagnostic injections - medial ankle joint injection with local anesthetic and possibly ultrasound-guided deltoid/spring ligament injection. If injections provide temporary relief, confirms pathology source. Treatment options include continued conservative care with custom orthotic to support medial longitudinal arch, ankle bracing for activities, and consideration of PRP or orthobiologic injections to stimulate healing (limited evidence). If injections confirm pain source and conservative measures fail, surgical options are deltoid ligament debridement with spring ligament repair/reconstruction. However, must counsel that outcomes for chronic partial injuries are less predictable than acute complete ruptures (70% vs 85% success) and may require 6-9 months recovery. Alternative consideration is that MRI findings are incidental and pain from different source (medial ankle impingement, PTT tendinopathy, subtalar arthritis) - diagnostic workup should include careful examination for other pathology before attributing symptoms solely to deltoid.
KEY POINTS TO SCORE
Chronic partial deltoid injury with borderline instability presents treatment challenge
Associated spring ligament injury affects prognosis and may require concurrent treatment
Diagnostic injections help confirm deltoid/spring ligament as pain generators before surgery
Conservative measures include orthotics, bracing, and consideration of PRP injections
Surgical reconstruction for chronic partial tears has less predictable outcomes than acute repairs
Must exclude other causes of medial ankle pain before attributing to deltoid pathology
COMMON TRAPS
✗Rushing to surgical reconstruction without confirming deltoid as pain source via injections
✗Not recognizing that MRI findings of chronic deltoid changes may be incidental to pain
✗Failing to address associated spring ligament pathology if performing deltoid surgery
✗Underestimating recovery time and setting unrealistic expectations (6-9 months typical)
✗Not considering that mild valgus alignment may indicate early PTTD rather than isolated deltoid
✗Assuming physical therapy failure automatically indicates surgery - may need extended trial with orthotics
LIKELY FOLLOW-UPS
"Q: How do you perform diagnostic injection for deltoid ligament? A: Under ultrasound guidance, identify deltoid fibers between medial malleolus and talus/calcaneus. Inject 3-5mL of local anesthetic (lidocaine or bupivacaine) into and around ligament substance. Re-examine after 15 minutes for pain relief with stress testing. Greater than 75% relief confirms deltoid as pain source."
"Q: Describe your surgical technique for chronic deltoid debridement and repair. A: Medial approach exposing deltoid complex. Debride thickened, scarred, and degenerate tissue back to healthy-appearing tissue. If adequate tissue remains, perform repair using suture anchors at medial malleolus with pants-over-vest imbrication to tighten elongated ligament. If insufficient tissue quality, proceed to augmentation with graft (gracilis autograft or allograft) to reinforce repair. Address spring ligament with suture anchor repair or FHL augmentation if grade 2-3 injury."
"Q: What role do orthobiologics like PRP have in chronic deltoid injuries? A: Limited evidence for PRP in chronic ligament injuries. Some studies show modest benefit for partial thickness tears when combined with rehabilitation. Mechanism theoretically involves growth factor stimulation of healing response. Reasonable option before surgery in motivated patient willing to commit to extended rehab. Typically series of 2-3 injections monthly. Not covered by insurance, patient pays out-of-pocket."
"Q: If you operate and find both deltoid and spring ligament requiring reconstruction, how does this change outcomes? A: Combined deltoid-spring ligament reconstruction is more extensive with longer recovery and less predictable outcomes than isolated procedures. Success rates 70-75% vs 85% for isolated deltoid. Recovery extends to 6-9 months due to dual healing requirements and need to protect medial longitudinal arch. May require permanent orthotic support even after successful surgery."

Exam Day Cheat Sheet

MCQ Practice Points

Exam Pearl

Q: What are the components of the deltoid ligament and their primary functions?

A: The deltoid ligament has superficial and deep components. Superficial (4 bands): tibionavicular, tibiospring, tibiocalcaneal, posterior tibiotalar - resists eversion/abduction. Deep (2 bands): anterior tibiotalar, posterior tibiotalar (strongest) - primary restraint to external rotation and lateral talar shift. The deep deltoid is the key stabilizer; isolated superficial injury rarely causes instability.

Exam Pearl

Q: When is deltoid ligament repair indicated in ankle fracture surgery?

A: Deltoid repair is rarely indicated in most ankle fractures. Indications: Medial clear space widening persists (greater than 4mm or greater than superior clear space) after lateral malleolus fixation; Deltoid interposition blocking reduction (interposed tissue visible on stress views); Grossly unstable medial ankle despite lateral fixation. Most cases: Anatomic fibular reduction restores medial stability without direct deltoid repair.

Exam Pearl

Q: How do you assess deltoid ligament integrity intraoperatively?

A: Intraoperative assessment: (1) Medial clear space measurement on mortise fluoroscopy after fibular fixation - should be less than 4mm and equal to superior clear space; (2) External rotation stress test - widening indicates deep deltoid incompetence; (3) Direct visualization through medial incision if concern for interposed tissue. If medial clear space normalizes with fibular fixation, deltoid is functionally competent even if torn.

Exam Pearl

Q: What is the clinical significance of isolated deltoid ligament injury without fracture?

A: Isolated deltoid injury is rare and usually occurs with: High ankle sprain (syndesmotic injury pattern); Ankle dislocation without fracture. Treatment: Most heal with non-operative management (immobilization 4-6 weeks). Surgery considered for: Chronic medial instability with valgus tilting; Associated syndesmotic instability requiring fixation; Deltoid avulsion with bone fragment amenable to fixation. Chronic deltoid insufficiency can lead to progressive valgus deformity.

Exam Pearl

Q: How does deltoid ligament status affect the treatment of Weber B ankle fractures?

A: Weber B fractures are classified as stable (deltoid intact) or unstable (deltoid incompetent). Assessment: Gravity stress radiographs or external rotation stress views - medial clear space widening greater than 4mm indicates deltoid rupture. Stable Weber B (intact deltoid): Non-operative treatment in walking boot. Unstable Weber B (torn deltoid): Requires ORIF of fibula to restore ankle stability. The deltoid determines fracture stability, not just fracture pattern.

Australian Context

Practice in Australia

Clinical Considerations:

  • Conservative management first-line for isolated injuries

  • Surgical intervention for associated fractures/syndesmosis

  • Rehabilitation through physiotherapy with Medicare rebates

  • 49518: Ankle ligament repair

  • 49521: Ankle ligament reconstruction

  • 49130: Ankle fracture ORIF

Medicare Rebates

ProcedureMBS ItemSetting
Ligament repair49518Public/private
Reconstruction49521Tertiary referral
Ankle ORIF49130Emergency/elective

Exam Viva Point

Australian Practice:

  • Conservative management first (4-6 weeks CAM boot)
  • Physiotherapy referral via EPC Medicare item
  • Surgical referral for failed conservative or associated injuries
  • MRI accessible via specialist referral

High-Yield Exam Summary

Immediate Answer Opener

  • •Deltoid ligament injuries range from grade 1 sprains to complete ruptures, representing 3-5% of ankle sprains
  • •Deltoid is 2-3 times stronger than lateral ligaments, making isolated injury rare
  • •Most occur with pronation-external rotation mechanisms causing combined deltoid-syndesmotic injuries (SER-4 pattern)
  • •Grading: Grade 1 (strain), Grade 2 (partial tear), Grade 3 (complete rupture)
  • •Medial clear space greater than 4mm on weight-bearing radiographs indicates pathology
  • •Treatment predominantly conservative; surgery for associated fractures/syndesmosis or chronic instability

Anatomy Quick Reference

  • •Superficial deltoid: Tibionavicular, tibiocalcaneal, tibiospring ligaments from anterior colliculus
  • •Superficial component restrains valgus and eversion
  • •Deep deltoid: Anterior and posterior tibiotalar, tibiocalcaneal from intercollicular groove
  • •Deep component critical for rotational stability and prevents lateral talar translation
  • •Posterior deep tibiotalar is strongest component
  • •Deltoid 2-3x stronger than ATFL (800-1200N vs 300-400N tensile strength)
  • •Provides 40-50% of ankle stability with intact osseous anatomy

Grading and Injury Mechanisms

  • •Grade 1: Intact fibers with edema, mild tenderness, minimal swelling, conservative 2-3 weeks, 90% recovery
  • •Grade 2: Partial tear, moderate-severe tenderness and swelling, mild instability, CAM boot 4-6 weeks, 70-80% recovery
  • •Grade 3: Complete rupture, extensive ecchymosis, gross instability, often associated injuries
  • •Pronation-external rotation: SER-4 with syndesmosis injury (most common mechanism)
  • •Pronation-abduction: Associated medial malleolus fracture
  • •Direct valgus: Rare isolated deltoid injury

Clinical Examination Essentials

  • •External rotation stress test: Knee flexed 90°, externally rotate foot, positive if increased rotation and medial pain
  • •Squeeze test: Compress mid-calf, positive if ankle syndesmotic pain
  • •Cotton test: Lateral translation of talus, positive if excessive (combined deltoid-syndesmosis)
  • •Palpation: Medial malleolus, deltoid course, spring ligament, PTT
  • •Always compare stress testing to contralateral ankle for asymmetry

Imaging Interpretation

  • •Medial clear space: Normal less than 4mm, pathologic if greater than 4mm or asymmetric to superior clear space
  • •Tibiofibular clear space: Normal less than 6mm
  • •Tibiofibular overlap: Normal greater than 6mm on AP view
  • •MRI grading: Grade 1 intact with edema, Grade 2 partial tear, Grade 3 complete discontinuity
  • •MRI must assess syndesmosis (AITFL, PITFL, IOL), spring ligament, PTT, bone bruising
  • •Weight-bearing views essential for detecting dynamic instability

Conservative Management Protocol

  • •Grade 1: PRICE, CAM boot or brace WBAT, ROM exercises week 1-3, return to activity 4-6 weeks
  • •Grade 2: CAM boot NWB progressing to partial weeks 2-3, immobilization 4-6 weeks, structured PT, return to sport 10-14 weeks
  • •Grade 3 isolated: Controversial management, NWB cast 2-3 weeks, progressive WB 4-6 weeks, extended rehab 3-6 months
  • •Grade 3 conservative success rate: 60-70%
  • •Serial radiographs required to monitor for instability development

Surgical Indications and Techniques

  • •Indications: Associated fracture requiring ORIF, syndesmotic injury with persistent MCS greater than 4mm, chronic instability failed 6 months conservative, irreducible ankle
  • •Approach: Curvilinear medial incision protecting saphenous nerve
  • •Suture anchors at anatomic origins: Anterior colliculus for superficial, intercollicular groove for deep
  • •Position: Ankle neutral dorsiflexion, 5° hindfoot inversion during repair
  • •Consider internal brace augmentation in athletes
  • •Address spring ligament if injured

Complications and Outcomes

  • •Conservative outcomes: Grade 1 (90% excellent), Grade 2 (70-80% good-excellent), Grade 3 (60-70% success)
  • •Surgical repair in SER-4 fractures: 80-85% good-excellent outcomes
  • •Missed syndesmotic injury: Most common and consequential complication
  • •Chronic medial pain: 20-30%; Persistent instability: 10-15%
  • •Post-traumatic arthritis: 15-25% at 10 years (higher with fractures)
  • •Prognostic factors: Grade, associated injuries, age, BMI, occupation, rehab compliance, deep vs superficial injury
Quick Stats
Reading Time151 min
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