Skip to main content
Top
Published in: Knee Surgery, Sports Traumatology, Arthroscopy 6/2013

01-06-2013 | Ankle

The deltoid ligament: an in-depth review of anatomy, function, and treatment strategies

Authors: Ian Savage-Elliott, Christopher D. Murawski, Niall A. Smyth, Pau Golanó, John G. Kennedy

Published in: Knee Surgery, Sports Traumatology, Arthroscopy | Issue 6/2013

Login to get access

Abstract

Purpose

A literature review of the deltoid ligament was conducted, examining the current literature on anatomy, function, and treatment strategies. In particular, anatomical inconsistencies within the literature were evaluated, and detailed anatomical dissections are presented.

Methods

A literature search was conducted on PubMed using keywords relevant to the deltoid ligament in the ankle and medial ankle instability. Primary research articles, as well as appropriate summary articles, were selected for review.

Results

While it is well defined that the deltoid is contiguous and divided into one superficial and one deep portion, the creation of the individual fibres may be artificial. Furthermore, while improvements in imaging techniques and arthroscopy have not led to a consensus on the anatomy of the ligament, they may help improve recognition of deltoid injuries. Once identified, the majority of deltoid injuries can be treated via conservative treatment. However, reparative and reconstructive treatment strategies can also be used for complex acute injuries or chronic medial ankle instability.

Conclusion

Given the continuing evolution of the anatomical understanding of the ligament, the current treatment protocol for deltoid injuries requires further standardization, with an emphasis on proper diagnosis.
Literature
1.
go back to reference Barclay-Smith E (1896) The astragalo-calcaneo-navicular joint. J Anat Physiol 30:390–412 Barclay-Smith E (1896) The astragalo-calcaneo-navicular joint. J Anat Physiol 30:390–412
2.
go back to reference Baumhauer JF, Alosa DM, Renstrom AF et al (1995) A prospective study of ankle injury risk factors. Am J Sports Med 23(5):564–570PubMedCrossRef Baumhauer JF, Alosa DM, Renstrom AF et al (1995) A prospective study of ankle injury risk factors. Am J Sports Med 23(5):564–570PubMedCrossRef
3.
go back to reference Beals TC, Crim J, Nickisch F (2010) Deltoid ligament injuries in athletes: techniques of repair and reconstruction. Oper Tech Sports Med 18(1):11–17CrossRef Beals TC, Crim J, Nickisch F (2010) Deltoid ligament injuries in athletes: techniques of repair and reconstruction. Oper Tech Sports Med 18(1):11–17CrossRef
4.
go back to reference Bluman EM, de Asla RJ (2010) Deltoid ligament reconstruction. In: Wiesel SW, Easley ME (eds) Operative technique in foot and ankle surgery. Lippincott Williams & Wilkins, New York, pp 867–873 Bluman EM, de Asla RJ (2010) Deltoid ligament reconstruction. In: Wiesel SW, Easley ME (eds) Operative technique in foot and ankle surgery. Lippincott Williams & Wilkins, New York, pp 867–873
5.
go back to reference Boss AP, Hintermann B (2002) Anatomical study of the medial ankle ligament complex. Foot Ankle Int 23(6):547–553PubMed Boss AP, Hintermann B (2002) Anatomical study of the medial ankle ligament complex. Foot Ankle Int 23(6):547–553PubMed
6.
go back to reference Boyer MI, Bowen V, Weiler P (1994) Reconstruction of a severe grinding injury to the medial malleolus and the deltoid ligament of the ankle using a free plantaris tendon graft vascularized gracilis case report. J Trauma 36(3):454–457PubMedCrossRef Boyer MI, Bowen V, Weiler P (1994) Reconstruction of a severe grinding injury to the medial malleolus and the deltoid ligament of the ankle using a free plantaris tendon graft vascularized gracilis case report. J Trauma 36(3):454–457PubMedCrossRef
7.
go back to reference Cedell CA (1974) Rupture of the posterior talotibial ligament with the avulsion of a bone fragment from the talus. Acta Orthop Scand 45(3):454–461PubMed Cedell CA (1974) Rupture of the posterior talotibial ligament with the avulsion of a bone fragment from the talus. Acta Orthop Scand 45(3):454–461PubMed
8.
go back to reference De Souza LJ, Gustilo RB, Meyer TJ (1985) Results of operative treatment of displaced external rotation-abduction fractures of the ankle. J Bone Joint Surg Am 67(7):1066–1074PubMed De Souza LJ, Gustilo RB, Meyer TJ (1985) Results of operative treatment of displaced external rotation-abduction fractures of the ankle. J Bone Joint Surg Am 67(7):1066–1074PubMed
9.
go back to reference DeAngelis NA, Eskander MS, French BG (2007) Does medial tenderness predict deep deltoid ligament incompetence in supination-external rotation type ankle fractures? J Orthop Trauma 21(4):244–247PubMedCrossRef DeAngelis NA, Eskander MS, French BG (2007) Does medial tenderness predict deep deltoid ligament incompetence in supination-external rotation type ankle fractures? J Orthop Trauma 21(4):244–247PubMedCrossRef
10.
go back to reference Deland JT, de Asla RJ, Segal AR (2004) Reconstruction of the chronically failed deltoid ligament: a new technique. Foot Ankle Int 25(11):795–799PubMed Deland JT, de Asla RJ, Segal AR (2004) Reconstruction of the chronically failed deltoid ligament: a new technique. Foot Ankle Int 25(11):795–799PubMed
11.
go back to reference Ellis SJ, Williams BR, Wagshul AD, Pavlov H, Deland JT (2010) Deltoid ligament reconstruction with peroneus longus autograft in flatfoot deformity. Foot Ankle Int 31(9):781–788PubMedCrossRef Ellis SJ, Williams BR, Wagshul AD, Pavlov H, Deland JT (2010) Deltoid ligament reconstruction with peroneus longus autograft in flatfoot deformity. Foot Ankle Int 31(9):781–788PubMedCrossRef
12.
go back to reference Fairbank A, Myerson MS, Fortin P, Yu-Yahiro J (1995) The effect of calcaneal osteotomy on contact characteristics of the tibiotalar joint. Foot 5(3):137–142CrossRef Fairbank A, Myerson MS, Fortin P, Yu-Yahiro J (1995) The effect of calcaneal osteotomy on contact characteristics of the tibiotalar joint. Foot 5(3):137–142CrossRef
13.
go back to reference Federative committee on anatomical terminology (1998) Anatomical terminology. Thieme, Stuttgart Federative committee on anatomical terminology (1998) Anatomical terminology. Thieme, Stuttgart
14.
go back to reference Ferran NA, Oliva F, Maffulli N (2009) Ankle instability. Sports Med Arthrosc Rev 17(2):139–145CrossRef Ferran NA, Oliva F, Maffulli N (2009) Ankle instability. Sports Med Arthrosc Rev 17(2):139–145CrossRef
15.
go back to reference Gluck GS, Heckman DS, Selene PG (2010) Tendon disorders of the foot and ankle, part 3: the posterior tibial tendon. Am J Sports Med 38(10):2133–2144PubMedCrossRef Gluck GS, Heckman DS, Selene PG (2010) Tendon disorders of the foot and ankle, part 3: the posterior tibial tendon. Am J Sports Med 38(10):2133–2144PubMedCrossRef
16.
go back to reference Golanó P, Vega J, de Leeuw PAJ, Malagelada F, Manzanares MC, Götzens V, van Dijk CN (2010) Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc 18(5):557–569PubMedCrossRef Golanó P, Vega J, de Leeuw PAJ, Malagelada F, Manzanares MC, Götzens V, van Dijk CN (2010) Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc 18(5):557–569PubMedCrossRef
17.
go back to reference Harper MC (1988) The deltoid ligament: an evaluation of need for surgical repair. Clin Orthop Relat Res 226:156–168PubMed Harper MC (1988) The deltoid ligament: an evaluation of need for surgical repair. Clin Orthop Relat Res 226:156–168PubMed
18.
go back to reference Henari S, Banks LN, Radovanovic I, Queally J, Morris S (2011) Ultrasonography as a diagnostic tool in assessing deltoid ligament injury in supination external rotation fractures of the ankle. Orthopedics 34(10):639–643 Henari S, Banks LN, Radovanovic I, Queally J, Morris S (2011) Ultrasonography as a diagnostic tool in assessing deltoid ligament injury in supination external rotation fractures of the ankle. Orthopedics 34(10):639–643
19.
go back to reference Hintermann B (2003) Medial ankle instability. Foot Ankle Clin N Am 8(4):723–738CrossRef Hintermann B (2003) Medial ankle instability. Foot Ankle Clin N Am 8(4):723–738CrossRef
20.
go back to reference Hintermann B, Boss A, Shafer D (2002) Arthroscopic findings in patients with chronic ankle instability. Am J Sports Med 30(3):402–409PubMed Hintermann B, Boss A, Shafer D (2002) Arthroscopic findings in patients with chronic ankle instability. Am J Sports Med 30(3):402–409PubMed
21.
go back to reference Hintermann B, Regazzoni P, Lampert C, Stutz G, Gachter A (2000) Arthroscopic findings in acute fractures of the ankle. J Bone Joint Surg Br 82(3):345–351PubMedCrossRef Hintermann B, Regazzoni P, Lampert C, Stutz G, Gachter A (2000) Arthroscopic findings in acute fractures of the ankle. J Bone Joint Surg Br 82(3):345–351PubMedCrossRef
22.
go back to reference Hintermann B, Schäfer D (1996) Arthroscopic assessment of the chronic unstable ankle joint. Knee Surg Sports Traumatol Arthrosc 4(1):48–52PubMedCrossRef Hintermann B, Schäfer D (1996) Arthroscopic assessment of the chronic unstable ankle joint. Knee Surg Sports Traumatol Arthrosc 4(1):48–52PubMedCrossRef
23.
go back to reference Hintermann B, Valderrabano V (2010) Medial ankle/deltoid ligament reconstruction. In: Easley ME, Wiesel SW (eds) Operative technique of the foot and ankle. Lippincott Williams & Wilkins, Philadelphia, pp 874–886 Hintermann B, Valderrabano V (2010) Medial ankle/deltoid ligament reconstruction. In: Easley ME, Wiesel SW (eds) Operative technique of the foot and ankle. Lippincott Williams & Wilkins, Philadelphia, pp 874–886
24.
go back to reference Hintermann B, Valderrabano V, Boss A, Trouillier HH, Dick W (2004) Medial ankle instability: an exploratory, prospective study of fifty-two cases. Am J Sports Med 32(1):183–190PubMedCrossRef Hintermann B, Valderrabano V, Boss A, Trouillier HH, Dick W (2004) Medial ankle instability: an exploratory, prospective study of fifty-two cases. Am J Sports Med 32(1):183–190PubMedCrossRef
25.
go back to reference Hintermann B, Valderrabano V, Kundert H (1999) Lengthening of the lateral column and reconstruction of the medial soft tissue for treatment of acquired flatfoot deformity associated with insufficiency of the posterior tibial tendon. Foot Ankle Int 20(10):622–629PubMedCrossRef Hintermann B, Valderrabano V, Kundert H (1999) Lengthening of the lateral column and reconstruction of the medial soft tissue for treatment of acquired flatfoot deformity associated with insufficiency of the posterior tibial tendon. Foot Ankle Int 20(10):622–629PubMedCrossRef
26.
go back to reference Jelinek JA, Porter DA (2009) Management of unstable ankle fractures and syndesmosis injuries in athletes. Foot Ankle Clin 14(2):277–298PubMedCrossRef Jelinek JA, Porter DA (2009) Management of unstable ankle fractures and syndesmosis injuries in athletes. Foot Ankle Clin 14(2):277–298PubMedCrossRef
27.
go back to reference Jeng C, Bluman E, Myerson M (2011) Minimally invasive deltoid ligament reconstruction for stage IV flatfoot deformity. Foot Ankle Int 32(1):21–30PubMedCrossRef Jeng C, Bluman E, Myerson M (2011) Minimally invasive deltoid ligament reconstruction for stage IV flatfoot deformity. Foot Ankle Int 32(1):21–30PubMedCrossRef
28.
go back to reference Johnson DP, Hill J (1988) Fracture-dislocation of the ankle with rupture of the deltoid ligament. Injury 19(2):59–61PubMedCrossRef Johnson DP, Hill J (1988) Fracture-dislocation of the ankle with rupture of the deltoid ligament. Injury 19(2):59–61PubMedCrossRef
29.
go back to reference Khoury NJ, el-Khoury GY, Saltzman CL, Brandser EA (1996) MR imaging of posterior tibial tendon dysfunction. AJR Am J Roentgenol 167(3):675–682PubMedCrossRef Khoury NJ, el-Khoury GY, Saltzman CL, Brandser EA (1996) MR imaging of posterior tibial tendon dysfunction. AJR Am J Roentgenol 167(3):675–682PubMedCrossRef
30.
go back to reference Koval KJ, Egol K, Cheung Y, Goodwin DW, Spratt KF (2007) Does a positive ankle stress test indicate the need for operative treatment after lateral malleolus fracture? A preliminary report. J Orthop Trauma 21(7):449–455PubMedCrossRef Koval KJ, Egol K, Cheung Y, Goodwin DW, Spratt KF (2007) Does a positive ankle stress test indicate the need for operative treatment after lateral malleolus fracture? A preliminary report. J Orthop Trauma 21(7):449–455PubMedCrossRef
31.
go back to reference Leith JM, McConkey JP, Li D, Masri B (1997) Valgus stress radiography in normal ankles. Foot Ankle Int 18(10):654–657PubMedCrossRef Leith JM, McConkey JP, Li D, Masri B (1997) Valgus stress radiography in normal ankles. Foot Ankle Int 18(10):654–657PubMedCrossRef
32.
go back to reference McConkey JP, Lloyd-Smith R, Li D (1991) Complete rupture of the deltoid ligament. Clin J Sports Med 1(2):133–137CrossRef McConkey JP, Lloyd-Smith R, Li D (1991) Complete rupture of the deltoid ligament. Clin J Sports Med 1(2):133–137CrossRef
33.
go back to reference McConnell T, Creevy W, Tornetta P 3rd (2004) Stress examination of supination external rotation-type fibular fractures. J Bone Joint Surg 86A(10):2171–2178 McConnell T, Creevy W, Tornetta P 3rd (2004) Stress examination of supination external rotation-type fibular fractures. J Bone Joint Surg 86A(10):2171–2178
34.
go back to reference Michelson JD, Waldman B (1996) An axially loaded model of the ankle after pronation external rotation injury. Clin Orthop Relat Res 328:285–293PubMedCrossRef Michelson JD, Waldman B (1996) An axially loaded model of the ankle after pronation external rotation injury. Clin Orthop Relat Res 328:285–293PubMedCrossRef
35.
go back to reference Michelson JD, Hamel AJ, Buczek FL, Sharkey NA (2004) The effect of ankle injury on subtalar motion. Foot Ankle Int 25(9):639–646PubMed Michelson JD, Hamel AJ, Buczek FL, Sharkey NA (2004) The effect of ankle injury on subtalar motion. Foot Ankle Int 25(9):639–646PubMed
36.
go back to reference Milner CE, Soames RW (1998) Anatomy of the collateral ligaments of the human ankle joint. Foot Ankle 19(11):757–760PubMedCrossRef Milner CE, Soames RW (1998) Anatomy of the collateral ligaments of the human ankle joint. Foot Ankle 19(11):757–760PubMedCrossRef
37.
go back to reference Morvan G, Busson J, Wybier M, Mathieu P (2001) Ultrasound of the ankle. Eur J Ultrasound 14(1):73–82PubMedCrossRef Morvan G, Busson J, Wybier M, Mathieu P (2001) Ultrasound of the ankle. Eur J Ultrasound 14(1):73–82PubMedCrossRef
38.
go back to reference Mosier-La Clair SM, Monroe MT, Manoli A (2010) Medial impingement syndrome of the anterior tibiotalar fascicle of the deltoid ligament on the talus. Foot Ankle Int 21(5):385–391 Mosier-La Clair SM, Monroe MT, Manoli A (2010) Medial impingement syndrome of the anterior tibiotalar fascicle of the deltoid ligament on the talus. Foot Ankle Int 21(5):385–391
39.
go back to reference Muhle C, Frank L, Rand T et al (1999) Collateral ligaments of the ankle: high resolution MR Imaging with a local gradient coil and anatomic correlation in cadavers. Radiographics 19(3):673–683PubMed Muhle C, Frank L, Rand T et al (1999) Collateral ligaments of the ankle: high resolution MR Imaging with a local gradient coil and anatomic correlation in cadavers. Radiographics 19(3):673–683PubMed
40.
go back to reference Murawski CD, Kennedy JK (2010) Anteromedial impingement in the ankle joint: outcomes following arthroscopy. Am J Sports Med 38(10):2017–2024PubMedCrossRef Murawski CD, Kennedy JK (2010) Anteromedial impingement in the ankle joint: outcomes following arthroscopy. Am J Sports Med 38(10):2017–2024PubMedCrossRef
41.
go back to reference O’Loughlin P, Murawski CD, Egan C, Kennedy JG (2009) Ankle instability in sports. Phys Sportsmed 37(2):1–12 O’Loughlin P, Murawski CD, Egan C, Kennedy JG (2009) Ankle instability in sports. Phys Sportsmed 37(2):1–12
42.
go back to reference Pai VS (1999) Medial malleolar fracture associated with deltoid ligament rupture. J Foot Ankle Surg 38(6):420–422PubMedCrossRef Pai VS (1999) Medial malleolar fracture associated with deltoid ligament rupture. J Foot Ankle Surg 38(6):420–422PubMedCrossRef
43.
go back to reference Pankovich AM, Shivaram MS (1979) Anatomical basis of variability in injuries of the medial malleolus and the deltoid ligament I. Anatomical studies. Acta Orthop Scand 50(2):217–223PubMedCrossRef Pankovich AM, Shivaram MS (1979) Anatomical basis of variability in injuries of the medial malleolus and the deltoid ligament I. Anatomical studies. Acta Orthop Scand 50(2):217–223PubMedCrossRef
44.
go back to reference Park SS, Kubiak EN, Egol KA, Kummer F, Koval KJ (2006) Stress radiographs after ankle fracture: the effect of ankle position and deltoid ligament status on medial clear space measurements. J Orthop Trauma 20(1):11–18PubMedCrossRef Park SS, Kubiak EN, Egol KA, Kummer F, Koval KJ (2006) Stress radiographs after ankle fracture: the effect of ankle position and deltoid ligament status on medial clear space measurements. J Orthop Trauma 20(1):11–18PubMedCrossRef
45.
go back to reference Peetrons P, Creteur V, Bacq C (2004) Sonography of ankle ligaments. J Clin 32(9):491–499 Peetrons P, Creteur V, Bacq C (2004) Sonography of ankle ligaments. J Clin 32(9):491–499
46.
go back to reference Porter DA, Schon LC (2007) Baxter’s the foot and ankle in sport. Mosby-Elsevier, Philadelphia, p 656 Porter DA, Schon LC (2007) Baxter’s the foot and ankle in sport. Mosby-Elsevier, Philadelphia, p 656
47.
go back to reference Rasmussen O (1985) Stability of the ankle joint: analysis of the function and traumatology of the ankle ligaments. Acta Orthop Scand 56(Suppl):1–75 Rasmussen O (1985) Stability of the ankle joint: analysis of the function and traumatology of the ankle ligaments. Acta Orthop Scand 56(Suppl):1–75
48.
go back to reference Reimer J, Stitik TP, Foye PM (2007) Poster 123: patrolman’s ankle: determining a physiatric approach to deltoid ligament injury: a case report. Arch Phys Med Rehabil 88(9):E44 Reimer J, Stitik TP, Foye PM (2007) Poster 123: patrolman’s ankle: determining a physiatric approach to deltoid ligament injury: a case report. Arch Phys Med Rehabil 88(9):E44
49.
go back to reference Richardson DR (2007) Ankle injuries. In: Canale ST, Beaty JH (eds) Campbell’s operative orthopaedics, 11th edn. Mosby Elsevier, Philadelphia, pp 2353–2389 Richardson DR (2007) Ankle injuries. In: Canale ST, Beaty JH (eds) Campbell’s operative orthopaedics, 11th edn. Mosby Elsevier, Philadelphia, pp 2353–2389
50.
go back to reference Schuberth JM, Collman DR, Rush SM, Ford LA (2004) Deltoid ligament integrity in lateral malleolar fractures: a comparative analysis of arthroscopic and radiographic assessments. J Foot Ankle Surg 43(1):20–29PubMedCrossRef Schuberth JM, Collman DR, Rush SM, Ford LA (2004) Deltoid ligament integrity in lateral malleolar fractures: a comparative analysis of arthroscopic and radiographic assessments. J Foot Ankle Surg 43(1):20–29PubMedCrossRef
51.
go back to reference Sproule JA, Khalid M, O’Sullivan M, McCabe JP (2004) Outcome after surgery for Maissonneuve fracture of the fibula. Injury 35(8):791–798PubMedCrossRef Sproule JA, Khalid M, O’Sullivan M, McCabe JP (2004) Outcome after surgery for Maissonneuve fracture of the fibula. Injury 35(8):791–798PubMedCrossRef
52.
go back to reference Stromsoe K, Hoqevold HE, Skjeldal S, Alho A (1995) The repair of a ruptured deltoid ligament is not necessary in ankle fractures. J Bone Joint Surg Br 77-B:920–921 Stromsoe K, Hoqevold HE, Skjeldal S, Alho A (1995) The repair of a ruptured deltoid ligament is not necessary in ankle fractures. J Bone Joint Surg Br 77-B:920–921
53.
go back to reference Van den Bekerom MP, Mutsaerts EL, Van Dijk CN (2009) Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures: a systematic review of the literature. Arch Orthop Trauma Surg 129(2):227–235PubMedCrossRef Van den Bekerom MP, Mutsaerts EL, Van Dijk CN (2009) Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures: a systematic review of the literature. Arch Orthop Trauma Surg 129(2):227–235PubMedCrossRef
54.
go back to reference Waterman BR, Belmont PJ Jr, Cameron KL, Svoboda SJ, Alitz CJ, Owens BD (2011) Risk factors for syndesmotic and medial ankle sprain: role of sex, sport, and level of competition. Am J Sports Med 39(5):992–998PubMedCrossRef Waterman BR, Belmont PJ Jr, Cameron KL, Svoboda SJ, Alitz CJ, Owens BD (2011) Risk factors for syndesmotic and medial ankle sprain: role of sex, sport, and level of competition. Am J Sports Med 39(5):992–998PubMedCrossRef
55.
go back to reference Wiltberger BR, Mallory TM (1972) A new method for the reconstruction of the deltoid ligament of the ankle. Orthop Rev 1:37–42 Wiltberger BR, Mallory TM (1972) A new method for the reconstruction of the deltoid ligament of the ankle. Orthop Rev 1:37–42
56.
go back to reference Yufit P, Seligson D (2010) Malleolar ankle fractures: a guide to evaluation and treatment. Orthop Trauma 24(4):286–297CrossRef Yufit P, Seligson D (2010) Malleolar ankle fractures: a guide to evaluation and treatment. Orthop Trauma 24(4):286–297CrossRef
57.
go back to reference Zeegers AV, van der Werken C (1989) Rupture of the deltoid ligament in ankle fractures: should it be repaired? Injury 20(1):39–41PubMedCrossRef Zeegers AV, van der Werken C (1989) Rupture of the deltoid ligament in ankle fractures: should it be repaired? Injury 20(1):39–41PubMedCrossRef
Metadata
Title
The deltoid ligament: an in-depth review of anatomy, function, and treatment strategies
Authors
Ian Savage-Elliott
Christopher D. Murawski
Niall A. Smyth
Pau Golanó
John G. Kennedy
Publication date
01-06-2013
Publisher
Springer-Verlag
Published in
Knee Surgery, Sports Traumatology, Arthroscopy / Issue 6/2013
Print ISSN: 0942-2056
Electronic ISSN: 1433-7347
DOI
https://doi.org/10.1007/s00167-012-2159-3

Other articles of this Issue 6/2013

Knee Surgery, Sports Traumatology, Arthroscopy 6/2013 Go to the issue