Eversion during external rotation of the human cadaver foot produces high ankle sprains

While high ankle sprains are often clinically ascribed to excessive external foot rotation, no experimental study documents isolated anterior tibiofibular ligament (ATiFL) injury under this loading. We hypothesized that external rotation of a highly everted foot would generate ATiFL injury, in contrast to deltoid ligament injury from external rotation of a neutral foot. Twelve (six pairs) male cadaveric lower extremity limbs underwent external foot rotation until gross failure. All limbs were positioned in 20° of dorsiflexion and restrained with elastic athletic tape. Right limbs were in neutral while left limbs were everted 20°. Talus motion relative to the tibia was measured using motion capture. Rotation at failure for everted limbs (46.8 ± 6.1°) was significantly greater than for neutral limbs (37.7 ± 5.4°). Everted limbs showed ATiFL injury only, while neutral limbs mostly demonstrated deltoid ligament failure. This is the first biomechanical study to produce isolated ATiFL injury under external foot rotation. Eversion of the axially loaded foot predisposes the ATiFL to injury, forming a basis for high ankle sprain. The study helps clarify a mechanism of high ankle sprain and may heighten clinical awareness of isolated ATiFL injury in cases of foot eversion prior to external rotation. It may also provide guidance to investigate the effect of prophylactic measures for this injury.