Ligament Injuries of the Ankle

  • Acute lateral ligament complex injuries

    Acute lateral ligament complex injuries : Ankle injuries are among the most common injuries to occur in civilian and sports domain.

    Twisting injuries of the ankle result in considerable morbidity in terms of loss from work and recreation.

    Correct diagnosis is very important to initiate proper management of these common injuries

    Serial casting with visible improvement

    Mechanism of a twisting ankle injury

    Correct technique for manipulation on foot

    Ligament complex around the ankle

    Injured patients often present with a lot of swelling and pain. Swelling is proportionate to the degree of ligament injury and duration of patient mobility with the injury.

    Investigations: x rays are done to rule out a fracture. In pure ligament injury, X rays are normal. An MRI will reveal the extent of an ankle ligament injury. To clinch the diagnosis, it is important to have an MRI at the earliest, when symptoms persist beyond 2-3 weeks.

    MRI shows a tear of ATF(anterior talo-fibular ligament) on the outside of the ankle ligament complex

    Treatment : The most important aspect of ankle ligament injury is reduction of swelling. It is important to avoid massage of the injured area, as it tends to increase swelling due to bleeding. Elevation, icing and compression is paramount to initiate early healing.

    Serial casting with visible improvement

    Elevation & Icing for Ligament Injuries

    Correct technique for manipulation on foot


    Majority of ankle ligament injuries are partial and tend to heal if given enough rest, elevation and icing. After edema subsides, an ankle brace is worn to reduce excessive movements. Use of anti-inflammatory medicines also reduces swelling and aid in rapid recovery. Rarely a patient may require POP cast application for excess pain.

    When pain does not subside despite the above outlined treatment, an MRI is warranted. MRI helps to identify partial or complete tears. Amongst the 3 ligaments that constitute the lateral ankle ligament complex, tears of the ATF are more common (CFL & PTF are the other two ligaments). Complete tears will require surgical ligament reconstruction. The torn ligament ends are sutured end to end alone or reinforced with a neighboring muscle called peroneus brevis.

    Serial casting with visible improvement

    Grades of Ligament Injuries

    Correct technique for manipulation on foot

    Repair of Ligament

    Chronic Ligamentous instability

    Chronic Ligamentous instability : Chronic ankle instability is a condition characterized by a recurring “giving way” of the outer (lateral) side of the ankle. This condition often develops after repeated ankle sprains. Usually the “giving way” occurs while walking on uneven surfaces or getting down stairs. It is a common problem in athletes. Other symptoms are discomfort and swelling around the ankle, or ankle joint feeling wobbly or unstable.

    Causes : Chronic ankle instability usually develops following an ankle sprain that has not adequately healed or was not rehabilitated completely. The ability to balance is affected after an injury. Proper rehabilitation is needed to strengthen the muscles around the ankle.

    Repeated ankle sprains result in chronic stretching of ligaments. Each subsequent sprain leads to further weakening (or stretching) of the ligaments, resulting in greater instability.

    Diagnosis : In evaluating and diagnosing the condition,The Podiatrist will ask about any previous ankle injuries and instability. A complete ankle examination for tears and stability is done. Stress X-rays and MRI may be helpful in diagnosing the condition.

    Serial casting with visible improvement

    Testing For Chronic Ligament Injuries

    Correct technique for manipulation on foot

    Testing for ankle stability

    Treatment : Treatment for chronic ankle instability is based on the results of the examination and tests, as well as on the patient’s level of activity. Non-surgical treatment may include

    a) Physical therapy : Physical therapy involves various treatments and exercises to strengthen the ankle, improve balance and range of motion, and retraining of muscles. Bracing: Bracing is prescribed for patients to give support to the ankle and keep the ankle from twisting

    b) Surgery : Based on the degree of instability or lack of response to non-surgical approaches, the Podiatrist will recommend surgery. The procedure might involve:

    ♦ Brostrom-Gould repair: Repairing the stretched ligament with sutures or bone anchors

    ♦ Brostrom-Evans repair: Reinforcing the ligament repair with a neighboring tendon, usually the peroneus brevis. The length of the recovery period will vary, depending on the procedure or procedures performed.

    Ligament injuries behind the ankle: Peroneal Tendons Injuries

    A tendon is a band of tissue that connects a muscle to a bone. The two peroneal tendons in the foot run side-by-side behind the outer ankle bone. The peroneus brevis tendon attaches to the outer part of the midfoot, while the peroneus longus runs under the foot and attaches near the inside of the arch. The main function of the peroneal tendons is to stabilize the foot and ankle and protect them from sprains.

    with a splint for night wear

    Peroneal tendons and their relationship to the outside of ankle

    Causes and Symptoms of Peroneal Tendon Injuries

    Peroneal tendon injuries may be 1) acute (occurring suddenly) or 2) Chronic (developing over a period of time). They are more common in individuals who participate in sports that involve repetitive ankle motion. In addition, people with higher arches are at risk for developing peroneal tendon injuries. Basic types of peroneal tendon injuries are tendonitis, tears, and subluxation.

    a) Tendonitis : is an inflammation of one or both tendons. The inflammation is caused by activities involving repetitive use of the tendon, overuse of the tendon, or trauma (such as an ankle sprain). Symptoms of tendonitis include pain, swelling and warmth to the touch.

    b) Acute tears : are caused by repetitive activity or trauma. Immediate symptoms of acute tears include: Pain, Swelling, weakness or instability of the foot and ankle. As time goes on, these tears may lead to a change in the shape of the foot, in which the arch may become higher.

    c) Degenerative tears (tendonosis) : are usually due to overuse and occur over long periods of time-often years. In degenerative tears, the tendon has been overstretched until it becomes thin and eventually frays. Having high arches also puts you at risk for developing a degenerative tear. The symptoms of degenerative tears may include: sporadic pain (occurring from time to time) on the outside of the ankle, weakness or instability in the ankle or an increase in the height of the arch.

    d) Subluxation : – Occurs when one or both tendons have slipped out of their normal position. In some cases, subluxation is due to a congenital shallow groove for the peroneal tendons on the posterior aspect of the fibula. In other cases, subluxation occurs following acute trauma, or repetitive trauma. Damage or injury to the tissues that stabilize the tendons (retinaculum) can lead to chronic tendon subluxation.

    Tendon subluxating or moving forward

    Early treatment of a subluxation is critical, since a tendon that continues to subluxate (move out of position) is more likely to tear or rupture. Therefore, if you feel the characteristic snapping, see a foot and ankle surgeon immediately

    Diagnosis : Because peroneal tendon injuries are sometimes misdiagnosed and may worsen without proper treatment, prompt evaluation by a Podiatrist is advised. Things to look for in a peroneal tendon injury are: pain, instability, swelling, warmth, and weakness on the outer side of the ankle. In addition, an x-ray or MRI studies may be needed to fully evaluate the injury. Proper diagnosis is important because chronicity can occur after a simple sprain leading to additional problems.

    with a splint for night wear

    MRI showing a stretched, attenuated peronei tendons

    Treatment :

    a) Non-Surgical Treatment : Treatment depends on the type of peroneal tendon injury. Options include

    Immobilization : A cast or splint may be used to keep the foot and ankle from moving and allow the injury to heal.

    Medications : Oral or injectable anti-inflammatory medicines may help relieve the pain and inflammation.

    Physiotherapy : Ice, heat, or ultrasound therapy may be used to reduce swelling and pain. As symptoms improve, exercises can be added to strengthen the muscles and improve range of motion and balance.

    Bracing : The surgeon may provide a brace to use for a short while or during activities requiring repetitive ankle motion. Bracing may also be an option when a patient is not a candidate for surgery

    b) Surgery : In some cases, Podiatric surgery may be needed to repair the tendon or tendons and perhaps the supporting structures of the foot. If the tendons are subluxating due to a shallow groove, a tubulization procedure is done. Also the peroneal retinaculum- the sheath carrying the tendons, will need to be repaired. The Podiatrist will determine the most appropriate procedure for the patient’s condition and lifestyle. After surgery, physical therapy is an important part of rehabilitation.