Ligament Damage Of The Ankle

Structure of the ankle joint

The ankle joint is a synovial joint, meaning that it has cartilage at the end as well as the presence of synovial fluid to lubricate the joint. 

It is a hinge joint which allows dorsiflexion (raising the toes upwards towards the shin) and plantarflexion (moving the toes downwards in a pointing toes motion) of the foot. 

Dorsalextension und Plantarflexion.PNG

The ankle consists of three bones: the tibia, the fibula and the talus. The calcaneus is a bone in the foot that sits underneath the talus but isn’t considered part of the ankle joint.  

The bony ball that sticks out on each side of the ankle is known as a malleolus. 

Lateral collateral ligament of ankle joint.png

The bones

The tibia and fibula are bones of the leg and are bound together by strong ligaments; they form a bracket-shaped socket, known as a mortise. The talus is the foot bone in the ankle and fits into the mortise with its wedge shape on one side. The wedge shape is wider on the front side and is narrower on the back side. Your ankle changes its stability by the position it is in:

The ligaments

There are two main sets of ligaments within the ankle joint, each set originating from one of the malleoli in the ankle.

The medial ligament (also called the deltoid ligament) is attached to the medial malleolus (the bone on the inner side of the ankle). It is made up of four ligaments which attach to the talus, calcaneus and navicular bones (a small bone in the foot). The role of these ligaments is to prevent over-eversion of the foot - where the foot goes inward or downward, causing the loss of the arch in the base of the foot (causing flat feet). 

Éversion du pied.jpg

The lateral ligament is attached to the lateral malleolus (the bone on the outer side of the ankle). This ligament is made up of three distinct ligaments: the anterior talofibular, posterior talofibular and calcaneofibular. These ligaments are there to try and prevent the over-inversion of the foot, in which the foot goes outwards and leans more on the sole. 

Ankle Inversion.jpg

Ankle sprain

Sprain vs strain

​​A strained ankle is caused by the overstretching or tearing of muscles and tendons. Its symptoms can include pain, inflammation, swelling, redness, muscle cramps or weakness, and loss of motion. 

In comparison, a sprained ankle is when ligaments are overstretched or torn. Its symptoms are similar to those of a strained ankle, with the addition of bruising, which is a major difference. The bruising occurs due to damage to blood vessels alongside the ligament tears. 

Ankle sprains are among the most common type of injuries, especially in those that are physically active.¹

Ligament rupture of the ankle

Signs and symptoms

The symptoms are dependent on the severity of the sprain. The most common signs and symptoms of a sprain include:

• Pain in the area, especially when you put your weight on the injured ankle
• The ankle feels tender to touch
• Swelling
• Bruising 
• Reduced range of motion in the ankle (may also experience pain when moving in certain directions)
• Ankle instability
• A popping sound at the time of injury or popping sensation afterwards⁴

Grades of rupture/tear

Ankle sprains can be graded depending on their severity. There are three grades that they may be categorised into:²

• Grade 1: stretched or slightly torn ligament. The ankle feels stable and the individual is usually able to walk on it without much pain. The ankle is likely to have mild tenderness, swelling and stiffness
• Grade 2: the sprain is more severe but the ligament isn’t completely torn. The ankle feels stable to some extent but walking is painful and the ankle is tender to touch. Pain is likely to be moderate with some swelling and bruising
• Grade 3: the ligament is completely torn and there is significant swelling and bruising. The ankle is unstable and the individual is unable to walk on it. The pain can be intense

Causes and risk factors

​​Ankle sprains are caused by the ankle being forced out of its normal position causing the ligaments to stretch, potentially going on to tear partially or even completely. 

Potential causes of this occurring include:

• A trip or fall in which the ankle twists
• Landing on your foot in an awkward position after a jump or pivot
• Walking or exercising on uneven terrain
• Another individual stepping or landing on your foot during sports

The risk factors that increase the chances of spraining your ankle include:

• Sports participation. They commonly occur in sports with jumping, rolling or twisting the foot
• Uneven surfaces
• Previous ankle injury
• Poor strength or flexibility of the ankles
• Shoes that don’t fit correctly or don’t offer the correct sport for the activity. (High heel shoes, in general, increase the risk of an ankle injury) 

Diagnosis

Diagnosis involves a medical professional conducting a physical exam on the ankle. This will look at the range of motion, points of tenderness and which positions cause pain or discomfort. 

If the injury is severe, a doctor may order photos of the ankle to be taken to rule out a bone fracture or to see the extent of ligament damage. The photos are taken using imaging techniques such as:

• X-ray
• MRI (magnetic resonance imaging)
• CT scan
• Ultrasound

Rehabilitation and treatment options

The treatment for sprained ankles is dependent on the severity of the injury. For most cases, all that’s required is self-care.

You shouldn’t resume exercise to your previous levels of activity until fully recovered, but gentle exercises are encouraged to improve movement in the ankle. As the ankle becomes easier to move, and pain levels decrease, stretches to strengthen the ankle can be introduced.³ 

Self care

For a mild injury, the acronym PRICE can be used as initial treatment for the first couple of days:

• P - Protection: prevent further injury by protecting the sprain, potentially with the use of ankle supports
• R - Rest: avoid putting extra weight on the ankle by avoiding exercise and reducing daily activities to a short time period
• I - Ice: use an ice pack on the ankle for 15-20 minutes every two to three hours. If you don’t have an ice pack, a bag of frozen peas or something similar works well. Remember not to apply an ice pack directly to the skin - wrap it in a towel to avoid an ice burn
• C - Compression: Use compression bandages during the day to limit the swelling
• E - Elevation: raise the ankle above heart level whenever possible

Over-the-counter pain medications such as paracetamol are good for relieving the pain. Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may also ease the pain as well as reduce inflammation.³ 

Physiotherapy

If symptoms persist for a long period, it is worth consulting a physiotherapist. Following assessment, a physiotherapist will provide specialist treatment involving exercise and massage used to strengthen the ankle muscles and improve ankle balance. An ankle brace or foot insoles may be ‘prescribed’ to support the symptoms. 

Operative treatments

Surgery is a more extreme treatment option for cases in which non-operative treatments have not helped the symptoms or chronic ankle injuries where there is a lot of weakness and instability or a lot of pain that hasn’t got any better with a physiotherapist. This is because the ligament damage may then begin to cause damage to surrounding joints or tendons. 

There are two potential types of surgeries for lateral ligament damage: 

• Tightening up and re-attaching the ligaments
• Using nearby tendons to replace the ligaments 

These options are dependent on many factors and like almost all surgical procedures, have a more lengthy recovery time. They tend to be done under general anaesthesia with hospital discharge within 24 hours.⁴ 

Complications

​​Complications of improper treatment

Failure to treat a sprain correctly or not giving the injury plenty of time before engaging in physical activity as well as repeated sprains, can lead to further complications such as:³

• Chronic ankle pain
• Chronic ankle joint instability
• Arthritis in the ankle joint

Surgical complications

Like all surgical procedures, there are a host of potential complications that may arise despite care being taken to reduce the chances. These complications include:³

• Long-term pain of the ankle - it may persist or worsen
• Continued ankle instability 
• Infections at the site of surgery
• Permanent swelling (in the majority of cases, it resolves itself)
• Pain or sensitivity at the scar
• Numbness or tingling (usually resolves but in some cases may be permanent)
• Although rare, there is a risk of blood clots after surgery (deep vein thrombosis or pulmonary embolism)

Prevention

An ankle sprain can be prevented by:⁴

• Warming up before physical exercise
• Take caution when going over uneven terrain
• Using ankle support or tape on weak or previously injured ankles
• Wear well-fitted shoes that are specifically designed for your sport/activity
• Take care in high heels
• Ensure that good muscle strength is maintained in the ankles 
• Practice stability training and balance exercises

When to see a doctor

As self-care is the primary treatment, visiting your local pharmacist for advice is recommended. They may be able to suggest tablets for the pain as well as a cream or gel to rub onto the skin. 

If the symptoms or pain are severe you may have damaged the ankle significantly. This requires calling your doctor as soon as possible for an X-ray. 

Summary

The ankle consists of three bones (the tibia, fibula and talus), as well as two main sets of ligaments (the medial and lateral ligaments). A ‘ligament rupture of the ankle’ describes an ankle sprain - the overstretching or tearing (partial or complete) of ligaments. Its symptoms usually include pain, swelling, bruising, loss of motion and a popping sound at the time of injury. The rupture can be graded depending on its severity. Sprains are caused by the ankle being forced out of its normal position, typically a sports injury or by going over uneven terrain. Professional diagnosis involves a physical exam looking out for the signs and symptoms previously described, with imaging techniques used to rule out fractures or see the extent of the damage. The first line of treatment is usually self-care using the PRICE method for the first couple of days. Over-the-counter pain relief may also be used. If the pain and symptoms persist, it may be beneficial to consult a physiotherapist. In more extreme circumstances, surgical treatments may be used.