Ankle Ligament Injuries
What are the main ankle ligaments?
The bones of the ankle joint are held together by strong bands of tissue called ligaments. Each ligament is made of many strands of collagen fibres which is extremely strong.
The ligament on the inside of the ankle (deltoid ligament) is very strong. it mainly torn in association with severe fractures of the ankle bones.
The ligament on the outside of the ankle (lateral ligament) is made up of three separate bands: one at the front (anterior talo-fibular ligament), one in the middle (calcaneo-fibular ligament) and one at the back (posterior talo-fibular ligament). The front band is the usual ligament injured in sprains or tears of the ankle ligaments, and the middle band is sometimes affected.
What should I do if I sprain my ankle?
It is best to get professional advice immediately. Things that suggest a severe injury include:
- You cannot bear any weight on it.
- The ankle is deformed or the skin over the ankle is injured.
- High impact injuries like a fall from a height or a blow from a heavy object.
- The pain and swelling seem to get worse rather than better over the first couple of days.
Most sprains will get better with simple treatment. The word RICE reminds us of the basic treatment of a sprained joint:
- Rest: minimal weight bearing if possible for a few days.
- Ice: Apply an ice pack can be applied for 15 minutes 3-4 times a day
- Compression: An elastic bandage should help to get swelling down
- Elevation: This will allow swelling to drain away into the bloodstream
It is recommended to start taking some weight on the injured ankle reasonably soon after injury, usually within 2-3 days. It is also important start to exercise the injured ankle as soon as possible after the injury.
Normally a sprained ankle will recover within 6-8 weeks, although the swelling may take for a few weeks longer to resolve.
Do I need physiotherapy?
Minor sprains usually resolve without the need of a specialist physiotherapy. It is recommended to see a physiotherapist if you have a severe injury or the initial injury does not recover normally. The hospital, your own GP or your sports club can arrange this.
What causes persistent pain after ankle sprain?
A small percentage of ankle injuries will fail to fully resolve. The ligaments may fail to heal adequately and become weak, or there may be damage to the joint surface or the tendons nearby. Inadequate rehabilitation is also a common cause of residual pain.
You need to seek specialist advice if you feel a tendency for your ankle to swell or aches with minor stresses. Or the ankle feels weak leading to repeated sprains. This is referred to as "chronic ankle instability"
What is the treatment of chronic ankle instability?
Your doctor will examine the ankle and possibly arrange further x rays and scans. As many patients with ankle instability have associated proprioceptive nerves injury, the first treatment is a physiotherapy programme to re-train these nerves. A moulded insole may be advised for your shoe to reduce the load on the ligaments.
Many people will find their ankle more stable and comfortable after physiotherapy. If the problems continue, the surgeon may suggest a key-hole operation (arthroscopy) to check on the state of the joint. If these tests suggest weakness of the ankle ligaments, an operation to repair the ligament may be advised.
Who needs an operation?
If non operative treatment fails to make your ankle comfortable and tests show that the ligaments are weak, an operation may help. There are two main types of operation:
- The damaged ligaments are tightened up and re-attached to the bone. This is known as the anatomic repair (Brostrom procedure). Its main advantage is that it causes less stiffness than the other type of repair, as it aims to an anatomical repair of the ligaments.
- Part of one of the nearby tendons, is used to replace the damaged ligament. This is suitable when the instability is severe or if anatomic repair fails. It is a strong repair but often causes some stiffness in the ankle afterwards.
You would usually be in a plaster or brace for six weeks after an operation and would need further physiotherapy to help regain normal function.
The complications that may occur after a ligament reconstruction operation include:
- Residual pain in the ankle, either because of damage at the time of the original injury or because the ankle is tighter than before.
- Numbness or tingling down the outer side of the foot due to stretching or injury of the nerves.
- Persistent swelling of the ankle.
Can I prevent ankle sprain happening again?
You can't prevent another injury, but you can do to reduce the risk. High-heeled shoes should be avoided. If you play sport, you should take extra care to warm up properly. Strapping the ankle or wearing a sports ankle support may reduce the risk of another injury but this has not been conclusively proven.