Foot Case Study 2 : Lateral Collateral

Ligament Damage
Paul McMaster is a 30-year-old delivery van driver who overbalanced at work whilst
loading parcels into his van. He sustained an inversion sprain of the left ankle 3 days
ago and has a severe sprain to the lateral ligament complex of the ankle. At present it
is difficult to diagnose precisely as the ankle is very swollen/bruised and painful on
certain movements and he requires crutches to walk. There is No Bony Injury to the
ankle, but he is keen to return to activities as soon as possible. He has a pronounced
limp and in not weight bearing evenly through the ankle, showing obvious pain as a
result. He lives with his girlfriend in a 2nd storey flat.

Anatomy & Pathology

Lateral Collateral Ligaments:
Anterior talofibular ligament – ATL
Calcaneal fibular Ligament
Posterior talon fibular ligament

Severe pain more common in repeating patients: commonly damage to interosseos

ligaments and associated deltoid pain.

Subjective Examination
Where\What: left ankle – expect pain over injured ligaments – ask is there any
medial pain (around deltoid ligament) and had this happened before?

When: 3 days ago

How: overbalanced at work

0-10 rating: ask?

24-hour cycle: ask?

Better for: expect rest

Worse for: weight bearing

Type of pain: ask?

Past Medical History/ General History: none

Red Flags and general concerns: repeated sprain => chronic instability of ankle.
Undiagnosed fracture.

SH: lives with girlfriend in flat

DH: ask?

Patient’s main outcome: possibly return to work

Objective Examination

Working Hypothesis:
Establish extent of injury – double check for fracture

Advice & Consent: give and obtain

General Observations: observe walking – does he protect ankle form

lateral strain as he turns

Acute Observations:
Skin colour – bruising
Swelling – around lateral ankle
Posture – adapted to non-weight bearing
Muscle bulk – unlikely to be affected
Active Tests , Passive Tests , Resisted Tests
Have the patient sitting up for these:

Dorsiflexion
Plantarflexion
Inversion
Eversion
Pronation
Supination
Flexion extension of toes

In active tests plantarflexion and dorsiflexion may pain at full range eversion may
pain as the peroneus attachments pull through this area

In passive tests one should feel for joint instability – changes in ligament end feel may
be evident and the ankle may be stiff from swelling

In resisted tests muscle damage may be evident as weakness

Special Tests:
In supine with feet off edge of couch – anterior drawer test: this focuses on the ATL –
can be tried in plantarflexion and dorsiflexion – stabilise lower leg – other hand pulls
anterior posterior bilaterally! Sign – excessive movement is a sign of ATL instability.

In supine sitting on bed with feet off – talar tilt test: this focuses on the CFL – one
hand stabilises ankle – excessive adduction = cfl damage – excessive abduction =
deltoid damage – bilateral comparison is essential

Functional Tests:
Walking – altered gait – expect patient to avoid turning foot medially in on affected ankle

Palpation: elicit pain on the lateral aspect of ankle

Measurements: If any of the special tests are positive quantify the result –
indeed quantify any discrepancy in active, or passive tests.

Advice & Possible Treatment: advise patient they may experience

pain following examination