InjuryoftheAnkleLigaments

AlexWeeBScFRCS(orth)ConsultantTrauma&OrthopaedicSurgeon. FredRobinsonBScFRCSFRCS(orth)ConsultantTrauma&OrthopaedicSurgeon.

Apatientsguide
Whataretheligamentsoftheankle? Theankleisahingejointbetweenthelegandthefoot,andallowsupanddown movement.Thebonesoftheleg(tibiaandfibula)formaslot,andthetalusboneof thefootfitsbetweenthem.Thetalusisheldtothetibiaandfibulabystrongbandsof tissuecalledligaments.Eachligamentismadeofmanystrandsorfibresofamaterial calledcollagen,whichisextremelystrong. Theligamentontheinsideoftheankle(thedeltoidligament)hastwolayersthe deepestoneismostimportant.Thisligamentismainlytorninassociationwithsevere fracturesoftheanklebones.Sportinginjuriesofthisligamentarerare. Theligamentontheoutsideoftheankle(lateralligament)ismadeupofthree separatebands:oneatthefront(anteriortalofibularligament),oneinthemiddle (calcaneofibularligament)andoneattheback(posteriortalofibularligament).The frontandmiddlebandsaretheligamentsinjuredinasprain.

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Thetibiaandfibulaformajointbetweenthemselvesjustabovetheankle.Thisalsohas strongligaments,oneatthefrontandoneattheback(tibiofibularligaments).The ligamentatthefrontisinvolvedin1020%ofanklesprainsthisinjuryisimportant,asit takesalongtimetoheal,althoughitusuallyhealswithouttheneedforsurgical treatment. Howdotheankleligamentsgetinjured? Mostankleligamentinjuriesarecausedwhenthefoottwistsinwards.Allofthebodys weightisthenplacedonthelateralankleligaments.Theanteriorandmiddlefibresof theanklestretchortearainsprainorstrainoftheankle.Occasionallysmallpiecesof bonemaybetornoffwiththeligaments. Inafewcases,atwistingforceontheanklemaycauseotherdamage.Thebones aroundtheanklemaybebroken,apieceofthecartilageliningtheanklemaybe chippedoff,ligamentsconnectingotherbonesinthefootmaybesprainedortorn,or thetendonsaroundtheanklemaybedamaged. WhatshouldIdoifIsprainmyankle? Mostanklesprainsarefairlyminorinjuries,whichwillgetbetterwithsimpleselfcare treatment.ThewordRICEremindsusofthebasictreatmentofasprainedjoint: Resttaketheweightofftheinjuredjointasmuchaspossibleforadayortwo Iceanicepack(asmallbagoffrozenpeasisideal)canbeappliedfor1015 minutes,34timesadaytoreduceswelling Compressionasupportbandageorstrappingwillhelptoreducetheswelling Elevationrestingwiththeankleabovetheheightofthebodywillallowswelling todrainawayintothebloodstream

Althoughacoupleofdaysrestisuseful,itisbesttostarttakingsomeweightonthe injuredanklereasonablysoonafterinjury,usuallywithin23days.Alsostarttoexercise andstretchtheinjuredankleassoonaspossibleaftertheinjury. Normallyasprainedanklewillrecoverwithin68weeks,althoughitmaytendtoswell forafewmonthslonger. WhenshouldIgotocasualty? Ifyouhaveasevereankleinjuryitisbesttogetprofessionaladviceimmediately. Thingsthatsuggestasevereinjuryinclude: yourankleissopainfulthatyoucannotwalkonitall theanklelooksdeformed theskinovertheankleisbroken theinjurywascausedbyasevereforcesuchasafallfromaheightorablow fromaheavyobject thepainandswellingseemtogetworseratherthanbetteroverthefirst34 days(thebruisingoftengetsworseforaweekormorebeforeitstartstofade)
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ShouldIhavephysiotherapy? Mostsimplesprainsgetbetterwithoutanyspecialtreatment.However,ifyouhavea severeinjuryortheinitialinjurydoesnotrecovernormally,itisusuallybesttoseea physiotherapist.Thehospitalcasualtyororthopaedicdepartment,yourownGPoryour sportsclubcanarrangethis.PhysiotherapistsalsoadvertiseinYellowPagesandlocal papers. WillIkeephavingtroublewithmyankle? Themajorityofankleinjuriesgetbettercompletelyandcausenolongtermproblems. Unfortunatelyoccasionallythereispermanentdamagetotheankle.Theligamentsmay failtohealproperlyandbecomeweakleadingtoankleinstability,ortheremaybe damagetothejointitselforsomeotherstructurenearbyleadingtoanklepainand swelling. Howwouldankleinstabilitybediagnosed? Yourdoctororphysiotherapistwilllistentoyourcomplaintsaboutyourankleand examineyou.Theywilllookforanysignthatyouhavesomeotherproblemaroundyour ankle,suchasdamagetothejointsurface.Theywillstretchyourankletoseeifthe ligamentsareabnormallyweak. AnXraywillusuallybetakentoseeifthereisanydamagetothebonesofyourankle. LigamentsdonotshowonXrays.LigamentdamagecanbeshownbytakingXrays withyouranklestretchedinvariousdirections("stressviews)orwithamagnetic(MRI) scan.However,thesespecialtestsareusuallynotneededatfirst. Whatcanbedoneaboutankleinstability? Mostpeoplewithankleligamentinstabilityhavedamagetotheligaments,whichcanbe overcomewithappropriatephysiotherapyrehabilitation.Therehabilitationconcentrates ontwomainareas.Firstlystrengtheningthemusclesaroundtheoutsideoftheankle. Secondly,byimprovingyourbalance.Thismayrequiretheuseofspecialised equipmentsuchasawobbleboard,oratrampette.However,similarexercisescan bepractisedathomebyusingacushion,orapieceofsponge.Yourphysiotherapistwill helpyouwiththis. IfyourankleorAchillestendonarestiff,youwillalsobeshownexercisestostretch these.Ifyourfootshapemakesyoupronetoextrastressontheankleligaments,a mouldedinsolemaybeadvisedforyourshoetoreducethesestresses. Mostpeoplewillfindtheiranklemuchmorestableandcomfortableafterphysiotherapy. However,insomepeopleproblemscontinue.Atthispointtheopinionofanorthopaedic footandanklesurgeonmaybehelpful,andyourgeneralpractitionermayreferyoufor furthertreatment.Thesurgeonmayalsosuggestanexploratoryoperationonyourankle (arthroscopy)tocheckonthestateofthejoint.Ifthesetestssuggestweaknessofthe ankleligaments,anoperationmaybeadvised.
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WillIneedanoperation? Mostpeoplewithankleinstabilitywillnotneedanoperation.Evenifyouranklestillfeels unstableafterphysiotherapy,youcouldtryabraceratherthanhavinganoperationto tightenuporreplacetheligaments. However,ifnoothertreatmentmakesyouranklecomfortableandtestsshowthatthe ligamentsareweak,anoperationmayhelp.Therearetwomaintypesofoperation: thedamagedligamentsaretightenedupandreattachedtothebone. Oneofthenearbytendonsisusedtoreplacethedamagedligaments. Followingsurgeryyouwillbeinplasterforsixweeks.Afterthisyouneedtowearan anklebraceforafurther6weeks.Physiotherapytreatmentisusuallyrequired.After3 monthsyouwillworkwithyourphysiotherapisttoregainthestrength,andmobilityof yourankle.Youcanstartlightexerciseat3months,butsportinvolvingtwisting(suchas football,rugby,runningonroughgroundandsquash)arenotalloweduntil6months afterthesurgery. Thecomplicationswhichmayoccurafteraligamentreconstructionoperationinclude: painintheankle,eitherbecauseofdamageatthetimeoftheoriginalinjuryor becausetheankleisnowtighterthanbefore numbnessortinglingdownthesideofthefootduetostretchingofoneofthe nerveseitheratthetimeoftheoriginalinjuryortheoperation persistentswellingoftheankle Stiffnessoftheankle,restrictingtherangeofmovement In5to10%ofpeoplethesurgerydoesnotwork,andtheankleremains unstable

Isprainedmyanklethreemonthsagobutit'sstillpainfulandswollen.Why? Youranklemaybejusttakinglongerthanusualtorecover.However,theremaybe someotherdamagetotheankleifitisstillcausingtroublethreemonthsafterinjury.It wouldbeworthconsultingyourGPorphysiotherapist. Isprainedmyanklelastyear.It'sfinenowcanIpreventithappeningagain? Youcan'tabsolutelypreventanotherinjury,buttherearethingsyoucandotoreduce therisk.Obviously,takecarewhenwalkingtoavoidcatchingyourfootonunevenbitsof pavement(especiallywhenyouareinahurryorhavehadafewdrinks).Highheeled shoesputextrastressonyourankleandshouldbeavoided.IfyourankleorAchilles tendonarestiffthisputsextrastressonyourankleligamentswhenyouwalkorrun,and exerciseswouldprobablyimprovethis. Ifyouplaysport,youshouldtakeextracaretowarmupanddownproperly,withplenty ofstretchestoyourankleandAchillestendon.Strappingyourankleorwearingasports anklesupport(whichcanbeboughtatmostsportsshops)mayreducetheriskof anotherinjury.
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