Acute lateral ligament sprain

Findings

a)      A history of an inversion sprain with rapid swelling, which may or may not bruise laterally, or, if mild, pain but no swelling.

b)      It is tender to palpation over the anterior talofibular, and possibly the middle talofibular and/or calcaneofibular ligament.

c)      Distraction of the ankle joint by passive inversion and plantar flexion stresses the anterior talofibular ligament, and passive inversion and dorsiflexion tests the calcaneofibular ligament.

d)     Compression of the talus against the fibula is pain-free, but this test will be painful with a fracture of the fibula.

e)      If anterior translation is painful, it suggests a combined lesion, with capsulitis or posterior tibiofibular ligament damage, has occurred.

f)       Bruising is lateral and concentrated around the ankle and mid-foot, but will track up the leg.

Cause

An inversion sprain of the foot, with a sprain, partial tear, or tear of the ankle ligaments. The anterior talofibular ligament(ATFL) is damaged in plantar flexion and inversion, and the posterior calcaneofibular ligament during dorsiflexion and inversion.

Treatment

a)      RICE for 48 hours, plus non weight-bearing crutches.

b)      Compression can be specifically applied beneath and behind the lateral maleolus by using orthopaedic felt under the strapping.

c)      Non-steroidal anti-inflammatory drugs.

d)     Electrotherapeutic modalities to settle inflammation, such as laser and ultrasound.

e)      Massage techniques to remove tissue debris and to organize fibrocytes, such as effluage and frictions.

f)       Non-weight-bearing flexion, extension, inversion and eversion exercises. The non-injured ankle may be worked at the same time as this seems to give a feedback to the damaged side. Tracing the alphabet with the toes gives a full range of movement.

g)      Weight-bearing as soon as possible, with support, but note that the first few paces hurt and then pain eases up with continued walking. However, the pain returns after walking when the patient stands still or rests.

h)      Support the ankle, initially with a pressure pad, beneath the fibular and over the calcaneum, and use an adjustable elastic bandage, tubigrip, elasticated anklet or ankle brace.

i)        Cross-training should be non-weight-bearing, such as swimming, rowing or cycling, and raising or lowering the bicycle saddle will increase the ankle range of movements.

j)        Proprioception should be trained by performing one-legged balancing exercises at home whilst brushing the hair, cleaning the teeth, answering the phone… This requires the ankle to balance the body rather than the brain to concentrate on balancing. Balancing with the eyes shut and on a wobble board increases the coordination required.

k)      The movement and rhythm of the good leg may be used to educate the damaged ankle to perform normally. Counting from 1 to 9 will provide a good rhythm.

l)        Isometrics will maintain the strength of the posterior tibialis and peroneal muscles.

m)    Follow the Achilles ladders and, after the sprinting stage, the kicking ladder, figure-of-eight cutting drills and sidestep routines may be added.

n)      Surgery is required if the ankle is unstable, but this is usually assessed later.

Sports

Change of direction sports should not have too high a sole on the shoe because this leads to ankle instability. Use a support for about 6 weeks after returning to games. Evidence from basketball is that prophylactic ankle braces, or taping, is of value in preventing injury to the ankle. Straight line sports must follow the Achilles ladders, whilst change of direction sports must add sideways movements, such as sidesteps and cutting manoeuvres.

This is a very common injury, for which it is important to give home proprioceptive exercises so that rehabilitation is done frequently; too many feel that 20 minutes, three times per week, on a wobble board is all that is required. Rehabilitation is little and often, several times a day. The major problems are instability, with weak peroneals, or later a chronic stiff ankle that has not been rehabilitated properly. There is evidence that prophylactic strapping is of benefit.

"Concise guide to sports injuries, 2^nd edition",Churchill Livingstone, Malcolm T.F. Read,  foreword by Bryan English