The ligaments on the outside of the foot are the anterior talo-fibular ligament (ATFL), the calcaneo-fibular ligament (CFL) and the posterior talo-fibular ligament (PTFL). The inside of the foot (deltoid) ligament is much stronger than the lateral ligament and is therefore injured much less frequently. The joints, ligaments and joint capsule provide the natural stability of the ankle.

The muscles and their tendons provide stability during movements. The calf muscles (soleus and gastrocnemius) plantarflexes and the tibialis anterior dorsiflex the ankle. The peroneal muscle group found on the outside of the leg turns the foot out (everts) and the tibialis posterior tilt the foot in (inverts).

The three ligaments provide stability to the ankle and provide joint position sense (proprioception) to the brain to help it determine how the ankle is positioned. This prevents you from rolling in on your own ankle when you run or land awkwardly from a jump. The ligaments are made of collagen fibres which act like cables holding up a bridge. Above all the ligaments provide passive support resisting excessive movement.

ATFL

The anterior talo-fibular ligament (ATFL) is the foremost of the ligaments and is a flat thin band that is the most commonly injured ligament. It prevents the ankle from sliding forward and is damaged when you roll in over your ankle when your toes are pointed to the ground, i.e. in plantar flexion.

CFL

The calcaneo-fibular ligament (CFL) is cord-like and is the centre of the three ligaments. It is usually injured secondary to the AFTL when rolling the ankle with the toes pointed. It, however, is injured first when rolling over the ankle when the foot is planted flat.

PTFL

The posterior talofibular ligaments (PTFL) is a very short ligament right at the back and is injured secondary to the CFL when rolling over the ankle when the foot is planted flat.

This involves some minor tearing of the ligament, little or no instability, mild pain and swelling on the outside of the ankle. There may be very little stiffness and difficulty walking. Clinical testing shows normal range when stressing the ligament. Many times sporting activities can be continued as the adrenaline is still flowing. Recurrent injury can cause laxity and more severe sprains

Symptoms of mild injury (Gr 1)

• Slight tenderness over the outside knob of the ankle and just below the it
• Slight swelling
• Normally no bruising or bleeding
• Slight difficulty moving the ankle joint (point or flex) in particular pointing and turning the foot inwards
• Can put weight on the foot during standing or walking, but with slight pain
• Pulling pain, especially when twisting or rotating your ankle
• No instability of the ankle

Medical treatment

Consultation with a physiotherapist to determine the grade and the extent of the injury. The assessment is more accurate if done before the swelling sets in. The treatment of grade 1 injuries is very successful.

Research has shown that taking anti-inflammatories too early can delay healing, and it is recommended to take a painkiller (analgesic) instead for the first 24-48 hours after the injury.

PRICE protocol

Recovery time:

Grade 1 injuries can take between 2-4 weeks to heal if uncomplicated. More ligaments injured and other tissues injured in the area can increase the healing time. Lower limb injuries also heal slower than upper limb injuries due to a poorer blood supply. Remember that diseases like Diabetes can slow down the recovery time particularly in the foot.

There is a moderate amount of fibres torn (more that 20%) but less than 80%, some instability, moderate pain and swelling. There is marked stiffness and difficulty when walking. In our experience, the patients are hesitant to put weight on the ankle during walking. Bleeding and swelling sets in within the first 24 hours causing the foot to discolour.

Your ankle curves on the sides can disappear, and you will notice bleeding under your skin around your heel and over the arch of your foot. Clinical testing shows increased range when stressing the ligament, but with a firm end point. Very few athletes will continue activity despite the adrenaline.

Symptoms of moderate injury (Gr 2)

• Marked tenderness over the outside knob of the ankle and just below the it
• Marked swelling over the outside knob of the ankle
• Bruising or bleeding underneath the outside knob towards the heel
• Difficulty moving the ankle joint (point or flex) in particular pointing and turning the foot inwards
• Struggling to put weight on the foot during standing or walking
• Moderate pain, especially when twisting or rotating your ankle.
• Noticeable instability of the ankle

Medical treatment

Consultation with us to determine the grade and the extent of the injury. The assessment is more accurate if done before the swelling sets in. The sooner we start treating, the quicker the recovery is. According to research, a delay of 2 days in treatment can result in almost a week longer in recovery.

The treatment of grade 2 injuries is longer than grade 1 injuries not only due to ligament damage but associated damage in the surrounding area. Swelling can make the foot look very badly injured, but the swelling is not a very good indicator of actual damage.

• Follow the PRICE protocol
• Protection of  the ankle by taping, splinting or brace is required
• Short term (3-5 days) of crutch walking is highly recommended
• Comprehensive rehabilitation is required to prevent chronic ankle instability

Recovery time:

Grade 2 injuries can take between 4-8 weeks to heal if uncomplicated. Other ligaments and soft tissues damage in the area will prolong the healing time. Sporting activities are temporarily stopped and depending on individual progress jogging can be resumed in 6 weeks.

There is total rupture of the ligament or in excess of 80% of the fibres. This can result in severe instability of the joint. Severe swelling and bleeding are signs that something needs to be done as soon as possible. It is possible that if all of the fibres are completely torn off there may be no pain, or if some fibres are intact then pain can be excruciating. The person will struggle to place weight on the foot and will not walk without a limp.

Swelling and bruising will be severe and is often mistaken for a fractured ankle. Clinical testing shows excessive range when stressing the ligament and no endpoint. Very few athletes will continue activity despite the adrenaline.

Symptoms of severe injury (Gr 3)

• Severe tenderness over the outside knob of the ankle and just below the it
• Excessive swelling over the outside and/or inside of the ankle
• Severe bruising or bleeding underneath the outside knob towards the heel
• Not wanting to move the ankle joint at all
• Struggling to put weight on the foot during standing or walking
• Severe pain, especially when twisting or rotating your ankle (sometimes no pain if nerve fibres are no longer attached)
• Marked instability of the ankle

Medical treatment

Consult with us as soon as possible to determine the correct course of action. The determination of the extent of the injury allows us to guide you to the proper process. Not all Grade 3 ankle ligament injuries require surgery, but some do!

Patients will often go immediately to the hospital as the amount of swelling and bruising may be so severe that they expect the ankle to be fractured. Depending on your local emergency room and time of day, your suspected “ankle fracture” may be low on the priority scale. This can result in poor initial management, which you will pay for later in recovery time. If the x-ray shows no fracture, you are stable and free to go home. Unfortunately, you left without having the ligament stability and the extent of the damage assessed. Just because there is no fracture doesn’t mean you aren’t badly injured and have potential problems in the future.

We are focused on determining the extent of damage on all structures in the area and will spend more time trying to make an accurate diagnosis. If we determine you have a Grade 3 that requires potential surgery, we will refer you to an orthopaedic surgeon for a specialist opinion. Physiotherapy can help with pain management and treatment of the injury to restore your functional independence whether surgery is required or not.

• Follow the PRICE protocol immediately
• Moonboot is necessary to protect the ankle
• Non-weight bearing crutch is necessary to protect the ankle
• Referral to an orthopaedic surgeon if required
• Full comprehensive rehabilitation is necessary to prevent chronic ankle instability

Recovery time:

Grade 3 injuries recovery times are dependant on either conservative management or surgery. Conservative management will be 12-14 weeks with the first 4-6 weeks in a moonboot or speedboot. Depending on the type of surgery and surgeon recovery will take 4-6 months.

Selftest

These tests should preferably be done non-weight bearing not to damage the fibres more. The test is positive if it reproduces the pain or if there is more movement than the opposite side.

Sitting:

• Point foot downwards and point the toes
• Turn foot inwards
• Alternatively, pull ankle up and take the whole sole of the foot to the inside (as if trying to stand on the outside of the foot

Standing:

• Difficulty in weight bearing through the ankle
• Difficulty to stand or balance on one leg

Walking:

• Unable to walk without a limp
• Struggling to place equal weight through both legs

How we test

We determine the area and severity by stretching the ligament’s fibers. We test the different ligaments in the ankle by stressing each one individually using its direction of pull. This can give us a very clear picture of how many of the ligaments are injured and to what extent. This is a very common part of our job and we are highly skilled at it.

After we have performed our clinical tests, we will determine what, if any, other tests we should refer you for. Generally, a sonar/ultrasound is the preferred test to perform to determine the extent of the ligament damage. People tend to rush to the hospital. The standard procedure will involve taking X-rays to make sure there are no fractures or broken bones. A diagnostic Ultrasound (Sonar) will be the next step to determine which of the ligaments are completely or partially torn. However, physiotherapists can guide you to take the correct course of action(X-rays or Sonar). In most cases, only a diagnostic Ultrasound might be necessary to rule out a complete rupture of the ligaments.

• Talar Tilt: For the CFL (secondary PTFL)
• Anterior Drawer: For the ATFL
• Posterior Drawer: For the PTFL
• Squeeze test: For a syndesmosis sprain
• External rotation stress test: For a syndesmosis sprain

The test are more reliable after 3-4 days after the in injury and may reveal more information on the second consultation.

In case of a severe ankle sprain, a fracture should be excluded by proper use of the Ottawa ankle rules (OAR), and if indicated, an x-ray should be taken. Your physiotherapist is well aware of the rules as only 15% of lateral ankle injuries have fractures.

The Ottawa ankle rules (OAR):

• Bone tenderness along lower 6 cm of the back end of fibula or tip of the lateral malleolus
• Bony tenderness along lower 6 cm of the back end of tibia/tip of the medial malleolus
• The bone has sensitivity at the base of the 5th metatarsal bone
• Bone tenderness on the navicular bone
• Unable to weight bear both immediately after injury and for four steps during an assessment

We can refer you for X-rays. Your Physiotherapist will determine if it’s necessary to take X-rays to exclude fractures of the Tibia, Fibula or Tarsal bones. If your sprain is more severe, you may need X-rays to determine if there are any broken bones (fractures) or bones that have moved out of position (subluxation).

X-rays in children are more frequent due to a potential injury to the bone’s growth plate can disrupt the healthy growth of the bone. X-rays of both ankles will show the comparison between the two sides so that they can compare the injured ankle with a healthy one. If so few injuries have fractures why bother to take x-rays at all?

A professional physiotherapist’s diagnosis with every ankle sprain doesn’t only focus on the ligament.  Damage to tendons, bones and other joint tissues in addition to ligament damage is typical. Quite often fractures of the smaller foot bones are missed. Especially when an ankle sprain happens when falling from a jump and landing on the twisted ankle. The weight of your whole body comes down on that ankle joint and could cause compression fractures in between the ankle joints.

These type of fractures do happen and remains undetected until you start walking on your foot 6 weeks later, and the pain can be severe. The role of the physiotherapist is to look at the whole foot and ankle structure to determine how many structures are involved in the injury. The structures injured determines most importantly, the focus and views of the x-rays.

MRI:

An MRI is a very expensive scan which can only be referred by a specialist and in the ankle, it is an orthopaedic surgeon. This is the scan of choice if there is underlying pathology in the ankle joint that was not picked up by X-ray or sonar. This can show us all the soft tissues and often will be able to show us if there is any problem inside the ankle joint itself.

Sonar (Diagnostic Ultrasound):

A sonar is the test of choice to determine if and the extent of ankle ligament damage. This, however, becomes very difficult if the ankle is already very swollen. This is why it is better at stages to reduce the swelling first before going for a sonar or if it is possible before swelling sets in.

The sonar will show superficial soft tissue and can see the top layer of the bones it is not a good way to exclude a fracture. We are sometimes able to see a fracture if it is right at the top or if the ligament pulls a piece of bone from its attachment (avulsion fracture).

The most likely reasons are that a fracture has been missed or you have developed Chronic Ankle Instability (CAI). Research shows 30% of people can develop CAI. Causes have been linked to a delayed muscle reflex, poor stability of lower leg muscles, poor lower leg muscle strength, and impaired postural control.

The most common fracture missed is in the midfoot (foot bones) or an avulsion fracture where a piece of bone pulls away from the insertion of the ligament on the bone. Initially missing the fracture, the recommendation is to do an X-ray after six weeks. Above all, the second x-ray can show where bone healing took place.

One condition which is often missed is a syndesmosis injury . This is a very serious ankle injury where the ligament and membrane holding the two shin bones together tears. This can in certain instances allow the bones to gap and the ankle becomes very unstable. Further it has a poor healing rate, resulting in chronic ankle instability.