The Management of Lateral Ankle Ligamentous Injuries

---

Introduction

The vast majority of ankle sprains are sustained to the lateral, or outer, side of the ankle; with the ligament most affected being the Anterior Talo-Fibular Ligament (ATFL). 

ATFL sprains are one of the most common lower limb injuries sustained in football, and were recorded as comprising 7% of all lower limb injuries surveyed in a UEFA injury study in 2009 (Ekstrand et al, 2011).  

A sprain is the medical term used to describe the tearing or partial tearing of a ligament; with a ligament defined as the structure which joins bone to bone.

Basic anatomy

The functional anatomy of the ankle involves the talus, or ankle bone, which is a wedge-shaped bone articulating with the lower end of the tibia, or shin bone, and the lower part of the fibula.  The tibia is a fully weight-bearing bone while the fibula is the long thin bone that runs down the outside of the leg. 

The fibula is usually referred to as a non-weight bearing bone whose primary purpose is to provide attachments for the muscles of the calf and the lateral ligaments of the ankle and knee. 

The function of the fibula is essentially to provide origins for the muscles that act on the foot and the lateral (or outside part) of the ankle including the ligamentous structures that support the joint.

Because of the involvement of the fibula in the lateral ankle complex, some weight-bearing is inevitable and various authors have proposed that the exact extent of this varies between 6.7% (Takabe et al, 1984) and 17% (Wang et al, 1996) of body weight. 

Although others may differ in opinion, some authors argue that the fibula bears no physical weight at all.

Below the talus sits the calcaneus, or heel bone, and the joint formed by the articulation between these two bones is known as the sub-talar joint.  This is where the inversion, or ‘turning-in’ movement together with the opposite –eversion - occurs. 

All the bones in the ankle complex are bound together by strong ligaments.   of which the most frequently injured is the anterior talo-fibular ligament; or ATFL for short. 

In the adult population, the ATFL has been found to have the lowest tensile strength of all the ankle ligaments and is the weakest in comparison to the others (Pincivero et al, 1993).

On the medial side of the ankle, the strong triangular-shaped deltoid ligament connects the lower inner edge of the tibia to the calcaneus and talus, with some anterior fibres extending to navicular bone of the foot.

It is the combination of movements between the ankle and sub-talar joints that leads to ligamentous sprains.

Injury mechanics

Lateral ankle ligamentous sprains can occur either by indirect contact such as putting the foot in a divot on the pitch or by jumping and landing awkwardly. 

Ankle injuries can also be sustained through forced inversion or eversion mechanisms while making direct contact with an opponent; and in contact sports these can occur frequently both in training and matches. 

Most ankle injuries are impossible to legislate for and the likelihood of both contact and non-contact injuries are difficult to predict.  However, ankle sprains are often misdiagnosed in the early stages as several associated injuries can complicate matters.  

Fousekis at al (2003) looked at ankle injuries in soccer and found that a high percentage of these (17%) did not involve direct contact with an opponent.  Players who had sustained previous ankle injuries leading to ankle instability were also deemed to be at a higher risk of recurrent ankle injuries in the future. 

Most of the injuries to the lateral ankle complex involved the ATFL and these usually result from forced inversion movements combined with plantarflexion which leads to tissue damage, bleeding, inflammation, and swelling. 

Where youth players are concerned, Caine et al (2006) noted that in a series of studies, acute injuries to the growth plates accounted for 30% of adolescent sport injuries; most of which were reported as sprains, and not all of these were seen by a physician.  

Early stage management of ankle injuries

In terms of basic injury management, all the available evidence suggests that the important period in treating any injury is during the immediate 48 – 72 hrs after the injury has been sustained. 

During this period the body needs time for the injury to settle and for the acute period to pass.  However, although we talk about the first 48 hrs being the important time, in reality this acute stage can last up until 5 – 7 days depending on the severity of the injury sustained. 

During this early stage, the priorities in the treatment for all soft-tissue injuries are to relieve pain, limit swelling, and protect the body from further injury. 

Acute injuries such as ankle sprains and muscle strains are very easily aggravated and not only need time to settle, they also need to be allowed time to settle without being exposed to the risk of further injury.  

Protection from further damage, therefore, becomes the first priority in injury treatment.

Cold is required as opposed to heat at this stage, and ice is applied to relieve pain and reduce swelling.  Ice has a sedative effect on nerve endings, and the resultant cold treatment also limits any swelling present. 

If we take a typical ankle sprain, for example, the best thing to do is to apply an ice-pack as quickly as possible.  This will relieve some of the pain and help to control any swelling. 

In addition to applying ice in the acute stage, it’s also helpful to add some form of compression such as a light bandage to wrap around the injured area.  The compression is applied to support the injured ankle in addition to assisting with the control of any swelling that may be present. 

Since most ankle injuries typically swell within the first few hours of being sustained, applying a compression can be quite effective. 

Finally, elevating the injured ankle uses gravity to assist recovery and allows any swelling to drain away from the

 affected area.  This can then be dispersed naturally via the body's healing process.

Using a “Game Ready” compression unit helps with the immediate management of injury  

At the professional level, though, the treatment modality of choice favoured by most clubs today is a piece of equipment called the 'Game Ready Compression Unit'; which essentially provides high-pressure cold compression which relieves pain and reduces swelling.  
 

This can be used in other areas of the body; although the unit is particularly helpful in the management of injuries to the ankle and knee.  
 

Using the 'Game-Ready' machine really does reduce swelling and relieve pain far more effectively than in the days of the old ice-packs; thus justifying the break from the older, more traditional approach.  
 

Nowadays, professional players will simply have their injuries assessed by the physios virtually as soon as they are sustained, and the 'Game-Ready' compression unit will be applied immediately to maximise the required combination of cold and compression.  
 

This helps an injury to respond at the right speed by meeting the essential components of early-stage injury management.  
 

Naturally, it’s vital to rest. By that, however, the emphasis is on resting from activities that are known to aggravate the injury such as running and excessive walking. 

It is still possible to keep mobile and get around but the key is in not doing anything to make things worse during the acute stage.  

It is vitally important, though, to keep the injured part moving. Gentle ankle movements in the elevated position will help to prevent the ankle from becoming stiff.  

However, the actual movements themselves have to be quite specific. Moving the foot and ankle backwards and forwards without turning the ankle inwards or outwards will help to avoid the ankle becoming too stiff during the first 48 hours or so.  
 

The ideal scenario involves an Aircast Boot and crutches  

Of course, the ideal scenario is to have the injured ankle placed in an Aircast boot together with the use of crutches; but not everyone has access to that sort of treatment.  

Often referred to as an “Aircast Walker”, this is a protective plastic boot that contains an inflatable padded inner cushion that once applied, can be pumped up to provide support and protection to the injured part.  

These pneumatic walker boots provide a cushion of air via an inflatable sleeve fitted inside a solid outer plastic shell; which provides compression and support to the ankle or foot without the usual constrictions that a normal plaster cast would have.  
 

The inner lining can be inflated to a comfortable pressure which enables gradual compression to the injured tissues while the solid external casing gives protection from further injury to the ankle as a whole.  

Being light and removable, these are also ideal for allowing players to train while injured and at the same time allowing the body weight to be taken through the ankle and foot.  

This helps to increase the functional capability of the injured joint while at the same time avoiding compromising an injury further by unprotected movements. 

At the professional level, the combination of early applications of the Game Ready compression unit together with immobilising the foot in an Aircast walker and use of crutches has proved to be highly effective. 

Replicating this at a local level can be difficult but not impossible provided the basic principles of applying an ice pack to the injury as soon as possible together with some light compression that can be adhered to. Supporting the ankle in elevation is essential.  
 

So too is protecting the ankle from further injury. It is not a good idea to apply ice for ten minutes to an injured ankle and then hobble for a quarter a mile! 

Neither is it a good idea to try to "run the injury off" as frequently referred to in sports commentaries.  

Ankle inversion injuries are typically synonymous with some instability and attempting to run through these can lead to further injury.  

The normal procedure following this type of injury is to concentrate on active rehabilitation aiming to restore early movement ranges and improve strength and balance as the injury begins to heal. 

This is in direct contrast to the days when severe ankle ligamentous sprains used to be immobilised in a cast.  
 

Although this prevented any movement from taking place and allowed ligaments to heal in a stable position, immobilisation often resulted in so much stiffness being present after removal of the cast that a longer period of active rehab was required.  

Additionally, excess muscle wastage would take place as a direct result of the ankle being immobilised, and it took intensive training to get these back up to pre-injury strength levels.  

Today’s preferred strategy for injury management is delivered by encouraging gentle weight-bearing appropriate to the player’s limitations. 

Taking the traditional P.R.I.C.E. (Protection – Rest – Ice - Compression - Elevation) approach and adding in the weight-bearing recommendation gives us the ‘Optimum Loading’ part of the modern acronym P.O.L.I.C.E.

This translates fully as Protection, Optimum Loading, Ice, Compression and Elevation.

It shows how injury management has varied over the years from the old I.C.E. method before we even thought about adding the protection from further injury and rest aspects to the equation.

Although we did these anyway  - or in most cases at least - we often had to contend with the popular ''run it off'' approach that was prevalent in those days!

Summary of injury management  

In summary, therefore, following a soft-tissue inversion injury to the ankle, protection from further injury followed by ice, compression, and elevation are the key factors applicable. 

Additionally, avoiding aggravating the injury by over-enthusiastic examination is an essential aspect of early-stage injury management!  
 

As with all injuries, correct examination and diagnosis are essential. Consultation with a doctor and / or visiting the Accident and Emergency Department of the nearest hospital is advised.  

Fractures associated with ankle injuries need to be excluded as early in the diagnostic process as possible, and this is discussed on the next page where we also look at the Ottawa Ankle Rules.  

However, research shows that ligamentous sprains are often more difficult to deal with in reality than a straight-forward ankle fracture (Singh, 2003).

In the early stages, the management of ankle fractures tends to be 

centred on the fracture alone as opposed to addressing the ligamentous damage that will have simultaneously occurred.  

This can lead to delayed recovery unless all aspects of the injury are considered in the treatment plan.  

Examination by a physician will provide appropriate guidance on whether X-rays or further investigation is indicated. 

Bleakley CM, Glasgow P, MacAuley DC (2011). PRICE needs updating; should we call the POLICE? British Journal of Sports Medicine. Vol. 46; 220 – 221.

Caine D, Di Fiori J, Maffulli N (2006). Physeal injuries in children’s and youth sports: Reason for concern? British Journal of Sports Medicine. Vol. 40; 749 – 760. 

Edwards T (2006).  International Football Sports Medicine: caring for the soccer athlete worldwide.American Orthopaedic Society for Sports Medicine. Rosemont, Illinois, USA. 

Ekstrand J, Hagglund M, Walden M (2011). Injury Incidence and Injury Patterns in Professional Football. The UEFA Injury Study. British Journal of Sports Medicine. Vol 45; 553 – 558. 

Fousekis K, Tsepis E, Vagenas G (2012). Intrinsic risks factors of non-contact ankle sprains in soccer: a prospective study on 100 professional players. American Journal of Sports Medicine. Vol. 40 (8); 1842 – 1850.

Heyworth J (2003).  Ottawa ankle rules for the injured ankle (editorial).  British Medical Journal.  Vol. 326; pp 405. 

Pincivero at al, 1993; Ankle Injuries. in Football Traumatology, Current Concepts from Prevention to Treatment. Volpi V (2006), Milan, Springer. 

Rosenberg ZH, Beltran J, Bencardino JT (2000).  MR Imaging of the ankle and foot.  Radiographics.  Vol. 20: S153 – S179.

Singh D (2003).  Patients with ligamentous injury need better treatment in Britain (letter).  British Medical Journal.  Vol. 326, 2th May, 2003, pp 1147 

Soucacos PN, Dailiana Z, Beris AE, Johnson E0 (2006). Vascularised bone grafts for the management of non-union. Injury; International Journal of the Care of the Injured. Vol.37 (1); Supplement S41 – S50.

Takabe K, Nakagawa A, Minami H, Kanazawa H, Hirohata K (1984). Role of the Fibula in Weight-bearing. Clinical Orthopaedics & Related Research. Available at: http://journals.lww.com/corr/Abstract/1984/04000/Role_of_the_Fibula_in_Weight_bearing.47.aspx. Accessed 24th September, 2019.

Wang Q, Whittle M, Cunningham J, Kenwright J (1996). Fibula and it’s Ligaments in Load Transmission and Ankle Joint Stability. Clinical Orthopaedics & Related Research. Vol. 330; 261 – 270.