Symptom Checker

Where is your pain?

Check Now

Make an appointment

Ankle Lateral Ligament Injury

What Is an Ankle Lateral Ligament Injury?

An ankle lateral ligament injury is another term for an ankle sprain.

Ankle sprains are the commonest sports injury.

A lateral ligament injury involves damage to one or more ligaments around the outer aspect of the ankle. Ligaments are a specific type of tissue in the body that connects bone to bone allowing movement to occur. A joint is when at least one bone articulates with another. Ligaments provide stability to the joints.

On the outer (lateral) aspect of the ankle there are 3 ligaments: ATFL, CFL and PTFL. The ATFL is the most commonly injured ligament in an ankle sprain followed by CFL.

Please read more about the ligaments of the foot and ankle here.

Lateral aspect of foot and ankle illustrating the 3 lateral ligaments, ATFL is the most commonly injured ligament in the foot and ankle

Lateral aspect of foot and ankle illustrating the 3 lateral ligaments, ATFL is the most commonly injured ligament in the foot and ankle

What Can Cause it?

A lateral ankle ligament injury (ankle sprain) occurs when the foot and ankle are stressed beyond their normal range of motion and the ligaments are stretched or torn.

The mechanism of injury is typically an inversion of the ankle (rolling in, turning in) with or without an element of twisting.

The injury can occur when walking on uneven surfaces or while running and playing sports.

Stability to the joints is derived by two mechanisms:

  • Dynamic stability – muscle contraction across joints help to stabilise the joints
  • Static stability – ligaments and the shape of the bones help provide stability

Dynamic stability is the most important of the two during normal function and activities of daily living. It is only when dynamic stability fails, do the ligaments then come under tension. Poor dynamic control – weakness in core stability, gluteus medius, quadriceps, hamstring and peroneal muscle can predispose to ankle instability. Ankle proprioception: sense position, location, orientation and movement of the ankle is also vital for ankle stability.

Patients with hypermobility of their ligaments are also at risk of developing ankle sprains. In hypermobile patients the ligaments are more lax allowing for greater motion in the joint than usual.

Patients with a certain foot shape are also predisposed to lateral ligament ligament injury. If the hindfoot is in varus (turned in) such as in a cavus foot, the ligaments on the outer aspect of the foot are chronically stretched and can weaken over time.


In summary risk factors for ankle lateral ligament injury include:


 

Clinical picture illustrating a varus hindfoot deformity which predisposes the patient to a lateral ligament injury

Clinical picture illustrating a varus hindfoot deformity which predisposes the patient to a lateral ligament injury

What Are The Symptoms?

An ankle sprain typically presents with pain and swelling on the outer aspect of the ankle. Bruising may also be present depending on the severity of injury.

Patients often describe difficulty weight bearing immediately after the injury and often have a limp.

 Symptoms following an ankle sprain:

  • Popping sensation at the time of the injury
  • Pain – exacerbated by weight bearing
  • Swelling
  • Bruising
  • Limp

We grade the severity of the injury using the following classification system:

Grade 1 – No ligament disruption, minimal swelling and bruising, weight bear normally

Grade 2 – Ligament stretched, moderate swelling and bruising, mild pain on weight bearing

Grade 3 – Ligament torn, severe swelling and bruising, severe pain on weight bearing


On clinical examination your foot and ankle surgeon will look for signs of bruising and swelling. Your surgeon will grade the severity of the injury.

In addition other conditions that can be often confused for an ankle sprain will be looked for such as:

Your surgeon will also examine you for associated injuries such as:


Clinical picture of the foot and ankle in a patient with a severe lateral ligament injury demonstrating significant bruising and swelling

Clinical picture of the foot and ankle in a patient with a severe lateral ligament injury demonstrating significant bruising and swelling

What Investigations May Be Required?

In the acute setting no investigations are required if the history and clinical examination findings are consistent with a low grade uncomplicated ankle sprain.


Plain radiograph (x-ray)

Radiographs (x-rays) are requested if there is:

  • Inability to weight bear
  • Tenderness on palpation over the bony prominences (malleoli) on the inside or outside of the ankle (medial and lateral)
  • Tenderness on palpation over the base of the 5th metatarsal
  • Tenderness on palpation across the navicular
  • Severe swelling and bruising
Radiograph of a sprained ankle demonstrating extensive soft tissue swelling on the lateral side (arrows), note normal soft tissue margin medially (blue line)

Radiograph of a sprained ankle demonstrating extensive soft tissue swelling on the lateral side (arrows), note normal soft tissue margin medially (blue line)


MRI

MRI provides excellent high definition static images. It is generally not necessary in the investigation and treatment of routine low grade sprains. In severe injuries it may be necessary to exclude any other pathology in the hindfoot. It is also useful in monitoring healing.

In the setting of a severe ankle sprain an MRI is particularly useful in assessing:

  • Cartilage damage – osteochondral lesion
  • Reactive bone changes
  • Ligament damage – medial ligament involvement
  • Syndesmotic injury
  • Peroneal tendon pathology (tenosynovitis, tendon tears)
  • Any other pathology
MRI of the ankle revealing a torn ATFL

MRI of the ankle revealing a torn ATFL

Can The Problem Get Worse?

Yes, although the majority of ankle sprains (lateral ligament) recover without any long term complication.

Patients who have been misdiagnosed, have lacked proper rehabilitation post injury, and if the ligaments have failed to heal properly, may develop a chronic ankle sprain and instability.

Non-Operative Treatment Options

Non operative management is the mainstay of treatment for the acute lateral ankle ligament injury. Managed appropriately the vast majority of injuries, even severe ankle sprains, will recover by 4 to 6 weeks.


Acute phase

We recommend the PRICE regime:

  • Protection – minimise the risk of re-injury, for moderate to severe sprains, the use of crutches is recommended as well as a short period in a walker boot or ankle brace
  • Rest – by avoiding walking on the ankle while it remains painful and swollen (at least 48 hrs)
  • Ice – apply immediately or as soon as possible following the injury to minimise swelling (make sure ice is wrapped in a towel and you apply until area becomes numb, remove and discontinue the ice at this stage, continued application following numbing may result in tissue damage)
  • Compression – bandages and dressings help immobilise the injured ankle, reducing pain and swelling
  • Elevation – of the ankle to at least heart level to help minimise swelling and aid soft tissue healing

Non steroidal anti inflammatories (NSAIDs) help reduce inflammation and swelling but there also is a risk that this will have an adverse effect on ligament healing. We advise patients that if there continues to be considerable pain and swelling several days after the injury they should reflect on how much they are truly resting the ankle, rather than take more painkillers.

Your surgeon will guide you according to the grade of your ligament injury.


Rehabilitation phase

Effective rehabilitation is critical to ensuring full recovery: resolution of painful symptoms, swelling and restoration of stability. It is also important as it will prevent the risk of chronic ankle instability. Using an experienced physiotherapist can help with your recovery and rehabilitation.

The different stages of rehabilitation include:

  • Stage 1 –  this involves resting, protecting the ankle and reducing the swelling (week 1)
  • Stage 2 – this involves restoring the range of motion, strength, flexibility and most importantly proprioception exercises of the ankle (week 2-3)
  • Stage 3 at this stage return to activities that do not require twisting or turning, and commence pool based exercises
  • Stage 4 – return to activities that require sharp, sudden turns (cutting activities) such as tennis and football (weeks to months)

Proprioception based exercises work on sense position, location, orientation and movement of the ankle.

Operative Treatment Options

Surgical repair of an acute lateral ligament injury is recommended in instances where a rapid return return to sports is required. Surgery can aid rehabilitation and return to full function in the case of a severe ligament injury to the ankle. The success rate following this surgery is 90%.

Patients who fail to recover following non operative treatment and develop chronic ankle instability may benefit from surgical intervention. Please read chronic ankle sprain for further information.

Potential Complications

It should be borne in mind that complications can result from a condition with or without surgery.


Potential complications of a lateral ankle ligament injury

  • Worsening pain
  • Increased stiffness
  • Chronic swelling
  • Chronic instability (weakness in the joints)
  • Superficial peroneal nerve injury

FAQs

When can I drive?

Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen any swelling present and potentially result in chronic symptoms.


When can I return to work?

This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 4 to 6 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 1 to 2 weeks.


When can I return to sports?

This really depends on the grade of injury. It may be 6 weeks to several months.


What should the final outcome be?

Excellent pain relief and return to full activities of daily living in the majority of patients.


Chronic ankle sprain

This can result if you return to work, sports or other activities without letting the ankle heal properly and become rehabilitated.

Patient Experience - Lateral Ligament Reconstruction

Why did you decide to have your ankle treated?

I went to the doctors around 6 weeks after my initial incident as I was still experiencing issues, at first I thought it was a sprain but soon realised it was worse than that. Once meeting with the consultant following an MRI scan it was clear that operating was the best outcome for myself as I want to get back to playing football, running, gym and more…

What were your concerns before the operation?

My fears and concerns were that my ankle would never be the same again. I had also never been under general anaesthetic and was nervous regarding what to expect.

What was your experience of the operation and the post operative recovery?

A very positive experience with excellent staff on hand for assistance and keeping me up to date with what was going on.

What advice would you give future patients?

Not to be nervous or anxious. Don’t do any strenuous activity (prior to surgery) on the ankle and also buy an ankle support for the time leading up to the operation.

Patience and rest is key, do not rush or try anything silly. Follow the doctor’s advice and once you have seen the physiotherapist to make sure you do all the exercises daily.

D Lambeth March 2016

Make an appointment