Courtesy: Dr Rajiv Limaye, FRCS Tr and Orth, Consultant Orthopaedic Surgeon, UK

 

Overview

Chronic ligament injuries of the ankle are a common orthopaedic problem encountered in:

• Emergency settings
• Routine clinical practice
• Sports medicine

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Clinical Importance

These injuries can lead to:

• Persistent pain
• Instability
• Loss of sports and recreational activity

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Anatomy Review

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Bones Involved

• Tibia
• Fibula
• Talus
• Calcaneus (supporting structure)

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Ligaments

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Lateral Ligament Complex (Most Commonly Injured)

• Anterior talofibular ligament (ATFL)
• Calcaneofibular ligament (CFL)
• Posterior talofibular ligament (PTFL)

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Medial Ligament

• Deltoid ligament
  • Superficial component
  • Deep component

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Stabilizers of the Ankle

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Static Stabilizers

• Bony architecture
• Ligaments:
  • ATFL — prevents anterior translation and inversion
  • CFL — resists varus tilt
  • PTFL — posterior stability

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Dynamic Stabilizers

• Surrounding muscles (especially peroneals)

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Biomechanics of Injury

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Epidemiology

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• 10–40% of athletic injuries involve the ankle
• 80% are lateral ligament injuries
• 20% are medial injuries
• 10–30% progress to chronic instability

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Pathogenesis

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• 70–80% of acute injuries heal adequately
• Failure of healing leads to:
  • Ligament elongation
  • Recurrent sprains
  • Chronic instability

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Instability vs Laxity

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Functional Instability (Subjective)

• Sensation of “giving way”
• Lack of confidence in the ankle
• No objective laxity

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Mechanical Instability (Objective)

• Demonstrable on clinical testing
• True ligament laxity

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Clinical Evaluation

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History

• Mechanism of injury
• Previous ankle injuries
• Pain and swelling
• Ability to bear weight

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Examination

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Inspection

• Swelling
• Bruising
• Deformity

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Palpation

• Ligament tenderness
• Bone tenderness
• Tendons and neurovascular status

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Range of Motion

• Plantarflexion
• Dorsiflexion
• Inversion / eversion

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Special Tests

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Anterior Drawer Test

• Assesses ATFL
• Positive finding:
  • Increased anterior translation
  • “Suction sign”

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Talar Tilt Test

• Assesses CFL

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Syndesmotic Tests

• Squeeze test
• External rotation test

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Generalized Laxity

• Beighton score >/= 7 suggests hyperlaxity

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Imaging

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X-ray

• Weight-bearing views preferred

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MRI

• Detects:
  • Osteochondral lesions
  • Deltoid ligament injury
  • Bone edema

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Ultrasound

• Useful for:
  • Tendons
  • Soft tissue

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Stress Views

• Helpful in chronic instability

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Management

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Acute Phase (Conservative Management)

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Principles

• Rest
• Ice
• Compression
• Elevation

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Support

• Walking boot or brace (4–6 weeks)

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Weight Bearing

• As tolerated

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Physiotherapy

• Peroneal strengthening
• Proprioception training
• Gastrosoleus stretching

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Rehabilitation

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Early Phase

• Active range of motion exercises

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Late Phase

• Wobble board training
• Advanced proprioception

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Return to Sport

• Approximately 3 months
• Based on functional stability

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Failure of Conservative Treatment

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When to Consider

• After 6 months of structured rehabilitation

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High-Risk Groups

• Athletes
• Persistent instability

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Surgical Management

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Options

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1. Anatomic Repair (Preferred)

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Gold Standard

Broström–Gould Procedure

• Repair ATFL and CFL
• Reinforcement using extensor retinaculum

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Outcomes

• Success rate: 80–90%

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2. Non-Anatomic Reconstruction

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Example

• Chrisman–Snook procedure

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Disadvantages

• Stiffness
• Subtalar arthritis
• Altered biomechanics

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3. Arthroscopy-Assisted Procedures

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Role

• Detects intra-articular pathology in ~80%

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Associated Findings

• Loose bodies
• Osteochondral lesions
• Synovitis

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Recent Advances

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Internal Brace Augmentation

• Fiber tape reinforcement
• Faster return to sport
• Approximately 80% return by 6 months

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Adjunct Procedures

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• Microfracture
• Loose body removal
• AMIC (cartilage repair)

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Deltoid Ligament Injury

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Characteristics

• Rarely isolated

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Common Associations

• Syndesmotic injury
• Weber C fractures
• Flatfoot / posterior tibial dysfunction

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Management

• Treat associated pathology
• Repair if persistent symptoms

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Complications if Untreated

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• Chronic pain
• Persistent instability
• Osteoarthritis

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Deformities

• Varus deformity (lateral injury)
• Valgus deformity (medial injury)

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Key Take-Home Points

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• Lateral ligament complex is most commonly involved
• Differentiate functional vs mechanical instability
• Rehabilitation is first-line treatment
• Surgery indicated after failed conservative management
• Broström–Gould procedure remains the gold standard
• Arthroscopy helps identify associated intra-articular pathology