What are ligaments?
Ligaments are strong fibrous connective tissue that attaches bone to bone to help stabilise joints and prevent excessive movements.
What are the lateral ankle ligaments?
The lateral ligaments of the ankle are the ligaments over the outside of the ankle joint that attach from the fibula to the bones of the hindfoot (talus and calcaneum) and act to stabilise the ankle joint from excessively turning out to the side (supinating).
What causes the lateral ligaments to rupture/tear?
These ligaments can rupture/tear after a simple injury where the foot tilts inwards excessively stressing the ligaments on the outside. This is often referred to as an inversion injury. This can occur during a simple misstep or may be related to a pivoting or jumping movement during a sports activity. Lateral ankle sprains are one of the most common injuries in sports.
What are the symptoms?
There is normally immediate pain over the outside of the ankle with immediate difficulty putting weight through the foot. There is often localised swelling and bruising over the outside of the ankle and this gradually spreads out over the foot during the next few days to weeks. Patients can complain that the ankle feels unstable and that the movement is restricted.
How is it diagnosed?
It is diagnosed based on the history of the injury and the subsequent symptoms. It is often difficult to assess in the first 24 hours as there is diffuse swelling and tenderness around the ankle. An examination carried out after 5–7 days can localise the symptoms to the outside of the ankle and certain clinical tests can assess the stability of the lateral ligaments.
If there is specific boney tenderness around the ankle or significant difficulty weight bearing then an X-ray is organised to rule out a fracture around the bones of the ankle. In some circumstances, an MRI is organised.
What is non-surgical management?
Non-surgical management is the mainstay of treatment following these injuries. The rehab is focused on getting you back to functioning as quickly as possible. In the first 72 hrs, you should elevate and ice the foot to help with the pain and the swelling.
I will normally advise you to use a moon boot for the first few weeks as this provides comfort and support to allow you to get back to full weight-bearing in the early stages.
When is surgery considered?
With functional rehabilitation, 80–90% of patients will get back to good function and will not require surgical intervention. Most people will get back to a stable pain-free ankle function between 6–12 weeks but for some, the full recovery can take between 9–12 months. Surgery is reserved for patients who have ongoing pain or instability after a full course of physiotherapy.
What does surgery involve?
Surgery involves an arthroscopy (keyhole surgery) of the ankle joint to assess and treat problems within the ankle joint before carrying out an open anatomical repair of the ligaments with a small incision over the outside of the ankle. The torn ends of the ligament and scar tissue around the lateral ankle are divided and reattached with sutures in a tightened position.
What are the risks of the surgery?
General—General anaesthetic problems, scar irritation, infection or wound healing problems, ongoing symptoms, deep venous thrombosis (DVT) and pulmonary embolism (PE)
Specific—5% risk of some ongoing instability and a risk of some reduced range of movement.
What is the recovery following surgery?
Time frame
Activity
0–2 weeks
- One night in hospital
- Posterior slab/splint
- Non-weight-bearing with crutches
- Intrinsic foot exercises
- Complete straight leg raise exercises and elevate limb when sitting
2–6 weeks
- *† Building up to weight bearing as tolerated in a moon boot
- Intrinsic foot exercises
- Gentle active ankle range of movement avoiding inversion movement
- Modalities to control swelling
- Incision mobilisation modalities
- Knee/hip exercises
6–10 weeks
- Change to aircast splint or ankle stabilisation orthosis (ASO)
- Weight-bearing as tolerated
- Proprioceptive and gait retraining
- Incision mobilisation
- Fitness/cardiovascular exercise e.g bicycling, walking, elliptical machine
10–12 weeks
- Return to running as guided by physio goals
* Patients were required to wear the boot while sleeping.
† Patients could remove the boot for bathing, dressing and physio but are required to adhere to the weight-bearing restrictions according to the rehabilitation protocol.
When can I return to work?
This is always dependent on the type of work you do and the recovery period can be extremely varied for individuals.
2 weeks
- Desk work
4–6 weeks
- Standing work
8 weeks or more
- Heavy lifting work
When can I drive?
Some postoperative pain medicines can affect your concentration, mood, coordination and reactions thereby reducing your ability to drive safely. You mustn’t return to driving whilst still taking any of these medications. Please check this link for further information https://www.vicroads.vic.gov.au/safety-and-road-rules/driver-safety/drugs-and-alcohol/medicines-and-road-safety
You can not return to driving when any foot involved in driving the car is restricted by an orthotic (post-op shoe, walking boot or plaster cast).
Car type
Operated foot
Automatic
Right—6 weeks. When you are fully weight-bearing in normal shoes
Left—Restrictions related to post anaesthetic and pain medications
Manual
Right/Left—6 weeks. When you are fully weight-bearing in normal shoes
When can I return to sport?
This depends on the sport but it may take 6–9 months to get back to some activities and again this would be guided by your physiotherapist and your ability to build up your level of running and match fitness. You should wear ankle support ongoing during contact sport.
When can I run?
This is extremely variable and you should be guided by your physiotherapist. You should have 90% calf strength and proprioception in order to return to light jogging. Often when you can carry out 20 or more single leg calf raises or can hop on the spot then you are in a position to return to running. It would also be a staged return, starting with a light jog for a minute or two then gradually building up distance and speed over time.