The ankle joint ligament (calcaneofibular ligament) is a narrow thin bundle of tough fibrous tissue attached to outer malleolus of fibula and outer surface of calcaneus bone. Ankle joint ligament (calcaneofibular ligament) lies underneath the peroneal longus and brevis tendon. Forceful uncontrolled internal rotation or twist of the foot or injury at ankle joint results in overstretching of the ankle joint ligament (calcaneofibular ligament) and thus often causes injury, laceration, partial or complete tear of the ankle joint ligament. Complete tear of ankle joint ligament (calcaneofibular ligament) is rare.
Causes of Ankle Joint Ligament Injury
Sports injury involves mechanical problem resulting in twist of foot inward (internal rotation) and loss of balance during physical contact causes abrupt stretch of the ankle joint ligament.
Sports Injuries Causing Ankle Joint Ligament Injury
Sports like football, soccer, basketball and skiing involves quick movements of the foot and ankle and so people involved in playing such sports are likely to encounter ankle joint ligament injury.
Ankle Joint Ligament Injury Caused Due to Domestic Falls
Domestic injury causing ankle joint ligament injury or tear is observed mostly in elderly patients. Elderly patients are also often suffering with osteoporosis and ligament injury is associated with fracture of ankle bone, tibia or fibula. Causes of domestic fall such as fall on slippery surface, tripping on carpet, or fall over staircase can cause ankle joint ligament injury.
Direct Impact Causing Ankle Joint Ligament Injury
Ankle joint ligament (calcaneofibular ligament) is superficial and ligament lies between skin and ankle bone. Direct impact is often associated with skin laceration and ankle joint ligament injury or tear. Causes of direct impact causing ankle joint ligament injury is as follows-
Types of Ankle Joint Ligament Injuries
Ankle joint ligament injury can be a bruise, laceration which is superficial or deep and may be associated with superficial tear, partial tear or complete tear of the ankle joint ligament (calcaneofibular ligament).
Symptoms of Ankle Joint Ligament Injury
- Ankle Pain- One of the most common symptom of ankle joint ligament injury is severe pain in ankle that is observed over the outer side of ankle joint. Pain intensity is increased with ankle joint movement. Symptoms of pain intensity is increased while walking or sitting. Patient suffering from ankle joint ligament injury feels better in lying down position and when leg is elevated above the level body.
- Ankle Swelling- Patient with ankle joint ligament injury is most likely to have complaints of swelling of ankle joint. Ankle swelling could have grown slow or fast. Swelling is because of edema of soft tissue and bleeding in subcutaneous tissue caused due to ankle joint ligament injury.
- Inability To Move Feet- Patient with ankle joint injury would have symptoms of inability to move feet. Patients often restrict movement of ankle joint because of pain and inability to move because of hematoma (blood clot).
Signs of Ankle Joint Ligament Injury
- Tenderness at Ankle Joint- One of the signs of ankle joint ligament injury is that the ankle joint on lateral side over outer malleolus is extremely painful. Pain is severe on palpation. Pain after examination continues at higher intensity.
- Ankle Joint Stiffness- Examiner during examination of ankle joint following ankle joint ligament injury finds the ankles to be very stiff. Passive flexion (movement of feet towards floor) and extension (upward movement of feet) are restricted because of pain and hematoma (blood clot).
- Skin Discoloration- Skin looks purple because of blood underneath the skin. Bleeding is caused by tear of small blood vessels around the ligament. Slow bleeding causes slow growth of swelling and rapid bleeding causes rapid growth or swelling. Patient can loose up to 200 to 300 mL of blood around injured tendon. Blood and blood clots spread in subcutaneous tissue under the skin.
Investigations To Diagnose Ankle Joint Ligament Injury
Investigation is aimed to find the tissue injury and also to rule out fracture and dislocation of ankle joint.
- X-Ray: X-ray examination is useful to diagnose if there is any fracture and dislocation of ankle joint in addition to the ankle joint ligament injury.
- MRI: MRI is useful to evaluate fracture, dislocation and hematoma.
- Ultrasound: Ultrasound is a specific investigation to evaluate hematoma.
- Arthroscopy: An orthopedic surgeon performs arthroscopy. Arthroscopy examination is a specific test to diagnose and treat ankle joint ligament injury and tear.
- Blood Examination: White Blood Cell Count (WBC) is increased in infection and septic arthritis. WBC is normal in ankle joint sprain without any infection.
Treatment for Ankle Joint Ligament Injury
Conservative Treatment for Ankle Joint Ligament Injury
Ankle joint sprain associated with laceration and partial tear of ankle joint ligament (calcaneofibular ligament) are often treated with conservative treatment. Sprain of ankle joint associated with complete tear of ankle joint ligament (calcaneofibular ligament) may not respond to conservative treatment. Choice of conservative treatment is as follows
Cold Therapy For Ankle Joint Ligament Injury
- Ice bag is applied for 20 to 30 minutes for 3 to 4 times a day over the ankle joint ligament injury site.
- Cold therapy is used during initial phase following injury to the ankle joint ligament.
- Cold therapy helps to reduce bleeding.
Heat Treatment For Ankle Joint Ligament Injury
- Heating pad is applied for containing pain after few days of sustaining ankle joint ligament injury.
- Heating pad increases temperature of skin and underlying tissue.
- Increased temperature dilates blood vessels and increases blood loss during active bleeding following injury.
Restriction of Ankle Joint Movement to Treat Ankle Joint Ligament Injury
- Ankle joint movement is extremely painful following complete or partial tear of ankle joint ligament. Restriction of the ankle joint movement helps to prevent severe pain.
- Restriction of ankle joint movement also helps to heal the ankle joint ligament injury faster.
- Restriction is achieved by applying braces and cast to the ankles.
Physical Therapy (PT) for Ankle Joint Ligament Injury
Physical therapy is avoided immediately after ankle joint ligament injury. Ankle joint movement causes frequent separation of torn fragments of ankle joint ligament and slows down its healing process.
Indications for Physical Therapy For Ankle Joint Ligament Injury
Physical Therapy in Phase 1 of Ankle Joint Ligament Injury –
- The Phase 1 of ankle joint ligament injury lasts for 8 to 10 weeks following injury. During this phase, the ankle joint ligament injury is treated with cast, braces, arthroscopy or surgery.
- Patient is advised to keep injured ankle joint immobile.
- Physical therapy is advised during this phase of ankle joint ligament injury to prevent atrophy and weakness of leg and thigh muscles.
- Patient is encouraged to move knee joint, hip joint and toes.
Physical Therapy in Phase 2 of Ankle Joint Ligament Injury -
Second phase of ankle joint ligament injury is the phase after ligament injury is healed. Because of cast or braces, ankle joint is immobilized for over 8 to 12 weeks. Prolonged immobilization of the ankle joint causes atrophy and weakness of leg and foot muscles. Physical therapy is aimed at improving the function of these muscles.
Medications For Ankle Joint Ligament Injury
Medications are prescribed to treat pain and inflammation associated with ankle joint ligament injury.
Anti-inflammatory Medications For Ankle Joint Ligament Injury
- Anti-inflammatory medications are prescribed for inflammation and wound healing. They are prescribed as analgesics (pain relief).
- Most common anti-inflammatory medication used to treat the pain associated with ankle joint ligament injury are Motrin, Naproxen and Celebrex.
- Opioids are very rarely used after first 7 to 10 days. Pain intensity following ankle joint ligament injury is often decreased after 7 to 10 days.
- Pain associated with ankle joint ligament injury is treated with short acting opioids.
- Opioids used for pain are Vicodin, Norco or Lortab.
- Muscle relaxants are prescribed for muscle spasm. Ankle Joint immobilization using cast and braces following ankle joint ligament injury often results in muscle spasm. Muscle spasm causes severe pain as long as muscle is contracting.
- Muscle spasm associated with ankle joint ligament injury is treated with muscle relaxants.
- Most common muscle relaxants used are Baclofen, Skelaxin, Relaxin and Flexeril.
Interventional Therapy For Ankle Joint Ligament Injury
- Interventional pain therapy is advised after healing of ankle joint ligament injury or tear.
- Interventional pain therapy involves corticosteroid injection around the ankle joint.
- Corticosteroid helps to reduce the inflammation and soft tissue edema caused due to ankle joint ligament injury.
Surgery for Ankle Joint Ligament Injury
- Surgery is recommended for complete tear of ankle joint ligament (calcaneofibular ligament).
- Surgery is mostly performed after arthroscopy. Surgery involves suturing of the torn ankle joint ligament.
Ankle Joint Ligament Injury Recovery Time and Exercises
Ankle Joint Ligament Injuries are quite common, but they are severely painful. The normal recovery period for ankle joint ligament injuries is usually anywhere from 5 days to about a couple of weeks for mild form of injuries, but if the ankle joint ligament injury is far severe which is often medically termed as grade II injury then the recovery time may be substantially more, which can range from 4 to 6 weeks post injury.
For the Ankle Joint Ligament Injury to heal completely and in the fastest possible time it is imperative to do the following exercises diligently. Post ankle joint ligament injury, there is substantial swelling and reduced range of motion of the ankle. Hence to begin with, the exercises are aimed at recovering the lost range of motion and stability of the ankle caused due to ankle joint ligament injury or tear. This is started once the swelling from the injury has settled down and inflammation has calmed down. Mobility exercises can be started as early as the second day of the injury in cases of mild to moderate forms of ankle joint ligament injury. Initially, lateral movements of the ankle should be avoided so as not to put excess stress on the injured ankle joint ligaments. Once the pain subsides then lateral movements can be done.
Some of the Exercises for early recovery from Ankle Joint Ligament Injury are:
Seated Balance Board Exercise For Early Recovery From Ankle Joint Ligament Injury: During the initial phase of the Ankle Joint Ligament Injury, a wobble-board can be used for increasing range of motion of the injured ankle. To do this, sit on a chair with the feet rested on a wobble board. Now, move the feet in a to and fro motion that is forwards and backwards to make the injured ankle mobile. Make sure that the ankle does not move sideways as this may cause increased stress to the injured ankle joint ligaments. When the inflammation subsides and there is far less pain and then lateral movements can be performed.
Active Ankle Mobility Exercise: This exercise is also done during the initial stages of the ankle joint ligament injury. To do this exercise, just pull the foot up as far as possible and hold it for a few seconds and then point it away from you and maintain it in that position for a few seconds. This should be done initially in 2 sets of 20 with the ankle elevated. While doing this exercises, make sure that the injured ankle joint ligaments are not unduly stressed, the strength of the calf muscles are maintained and the towards and away motion allows reducing swelling.
Active Mobility Exercises (Lateral): This exercise should be done once the pain has subsided substantially and the injured ankle joint ligaments have healed to some extent, so that lateral movements of the ankle do not damage the injured ligaments. To do this exercise, just turn the feet such that the soles point outwards and then inwards. This movement should be done keeping pain tolerance in mind. If there is severe pain while doing this, then it should not be performed. If pain allows, you can also rotate the ankle in a circular fashion.
Standing Calf Stretch: To do this exercise, you need to stand facing a wall with the hands kept at the eye level. Now, keep the injured leg a bit backwards with the heels on the floor. Keep the uninjured leg forward with the knee bent. Now, turn the injured foot gently inwards. Gently, lean into the wall until a stretch is felt at the back of the calf. Maintain this position for about half a minute. Come back to the starting position and repeat the exercise. Do this exercise at least 3 times a day.
Standing Soleus Stretch: To perform this exercise, stand facing a wall with the hands on the wall at about chest height. Place the injured leg backwards with the heels firmly on the floor and the other leg forwards with the knees bent. Now, turn the injured foot inwards. Bend the knee of the injured ankle and lean slightly towards the wall until a stretch is felt in the calf of the injured leg. Maintain this position for about half a minute and repeat this exercise about 3 times a day.
Strengthening Exercises: This can be started as soon as pain allows. During the initial stages, any lateral movement of the ankle should be avoided, but can be started once the pain subsides.
Ankle Plantar Flexion: To do this exercise, sit with the injured leg crossed over the opposite knee. Use the opposite hand to pull the top of the foot and toes towards the body. This should give a feeling of a gentle stretch on the top of the foot and ankle. Maintain this position for about half a minute and repeat this exercise about 5 times and about 10 times a day.
Dorsiflexor Strengthening: To do this exercise, you need to have a rubber tube to act as resistance which should be fixed to a stationary object such as a table or a pole. Loop the other end of the tube around the injured leg. Now, sit on the floor facing the object. There should be slight tension felt in the tube when the foot is relaxed. Now gently pull the foot backwards towards the body using the ankle and toes. Maintain this position for about half a minute and then return to normal position. Repeat this exercise about five times and do it about 10 times a day.
Inversion or Eversion Balance Exercises: Make a balance board of about 1.5 feet long and 1.5 inch wide. Use a stick or a rod which is placed underneath the board across it. Now, stand on a smooth surface and step on the board with the feet about a hip width apart at an equal distance from each side of the rod or the stick. Now, use your feet to balance the board and at the same time tipping it from side to side making sure that the board does not touch the ground. You can rest for a few moments before starting to balance the board again. Repeat this exercise about five times and do it about four times a day.
Resisted Eccentric Inversion Exercise: This form of exercise is vital in preventing any reinjury to the ankle. In this exercise, the patient will attempt to resist the therapist from turning the foot outwards. This strengthens the muscles and stabilizes the ankle at the weak points where it is likely to sprain. For this exercise, a partner or a therapist is required to offer resistance. In the initial stages, not much resistance should be put but the resistance should be increased gradually.
Calf Raise: This exercise is done to increase the strength of the calf muscles consisting of the gastrocnemius and soleus muscles. To do this exercise, rise up and down on the toes. This should be done in 3 sets of 10 building up gradually. Once this exercise can be done easily and without any pain then you should attempt doing this on one leg. It will be a lot harder to do initially, but with time this can be done easily.
Once you are through with stretching, strengthening, and range of motion exercises then move on to function exercises in which there will be pressure put on the injured ankle with more lateral and rotational movements of the ankle. Some of the exercises are:
Lunge Exercise: This is mainly an exercise specific to the knee but it can also be done for ankles as well. This exercise improves the balance and strength of the injured ankle joint. To do this exercise, stand with the injured foot in front of the other with the toes facing forwards. Now, bend the back knee towards the floor all t he while keeping the back upright. Stop just before the knee touches the ground and then try and push yourself upwards again. Initially, do a small number of reps gradually increasing to 3 sets of 10.
Walking Calf Raise: This exercise strengthens the calf muscles along with improving balance at the ankle. To do this exercise, put one foot in front and rise up on tiptoes. Now, try and swing the back leg forwards and raise up on toes again. Try to walk in this fashion across the room.
Step Back Exercise: To do this exercise, stand on a small step. Put one leg backwards, touch the foot on the floor, and try and push forwards with the forefoot to move it back on the step. Try alternating the legs. This can be increased in difficulty by doing it faster or doing it on a step, which is a bit high.
Hopping: This exercise is quite easy to do. Initially, try and hop at one place and hop just a little bit and then gradually increase the height of the hop and the number of hops that you do. Try doing this in the front, sides, and backwards. You can also try hopping from one leg to the other. It can also be made difficult by using a hoop or some other form of hurdle.
Resistance Band Jump: In this exercise, a resistance band is put around the waist and held behind. You are then asked to perform side to side, forwards, or backward jumps. The resistance from the band acts as a hurdle. The difficulty of this exercise can be increased by the thickness of the band or jump further.
Box Jumps: To do this form of exercise, take a box and stand over it and try to jump either sideways or forwards. You can also alternate the legs rapidly from one foot to the other. This may also be performed front to back.
Sports Specific Drills: Once all the above exercises are able to be done pain free and without any discomfort, then the physical therapist will start on exercises which are specific for the sport that the individual has been trained on. These exercises are started slowly and then gradually increased in difficulty. Once this is able to be done without any pain or discomfort then you are ready to return back to your normal sporting activities.