Ruptured ligament

Synonyms

Fibular ligament rupture, desmorrhexis, ruptured ligament in ankle joint; ligament rupture; lateral ligament rupture; fibular capsule rupture; rupture of the Ligamentum fibulotalare anterius / posterius, Ligamentum fibulocalcaneare, OSG distortion, supination trauma, pulled ligament,

Definition

The ruptured ligament on the upper ankle joint describes a partial or complete rupture of one or several ligament structures. A painful swelling and bruise is evident on the affected joint. The treatment of ruptured ligaments is made primarily by putting the ankle at rest for 2-6 weeks or surgically by suturing or fixation of torn bone fragments.

Frequency

Damage to the lateral ligaments of the ankle joint belong to the most frequent sport injuries and thus to the most frequent injuries on the whole. In the post-traumatic, surgical emergency clinic, ligament rupture is the most frequent reason why patients come to the emergency room.

Cause

The apparatus of the lateral ligament consists of three, separate ligaments, which link the tip of the lateral ankle with the heel bone (Calcaneus) and the ankle bone (Talus). For a detailed structure of the foot, please refer to our page The Foot.

The most frequent ruptures of lateral ligaments occur in young adults. Older people suffer more from a fracture of the lateral ankle, while injuries of epiphyseal cartilage occur with younger children.

An injury of the lateral ligaments usually occurs by spraining the foot outwardly. Doctors describe the accidental event as "ankle joint distortion" or “supination trauma”. Thereby, the ligaments can only be "distorted" (pulled ligament) or an individual or all three lateral ligaments can be torn (partial rupture) or be entirely ruptured (torn ligament / rupture). The terrible pain that is experienced after the sprain does not provide any definitive indication about the severity of the injury. Sometimes ligament sprains can be more painful than ligament ruptures, since all pain receptors are destroyed upon rupture and thus they no longer cause pain.

Especially with sports such as soccer, tennis or volleyball, injuries of the lateral ligament apparatus occur frequently. But also by wearing shoes with high heels, a hazard exists that the foot may be sprained.

Symptoms

Nearly every sport injury, provided that it is a cohesive injury of the movement apparatus, is accompanied by bleeding of the affected tissue. Thus a bruise occurs (hematoma). Often no exact examination is possible directly on the sport field. Therefore, it is difficult to make a further differentiation of the injury. Is one dealing with a simple contusion, or is a sprain concealed therein, or a rupture of muscle fibers or a sprained ligament. Many sport injuries have similar complaint features, although they differ greatly in their severity:

• Often severe pain that begins immediately
• Weakness of affected muscles, limitation of mobility until inability to move
• Swelling and sensitivity to pressure

With a ligament rupture, one usually recognizes a significant swelling in the area of the outer ankle, which is caused by an intercalation of water and the bruise (hematoma). A strong pressure and movement pain arises via the injured ligaments. Standing and burdening the foot routinely lead to severe pain. . If the pain is not too great, the ankle joint can be "folded open", i.e.: the surfaces of the joint permit themselves to be separated from each other due to the loss of the lateral ligament function, if one rotates the foot inward or presses the lower leg in the direction of the heel when the foot is held fast. . If a hematoma is visible, with corresponding discoloring of the skin, this is an initial indication of a ruptured ligament. The bruise is an indication that perfused structures, such as the joint capsule and ligaments, have been damaged in their structure; but it can also be an indication for the rupture of the lateral ankle bone.

Diagnosis

For the affected patient himself, it is not possible to differentiate between a sprain and a rupture of the lateral ligaments. The doctor will ask questions about the details of the accident, He will examine the foot and prepare an X-ray image, in order to exclude any bone damage. In addition, the stability of the joint will be verified, which can sometimes be painful in the event of a recent injury. If further doubt exists, a so-called controlled X-ray image offers additional information about the severity of the injury. Thereby, the foot will be clasped in a frame and the joint rotated so that the stability can be observed in the X-ray image. At present, controlled images no longer play any significant role in the initial diagnosis (acute diagnosis). On one hand, many patients cannot tolerate the procedure; on the other hand, the severity of the injury is merely increased by the rotation. With chronic instability, the degree of the instability can be estimated. Since the joints of each human can be splayed outward to individually different degrees, the physician usually prepares a control X-ray image of the corresponding healthy ankle joint, in order to determine the healthy standard; then a better differentiation can be made between healthy and injured joints. Through a magnetic resonance image (MRI), the degree of ligament damage can be determined exactly. Since no direct consequences are yielded for subsequent treatment, and the MRI is expensive and it is not always available, it is usually not implemented in the diagnosis.

Therapy

Immediate measures

On the basis of a straightforward scheme (PECH-Scheme, according to Prof. Böhmer), proper immediate measures help to positively influence the healing process and to prevent additional damage.

P = Pause

For each injury of every type of sport the following is valid: Stop playing the sport immediately. The affected ankle joint should be put at rest immediately (e.g. support bandage, no walking). A direct examination is usually difficult, since the joint is very sensitive due to swelling and pain. The degree of the injury is usually indicated initially in the first few days after the injury.

E = Ice (Eis in German)

The immediate application of ice can positively influence the healing process. By applying ice, the blood vessels are constricted, which reduces the degree of blood infiltration and swelling. Furthermore, metabolism is slowed down by cooling, which leads to a reduction of tissue damage. Finally, cold has a pain-relieving effect. However, it must be observed that ice should never touch the skin directly, since cold damage could be caused thereby. Always first cover the site with a cloth or wrap it with a few layers of a compression bandage. Then apply a cooling package and fix it in place with a compression or elastic bandage.

The duration of the cooling depends on the degree of the injury as well as on the subjective comfort of the patient. Provided that the ice is well-tolerated, the ankle can be cooled for several hours. However, the cooling effect reaches a depth of only a few cm, so that no “deepening effect” can be achieved hereby. If cooling is done too long and consistently, the healing effect can also be negatively influenced. For this reason, a milder application of cooling is applied today, e.g. cold compresses are recommended.

C = Compression

In order to prevent an excessive swelling of the ankle joint, after or even during cooling, a compression bandage should be applied. However, it should only exert a moderate pressure, so that a good circulation is guaranteed. Since the swelling increases in the first few hours, the tension of the compression bandage should be examined routinely. If the foot becomes blue-colored, the compression bandage must be loosened immediately. .

H = High-elevation

By elevating the injured ankle joint, the backflow of blood will be physically facilitated and an increase of swelling will be minimized. Within the first 48 hours, the foot should be completely elevated. The routine elevation of the foot should be performed until the swelling of the foot has been completely reduced.

Conservative therapy

A physical examination by a sport doctor is required. For a ligament rupture on the ankle joint, the emergency room of a clinic, an orthopedist or a sport physician should be the first stations for consultation. The goal of each therapy is the healing of the ligament rupture with retention of the stability and physical stress of the ankle joint. In the event of non-treatment, permanent instability of the joint can arise with premature joint attrition (arthrosis).

Relief and careful treatment are the bases of the conservative therapy. All measures aim to reduce pain and work to counteract swelling. Supporting compresses, bandages, or plastic splints serve to stabilize the joint and to reduce swelling. With pronounced swelling or severe pain, a plaster cast can also be applied in exceptional situations. Sedatives (analgesics, NSAR) achieve relief. If swelling and pain have been reduced, one can begin to carefully burden the leg. The stress should be supported by physiotherapeutic treatment, with the aim of strengthening muscles and improving coordination and one’s own reflexes (proprioceptor training). This is also important, in order to prevent a renewed sprain. In most cases, the ligaments heal with scars and the joint becomes sufficiently stabilized. If the treatment is not successful, a surgical ligament suture can be made even after a few months.

Surgical therapy

If other injuries of bone and cartilage are present in addition to the ligament rupture, or if a conservative treatment was unsuccessful, then the ligaments can be sutured. However, only in exceptional circumstances, such as for example professional athletes, is surgery urgently recommended, since it does not lead fundamentally to a more rapid or more complete healing. In rare instances, complications can occur in connection with surgery. As with each operation, infection, bleeding or injury to nerves or blood vessels can occur in the region of the ankle joint. Then mobility of the joint can be permanently limited in very rare cases after an operation. At the conclusion of a surgical procedure, the ankle joint will be immobilized for six weeks in a lower leg plastic cast.

Independent of the manner of treatment, with each immobilization of the leg, the hazard of developing a venous thrombosis arises (thrombosis). This complication can be extensively prevented by applying anti-coagulant medicines (Thrombo-prophylaxis), which for example contain the active ingredient Heparin. All suitable medicines are applied by injection into the fatty tissue of the leg or into the stomach. On one hand, thrombosis can lead to damage of the veins themselves; on the other hand, it can lead to a life-threatening lung embolism...

After a complete rupture of the lateral ligament, with participation of all three lateral ligaments, sport may be resumed at the earliest after twelve weeks. Professional athletics can be resumed at the earliest after six months. The hazard of a renewed rupture (tear) is very great if stress is exerted prematurely and if the treatment was improper. However, these specifications must be viewed relatively and they depend on the degree of the injury and the type of sport. Physical therapy (physiotherapy) also plays a significant role after surgical treatment, whereby the mobility of the ankle joint is trained and measures are implemented to reduce swelling. The proprioceptor training occurs later and the strengthening of the muscles that stabilize the ankle joint. Strong muscles stabilize the joint during the course of movement, so that the ligaments are stressed to a lesser degree. With a persistent instability, orthopedic shoes or bandages can be suitable to stabilize the joint.

Rehabilitation

After completing the immobilization and careful treatment, the joint can gradually be burdened again; however, initially only with minimal stress, which can then be increased, depending on eventual pain. In the first four to six months, a suitable joint protection should be worn, especially for sport - for example, a tape bandage (please also refer to the recommended book “Taping-Seminar”). Prior to resumption of sporting activity, the musculature should absolutely be reconstituted to the extent that sufficient stability of the joint is guaranteed by the surrounding musculature.

Functional further treatment

• Early functional further treatment with leg braces (e.g. Aircast®, Malleoloc®, etc. Refer to the figure above) with axial full stress.
• Physical therapeutic exercise treatment in function- and activity-oriented intensity.
• Electrotherapy, ultrasonic
• Exercises for senso-motoric (proprioceptive) training (special physiotherapy, PNF)
• Disablement, depending on employment 1-6 weeks (according to profession and severity of the injury)
• Training specific to the type of sport after 2-12 weeks
• Competitive sport at the earliest after 12 weeks
• Orthopedic protection in sport for at least 3-6 months (orthesis or tape)

Prophylaxis

A good training condition and scrupulous warm-up exercises prior to sporting activity minimize the risk of a distortion / sprain; however, they cannot prevent a sprain completely. Proper shoes should be a basic prerequisite for each type of sport exercise. The higher that the sport shoe is, the greater is the protection against a ligament injury. However, it must be considered that the risk of a bone fracture or an injury to the knee joint is increased. Susceptible joints can be protected prophylactically, according to the types of sport (e.g. for volleyball, finger joints that are bandaged or also covered with tape.)

Prognosis

Simple ligament stretching usually heals within one to two weeks. If capsular ligaments have been torn, a scarred defective healing of the ligaments occurs under a conservative therapy. Usually the scarred ligaments suffice, in order to be able to resume the original function. If the healing runs an incomplete course, then a joint instability arises and the resumed tendency to bend and create a sprain. In this instance, an operation should be taken into consideration. With an uncomplicated procedure, the complete athletic ability is usually restored after three months.