Skip to main content

Advertisement

SpringerLink
Log in

Treatment of Acute Lateral Ankle Ligament Rupture in the Athlete

Conservative Versus Surgical Treatment

  • Injury Clinic
  • Published:
Sports Medicine Aims and scope Submit manuscript

Abstract

Acute lateral ankle ligament sprains are common in young athletes (15 to 35 years of age). Diagnostic and treatment protocols vary. Therapies range from cast immobilisation or acute surgical repair to functional rehabilitation.

The lateral ligament complex includes 3 capsular ligaments: the anterior tibiofibular (ATFL), calcaneofibular (CFL) and posterior talofibular (PTFL) ligaments. Injuries typically occur during plantar flexion and inversion; the ATFL is most commonly torn. The CFL and the PTFL can also be injured and, after severe inversion, subtalar joint ligaments are also affected.

Commonly, an athlete with a lateral ankle ligament sprain reports having ‘rolled over’ the outside of their ankle. The entire ankle and foot must be examined to ensure there are no other injuries. Clinical stability tests for ligamentous disruption include the anterior drawer test of ATFL function and inversion tilt test of both ATFL and CFL function. Radiographs may rule out treatable fractures in severe injuries or when pain or tenderness are not associated with lateral ligaments. Stress radiographs do not affect treatment.

Ankle sprains are classified from grades I to III (mild, moderate or severe). Grade I and II injuries recover quickly with nonoperative management. A nonoperative ‘functional treatment’ programme includes immediate use of RICE (rest, ice, compression, elevation), a short period of immobilisation and protection with a tape or bandage, and early range of motion, weight-bearing and neuromuscular training exercises. Proprioceptive training on a tilt board after 3 to 4 weeks helps improve balance and neuromuscular control of the ankle.

Treatment for grade III injuries is more controversial. A comprehensive literature evaluation and meta-analysis showed that early functional treatment provided the fastest recovery of ankle mobility and earliest return to work and physical activity without affecting late mechanical stability. Functional treatment was complication-free, whereas surgery had serious, though infrequent, complications. Functional treatment produced no more sequelae than casting with or without surgical repair. Secondary surgical repair, even years after an injury, has results comparable to those of primary repair, so even competitive athletes can receive initial conservative treatment.

Sequelae of lateral ligament injuries are common. After conservative or surgical treatment, 10 to 30% of patients have chronic symptoms, including persistent synovitis or tendinitis, ankle stiffness, swelling, pain, muscle weakness and ‘giving-way’. Well-designed physical therapy programmes usually reduce instability. For individuals with chronic instability refractory to conservative measures, surgery may be needed. Subtalar instability should be carefully evaluated when considering surgery.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Brooks SC, Potter BT, Rainey JB. Treatment for partial tears of the lateral ligament of the ankle: a prospective trial. BMJ 1981; 282: 606–7

    Article  PubMed  CAS  Google Scholar 

  2. McCulloch PG, Holden P, Robson DJ, et al. The value of mobilisation and nonsteroidal anti-inflammatory analgesia in the management of inversion injuries of the ankle. Br J Clin Pract 1985; 2: 69–72

    Google Scholar 

  3. Ruth C. The surgical treatment of injuries of the fibular collateral ligaments of the ankle. J Bone Joint Surg 1961; 43A: 229–39

    Google Scholar 

  4. Viljakka T, Rokkanen P. The treatment of ankle sprain by bandaging and antiphlogistic drugs. Ann Chir Gynaecol 1983; 72: 66–70

    PubMed  CAS  Google Scholar 

  5. Jackson DW, Ashley, RD, Powell JW. Ankle sprains in young athletes: relation of severity and disability. Clin Orthop 1974; 101: 201–15

    PubMed  Google Scholar 

  6. Balduini FC, Tetzlaff J. Historical perspectives on injuries of the ligaments of the ankle. Clin Sports Med 1982; 1: 3–12

    PubMed  CAS  Google Scholar 

  7. Garrick JM. The frequency of injury, mechanism of injury, and epidemiology of ankle sprains. Am J Sports Med 1977; 5: 241–2

    Article  PubMed  CAS  Google Scholar 

  8. Glick JM, Gordon RB, Nashimoto D. The prevention and treatment of ankle injuries. Am J Sports Med 1976; 4: 136–41

    Article  PubMed  CAS  Google Scholar 

  9. Lassiter Jr TE, Malone TR, Garrett WE. Injury to the lateral ligaments of the ankle. Orthop Clin North Am 1989; 20: 629–40

    PubMed  Google Scholar 

  10. McConkey JP. Ankle sprains, consequences and mimics. Med Sport Sci 1987; 23: 39–55

    Google Scholar 

  11. Maehlum S, Dahljord OA. Acute sports injuries in Oslo: a oneyear study. Br J Sports Med 1984; 18: 181–5

    Article  PubMed  CAS  Google Scholar 

  12. Axelsson R, Renstrom P, Svenson H-O. Acute sports injuries in a central hospital [in Swedish]. Lakartidningen 1980; 77: 3615–7

    Google Scholar 

  13. Nilsson S. Sprains of the lateral ankle ligaments II. Epidemiological and clinical study with special reference to differentforms of conservative treatment. J Oslo City Hosp 1983; 33: 13–36

    PubMed  CAS  Google Scholar 

  14. Stormont D, Morrey B, An K, et al. Stability of the loaded ankle: relation between articular restraint and primary and secondary static restraints. Am J Sports Med 1985; 13: 295–300

    Article  PubMed  CAS  Google Scholar 

  15. Brostrom L. Sprained ankles: I. Anatomic lesions in recent sprains. Acta Chir Scand 1964; 128: 483–95

    Google Scholar 

  16. Balduini FC, Vegso JT, Torg JT, et al. Management and rehabilitation of ligamentous Injuries to the ankle. Sports Med 1987; 4: 364–80

    Article  PubMed  CAS  Google Scholar 

  17. Drez DJ, Kaveney MF. Ankle ligament injuries: practical guidelines for examination and treatment. J Musculoskel Med 1989; 6: 21–36

    Google Scholar 

  18. Makhani JS. Lacerations of the lateral ligament of the ankle; an experimental appraisal. J Int Coll Surg 1962; 38: 454–66

    PubMed  CAS  Google Scholar 

  19. Renstrom P, Wertz M, Incavo S, et al. Strain in the lateral ligaments of the ankle. Foot Ankle 1988; 9: 59–63

    PubMed  CAS  Google Scholar 

  20. Brostrom L. Sprained ankles: V. Treatment and prognosis in recent ligament ruptures. Acta Chir Scand 1966; 132: 537–50

    PubMed  CAS  Google Scholar 

  21. Brostrom L. Sprained ankles: VI. Surgical treatment of ‘chronic’ ligament ruptures. Acta Chir Scand 1966; 132: 551–65

    PubMed  CAS  Google Scholar 

  22. Brantigan J, Petegana L, Lippert F. Instability of the subtalar join: diagnosis by stress tomography in three cases. J Bone Joint Surg 1977; 59A: 321–4

    PubMed  CAS  Google Scholar 

  23. Harper M. The lateral ligamentous support of the subtalar joint. Foot Ankle Int 1991; 11: 354–8

    CAS  Google Scholar 

  24. Lahde S, Putkonen M, Puranen J, et al. Examination of the sprained ankle: anterior drawer test or arthrography. Eur J Radiol 1988; 8: 255–7

    PubMed  CAS  Google Scholar 

  25. Rasmussen O. Stability of the ankle joint: analysis of the function and traumatology of the ankle ligaments. Acta Orthop Scand Suppl 1985; 211: 1–75

    PubMed  CAS  Google Scholar 

  26. Chapman MW. Sprains of the ankle. Instr Course Lect 1975; 24: 294–308

    Google Scholar 

  27. Ryan JB, Hopkinson WJ, Wheeler JH, et al. Office management of the acute ankle sprain. Clin Sports Med 1989; 8: 477–95

    PubMed  CAS  Google Scholar 

  28. Stiell I, Greenberg G, McKnight R, et al. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med 1992; 21 (4): 384–90

    Article  PubMed  CAS  Google Scholar 

  29. Verma S, Hamilton K, Hawkins H, et al. Clinical application of the Ottawa ankle rules for the use of radiography in acute ankle injuries. Am J Roentgenol 1997; 169 (3): 825–7

    CAS  Google Scholar 

  30. Karlsson J. Chronic lateral instability of the ankle. Gothenburg: Gothenburg University, 1989: 158

    Google Scholar 

  31. Perlman M, Leveille D, DeLeonibus J, et al. Inversion lateral ankle trauma: differential diagnosis, review of the literature, and prospective study. J Foot Surg 1987; 26: 95–135

    PubMed  CAS  Google Scholar 

  32. Cox J, Hewes T. ‘Normal’ talar tilt angle. Clin Orthop 1979; 140: 37–40

    PubMed  Google Scholar 

  33. Diamond JA. Rehabilitation of ankle sprains. Clin Sports Med 1989; 8: 877–91

    PubMed  CAS  Google Scholar 

  34. Freeman MAR. Treatment of ruptures of the lateral ligament of the ankle. J Bone Joint Surg 1965; 47B: 661–8

    CAS  Google Scholar 

  35. Gauffin H, Tropp H, Odenrick P. Effect of ankle disc training on postural control in patients with functional instability of the ankle joint. Int J Sports Med 1988; 9: 141–4

    Article  PubMed  CAS  Google Scholar 

  36. Anderson KJ, LeCocq JF, Clayton ML. Athletic injury to the fibular collateral ligament of the ankle. Clin Orthop 1962; 23: 147–60

    Google Scholar 

  37. Brand RL, Collins MD, Tempelton T. Surgical repair of ruptured lateral ankle ligaments. Am J Sports Med 1981; 9: 40–4

    Article  PubMed  CAS  Google Scholar 

  38. Jaskulka R, Fischer G, Schedl R. Injuries of the lateral ligaments of the ankle joint: operative treatment and long-term results. Arch Orthop Trauma Surg 1988; 107: 217–21

    Article  PubMed  CAS  Google Scholar 

  39. Korkala O, Lauttamus L, Tanskanen P. Lateral ligament injuries of the ankle: results of primary surgical treatment. Ann Chir Gynaecol 1982; 71: 161–3

    PubMed  CAS  Google Scholar 

  40. Redler I, Brown GG, Williams JT. Operative treatment of the acutely ruptured lateral ligament of the ankle. South Med J 1977; 70: 1168–71

    Article  PubMed  CAS  Google Scholar 

  41. Reichen A, Marti R. Rupture of the fibular collateral ligamentsdiagnosis, surgical treatment, results. Arch Orthop Unfallchir 1974; 80: 211–22

    Article  PubMed  CAS  Google Scholar 

  42. Staples OS. Ruptures of the fibular collateral ligaments of the ankle. J Bone Joint Surg 1975; 57A: 101–7

    PubMed  CAS  Google Scholar 

  43. Chirls M. Inversion injuries of the ankle. J Med Soc N J 1973; 70: 751–3

    PubMed  CAS  Google Scholar 

  44. Drez D, Young JC, Waldmar D, et al. Nonoperative treatment of double lateral ligament tears of the ankle. Am J Sports Med 1982; 10: 197–200

    Article  PubMed  Google Scholar 

  45. Hansen H, Damholt V, Termansen NB. Clinical and social status following injury to the lateral ligaments of the ankle. Acta Orthop Scand 1979; 50: 699–704

    Article  PubMed  CAS  Google Scholar 

  46. Henning CE, Egge LN. Cast brace treatment of acute unstable ankle sprains. Am J Sports Med 1977; 5: 252–5

    Article  PubMed  CAS  Google Scholar 

  47. Hughes JR. Sprains and subluxations of the ankle joint. Proc R Soc Med 1942; 35: 765–6

    Google Scholar 

  48. Jakob RP, Raemy H, Steffen R, et al. Zur functionellen Behandlung des frischen Aussenbanddrisses mit der Aircast-Schiene (Functional treatment of fresh outer ligament ruptures using an Aircast splint). Orthopäde 1986; 15: 434–40

    PubMed  CAS  Google Scholar 

  49. Leonard MH. Injuries to the lateral ligaments of the ankle. J Bone Joint Surg 1949; 31: 373–7

    Google Scholar 

  50. Kannus P, Renstrom P. Treatment for acute tears of the lateral ligaments of the ankle: surgery, cast, or early controlled mobilization? J Bone Joint Surg 1991; 73A: 305–12

    PubMed  CAS  Google Scholar 

  51. Clark BL, Derby AC, Power GR. Injuries of the lateral ligament of the ankle: conservative vs. operative repair. Can J Surg 1965; 8: 358–63

    PubMed  CAS  Google Scholar 

  52. Evans GA, Hardcastle P, Frenyo AD. Acute rupture of the lateral ligament of the ankle: to suture or not to suture? J Bone Joint Surg 1984; 66B: 209–12

    CAS  Google Scholar 

  53. Gronmark T, Johnsen O, Kogstad O. Rupture of the lateral ligaments of the ankle: a controlled clinical trial. Injury 1980; 11: 215–8

    Article  PubMed  CAS  Google Scholar 

  54. Klein J, Schreckenberger C, Roddecker K, et al. Operative or conservative treatment of recent rupture of the fibular ligament in the ankle: a randomized clinical trial. Unfallchirurg 1988; 91: 154–60

    PubMed  CAS  Google Scholar 

  55. Korkala O, Rusanen M, Jokipii P, et al. A prospective study of the treatment of severe tears of the lateral ligament of the ankle. Int Orthop 1987; 11: 13–7

    Article  PubMed  CAS  Google Scholar 

  56. Moller-Larsen F, Wethelund JO, Jurik AG, et al. Comparison of three different treatments for ruptured lateral ankle ligaments. Acta Orthop Scand 1988; 59: 564–6

    Article  PubMed  CAS  Google Scholar 

  57. Niedermann B, Andersen A, Andersen SB, et al. Rupture of the lateral ligaments of the ankle: operation or plaster cast? A prospective study. Acta Orthop Scand 1981; 52: 579–87

    Article  PubMed  CAS  Google Scholar 

  58. Prins JG. Diagnosis and treatment of injury to the lateral ligament of the ankle: a comparative clinical study. Acta Chir Scand Suppl 1978; 486: 1–149

    Google Scholar 

  59. Sommer HM, Arza D. Functional treatment of recent ruptures of the fibular ligament of the ankle. Int Orthop 1989; 13: 157–60

    Article  PubMed  CAS  Google Scholar 

  60. van Moppens FI, van den Hoogenband CR. Diagnostic and therapeutic aspects of inversion trauma of the ankle joint [thesis]. Bohn: University of Maastricht, 1982: 166

    Google Scholar 

  61. Konradsen L, Holmen P, Sondergaard L. Early mobilizing treatment for grade III ankle ligament injuries. Foot Ankle 1991; 12: 69–73

    PubMed  CAS  Google Scholar 

  62. Eiff M, Smith A, Smith G. Early mobilization versus immobilization in the treatment of lateral ankle sprains. Am J Sports Med 1994; 22: 83–8

    Article  PubMed  CAS  Google Scholar 

  63. Kaikkonen A, Kannus P, Järvinen M. Early mobilization versus immobilization in the treatment of lateral ankle sprains. Am J Sports Med 1994; 22: 462–9

    Article  PubMed  CAS  Google Scholar 

  64. Schrier I. Treatment of lateral collateral ligament sprains of the ankle: a critical appraisal of the literature. Clin J Sports Med 1995; 5: 187–95

    Article  Google Scholar 

  65. Sommer H, Schreiber T. Early functional conservative therapy of a fresh fibular rupture of the capsular ligament from a socioeconomic point of view. Sportverletz Sportschaden 1993; 7: 40–6

    Article  PubMed  CAS  Google Scholar 

  66. Leanderson J, Wredmark T. Treatment of acute ankle sprain. Acta Orthop Scand 1995; 66: 529–31

    Article  PubMed  CAS  Google Scholar 

  67. Ahlgren O, Larsson S. Reconstruction for lateral ligament injuries of the ankle. J Bone Joint Surg 1989; 71B: 300–3

    CAS  Google Scholar 

  68. Karlsson J, Bergsten T, Lasinger O, et al. Surgical treatment of chronic lateral instability of the ankle joint. Am J Sports Med 1989; 17: 268–74

    Article  PubMed  CAS  Google Scholar 

  69. Gould N, Seligson D, Glassman J. Early and late repair of lateral ligament of the ankle. Foot Ankle 1980; 1: 84–9

    PubMed  CAS  Google Scholar 

  70. Cass JR, Morrey BF, Katoh Y, et al. Ankle instability: comparison of primary repair and delayed reconstruction after longterm follow-up study. Clin Orthop 1985; 198: 110–7

    PubMed  Google Scholar 

  71. Akeson WH, Amiel D, Woo SL-Y. Immobility effects on synovial joints: the pathomechanics of joint contracture. Biorheology 1980; 17: 95–100

    PubMed  CAS  Google Scholar 

  72. Jozsa L, Jarvinen M, Kannus P, et al. Fine structural changes in the articular cartilage of the rat’s knee following short-term immobilization in various positions: a scanning electron microscopical study. Int Orthop 1987; 11: 137–40

    Article  Google Scholar 

  73. Jozsa L, Reffy A, Jarvinen M, et al. Cortical and trabecular osteopenia after immobilization: a quantitative histological study of the rat knee. Int Orthop 1988; 12: 169–72

    Article  PubMed  CAS  Google Scholar 

  74. Jozsa L, Thoring J, Jarvinen M, et al. Quantitative alterations in intramuscular connective tissue following immobilization: an experimental study in the rat calf muscles. Exp Mol Pathol 1988; 49: 267–78

    Article  PubMed  CAS  Google Scholar 

  75. Ogata K, Whiteside LA, Andersen DA. The intraarticular effect of various postoperative managements following knee ligament repair: an experimental study on dogs. Clin Orthop 1980; 150: 271–6

    PubMed  Google Scholar 

  76. Tipton CM, Mathews RD, Maynard IA, et al. The influence of physical activity on ligaments and tendons. Med Sci Sports 1975; 7: 165–75

    PubMed  CAS  Google Scholar 

  77. Leach R, Schepsis A. Acute injury to ligaments of the ankle. In: Evarts C, editor. Surgery of the musculoskeletal system. Vol. 4. New York (NY): Churchill Livingstone, 1990: 3887–913

    Google Scholar 

  78. Meyer J, Garcia J, Hoffmeyer P, et al. The subtalar sprain: roentgenographic study. Clin Orthop 1988; 226: 169–73

    PubMed  Google Scholar 

  79. Michlovitz S, Smith W, Watkins M. Ice and high voltage pulsed stimulation in treatment of acute lateral ankle sprains. J Orthop Sports Phys Ther 1988; 9: 301–4

    PubMed  CAS  Google Scholar 

  80. Williamson JB, George TK, Simpson DC, et al. Ultrasound in the treatment of ankle sprains. Injury 1986; 17: 176–8

    Article  PubMed  CAS  Google Scholar 

  81. Cote DJ, Prentice WE, Hooker DN, et al. Comparison of three treatment procedures for minimizing ankle sprain swelling. Phys Ther 1988; 68: 1072–6

    PubMed  CAS  Google Scholar 

  82. Hocutt JE, Jaffe R, Rylander R, et al. Cryotherapy in ankle sprains. Am J Sports Med 1982; 10: 316–9

    Article  PubMed  Google Scholar 

  83. Meeusen R, Lievens P. The use of cryotherapy in sports injuries. Sports Med 1986; 8: 398–414

    Article  Google Scholar 

  84. Dupont M, Beliveau P, Theriault G. The efficacy of antiinflammatory medication in the treatment of the acutely sprained ankle. Am J Sports Med 1987; 15: 41–5

    Article  PubMed  CAS  Google Scholar 

  85. Kannus P, Jarvinen M. Nonoperative treatment of acute knee ligament injuries: a review with special reference to indications and methods. Sports Med 1990; 9: 244–60

    Article  PubMed  CAS  Google Scholar 

  86. Renström P, Kannus P. Injuries of the foot and ankle. In: DeLee J, Drez D, editors. Orthopaedic sports medicine: practice and principles. Vol. 2. Philadelphia (PA): Saunders, 1994: 1705–67

    Google Scholar 

  87. Sitler M, Ryan J, Wheeler B, et al. The efficacy of a semirigid ankle stabilizer to reduce acute ankle injuries in basketball. Am J Sports Med 1994; 22 (4): 454–61

    Article  PubMed  CAS  Google Scholar 

  88. Gross MT, Batten AM, Lamm AL, et al. Comparison of Don Joy ankle ligament protection and subtalar sling ankle taping in restricting foot and ankle motion before and after exercise. J Orthop Sports Phys Ther 1992; 19 (1): 33–41

    Google Scholar 

  89. Millar J. Joint afferent fibres responding to muscle stretch vibration and contraction. Brain Res 1973; 63: 380–3

    Article  PubMed  CAS  Google Scholar 

  90. Anderson KJ, LeCocq JF. Operative treatment of injury to the fibular collateral ligament of the ankle. J Bone Joint Surg 1954; 36A: 825–32

    PubMed  Google Scholar 

  91. Chrisman OD, Snook GA. Reconstruction of lateral ligament tears of the ankle: an experimental study and clinical evaluation of seven patients treated by a new modification of the Elmslie procedure. J Bone Joint Surg 1969; 51A: 904–12

    PubMed  CAS  Google Scholar 

  92. Elmslie RC. Recurrent subluxation of the ankle joint. Ann Surg 1934; 100: 364–7

    Article  PubMed  CAS  Google Scholar 

  93. Evans DL. Recurrent instability of the ankle – a method of surgical treatment. Proc R Soc Med 1953; 46: 343–4

    PubMed  CAS  Google Scholar 

  94. Storen H. A new method for operative treatment of insufficiency of the lateral ligaments of the ankle joint. Acta Chir Scand 1959; 117: 501–9

    PubMed  CAS  Google Scholar 

  95. Watson-Jones R. Fractures and joint injuries. Vol. 2, Ed. 4. Edinburgh: Churchill Livingstone, 1955: 821–3

  96. Althoff B, Peterson L, Renstrom P. Simple plastic surgery of inveterate ligament damage in the ankle joint. Lakartidningen 1981; 78: 2857–61

    Google Scholar 

  97. Karlsson J, Bergsten T, Lasinger O, et al. Reconstruction of the lateral ligaments of the ankle for chronic lateral instability. J Bone Joint Surg 1988; 70A: 581–8

    Google Scholar 

  98. Peterson L, Althoff B, Renstrom P. Enkel plastik av invetererade ledbandsskador i fotieden. Lakartidningen 1981; 78: 2857–61

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Sports Medicine Section, Department of Orthopaedics, Penn State University, Hershey Medical Center, Hershey, Pennsylvania, USA

    Scott A. Lynch

  2. Sports Medicine Section, Division of Surgical Sciences, Karolinska Institute, Stockholm, Sweden

    Per A. F. H. Renström

Authors
  1. Scott A. Lynch
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Per A. F. H. Renström
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Per A. F. H. Renström.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Lynch, S.A., Renström, P.A.F.H. Treatment of Acute Lateral Ankle Ligament Rupture in the Athlete. Sports Med 27, 61–71 (1999). https://doi.org/10.2165/00007256-199927010-00005

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/00007256-199927010-00005

Keywords

Search

Navigation