Many different injuries can occur at the ankle joint but the ankle sprain is the most frequent. An ankle sprain is a joint injury involving damage to the supporting ligaments of the ankle joint. These injuries can range from mild, involving little damage to the ligaments, to severe, a complete rupture of one or more supporting ligaments. 1 The medial ankle sprain, also known as the eversion ankle sprain, involves the ankle being forced into eversion and external rotation. Sprains to the medial ankle complex are less common because biomechanics of the ankle joint allow for less eversion than inversion. Also the deltoid ligaments are strong and often an avulsion fracture at the medial malleolus occurs before a deltoid ligament sprain. This type of sprain can occur when the ankle is forced into eversion to stress the deltoid ligaments and commonly occur comorbidly with syndesmotic and medial malleolus fractures.2
The ankle joint consists of the tibia and fibula articulating with the talus, also known as the talocrural joint. This joint has many ligaments and a surrounding thick capsule to provide stability and absorb the high amounts of force traveling thought the joint.1
The primary ligament supporting the medial aspect of the ankle is the deltoid ligament, which is comprised of the anterior and posterior tibiotalar ligaments, the tibiocalcaneal ligament, and the tibionavicular ligaments. These ligaments branch from medial malleolus of the tibia to the talus, calcaneus, and navicular. Cadaver studies have shown up to 4 superficial and 2 deep bands can be found. The superficial ligaments cross the talocrural and subtalar joint, whereas the deep ligaments only cross the subtalar joint. Hintermann et al. identifies the 6 ligamentous layers: tibionavicular, tibiospring, tibiocalcaneal, anterior tibiotalar, superficial tibiotalar, and posterior tibiotalar. Between all these fibers the deltoid ligament limits the ankle’s eversion as well as plantarflexion and dorsiflexion.2,3
Other anatomic structures that may be involved in a deltoid ligament sprain include: medial maleolus, ankle syndesmosis, and spring ligament.2,3 Image Source
The ankle is one of the most commonly injured joints with sprains accounting for 77% of all ankle injuries5 and for 10-30% of all injuries in sport:1,6,7,22
- 10-18% of ankle sprains are medial sprains and are typically associated with subsequent syndesmosis injury or medial maleolus fracture.
- 85% of ankle sprains are lateral sprains.
Specific populations and sports display an increased incidence of medial ankle sprains:7
- male gender
- higher competition levels
- young populations
- intercollegiate rugby
Mechanism of Injury2
- Excessive pronation
- Excessive External Rotation
- Excessive Abduction
Acute injury can be caused by mechanical forces that exceed the ligamentous, capsular, and bony strength. This injury can occur during2
- Competitive sports that require jumping and cutting activities.
- Landing on uneven surfaces
- Misstep on stairs
Chronic ankle instability/dysfunction is often present after ligamentous injury. It has been reported that there is a 50% incidence of chronic ankle dysfunction after injury to the ankle ligaments. Research shows that functional instability is present in 29-42% of people with previous sprained ankles.8 Mechanical factors can include valgus of the foot, and medial ankle laxity.9 Symptoms include:
- Pain with activity
- Recurrent swelling
- Complaints of "giving way"
- Repetitive injuries
A patient's clinical presentation is based on the severity of the ankle sprain. Primary indicators of a medial ankle sprain are the mechanism of injury, inability to bear weight, pain located at the medial ankle, and bruising/ecchymosis. The mechanism of injury for the deltoid ligament should be an eversion force at the ankle caused by an uneven surface or unexpected step. The pain location and severity can help diagnose medial ankle complex injuries, which usually have pain along the medial aspect of the ankle where the deltoid ligament is. The appearance of deformity should not be severe but can be due to the bruising/ecchymosis, or swelling.2, 4
Ankle sprains grades based on severity of damage to ligament complex.18
Grade 1: Partial tear of a ligament
- Mild point tenderness
- Minimal to no loss of function; Patient should be able to tolerate weight bearing and perform daily activity without complaint of severe pain.
- No mechanical instability; The patient will have negative clinical stress tests.
Grade 2: Incomplete tear of a ligament
- Moderate pain and swelling
- Point tenderness over medial ankle complex
- Mild to moderate ecchymosis
- Loss of range of motion
- Loss of function; Patient will complain of pain with weight bearing and ambulation.
- Mild to moderate mechanical instability; Patient will have mild positive findings on the clinical stress tests.
Grade 3: Complete tear of a ligament
- Severe swelling
- Severe ecchymosis
- Severe loss of function; Patient will be unable to bear weight and ambulate.
- Mechanical instability; Patient will have moderate to severe positive findings on clinical stress tests.
Plain radiographs: Plain Radiographs are used to exclude fracture and other bony pathologies. Image Source
Stress radiographs: Can be used to determine lesions of the deltoid ligaments in acute cases. An external rotation force is applied to the ankle during the radiographic test. A width of 4-5mm of the medial clear space (MSC) is measured — the space between the medial border of the talus and the lateral border of the medial maleolus — and is used to determine deep deltoid ligament rupture and need for operative treatment. This test can determine whether there is a lesion to the deltoid ligament but not the extent of the lesion.10 Research has shown that there is a 100% sensitivity and specificity to detect deep deltoid transection in cadavers when using a 5 mm cut off when using stress radiograph techniques. As the MCS is increased the tests have increased specificity, and as the MCS is decreased the tests have increased sensitivity.11 Image Source
Radiography Showing Medial Clear Space Image Source
Gravity stress radiograph: These radiographs use a gravity stressed position to determine the status of the deep deltoid ligament. A systematic review by Van Den Beker et al. documents that there is a 100% sensitivity and specificity to identify deep deltoid ligament transection in cadavers with complete deep deltoid ligament transection.11 Also there is research by Gill et al. that there is no significant difference between the gravity and manual stress radiograph techniques. Gravity stress testing also had a significantly decrease mean visual analog scale pain score compared to the manual stress technique (.64 to 2.96). The gravity stress radiography is limited by the inability to control plantar and dorsiflexion.11,12
Magnetic Resonance Imaging: Magnetic resonance imaging (MRI) can be used to determine the extent of the deltoid ligament disruption. Research by Koval et al. found that 19 out of 21 patients with positive stress tests had only partial deltoid ligament tears, and the remaining 2 had complete tears. MRI must be used to determine partial and complete deltoid ligament tears to decide whether surgical fixation is necessary. Patients with partial tears were treated nonoperatively and responded well to treatment.10 Image Source
Arthroscopy: Arthroscopy is not considered to be a practical diagnostic modality for detecting deltoid ligament rupture. Research by Schuberth et al. determined that MCS cannot reliably predict the integrity of the deep deltoid ligaments. The false positive rate for MCS was 85% at 3mm, 53% at 4mm, 27% at 5 mm, and 7.7% at 6 mm.11,13
Ultrasound: Ultrasound was used by Chen et al. to determine if there was a full rupture in the deltoid ligament. Benefits are that no anesthesia or analgesics are necessary to perform this diagnostic test but it is not widely used.14
Evaluation/Special Orthopedic Tests:
Clinical Tests: external rotation stress test, tenderness/pain, swelling and ecchymosis. Tenderness, pain, swelling and ecchymosis are commonly used to assess deltoid injury and indicate surgical treatment. McConnel et al. found that 63% of patients positive with tenderness, swelling and ecchymosis were negative in stress radiograph. If these subjective findings are used to determine surgery, patients without instability may be operated on.15 These tests can implicate the need for stress radiograph but should not be used to indicate surgical treatment or diagnose deltoid lesions.
External rotation stress test:The external rotation stress test is use to determine the integrity of the deltoid ligament. Compared to the abduction stress test that primarily stresses the superficial deltoid ligaments, the external rotation stress test stresses the deep deltoid ligament bands as well.
To perform this test:
- Have the patient in short sitting with knee bent at 90 degrees.
- The examiner will stabilize the leg with one hand, hold the foot in 90 degrees.
- Then apply a passive external rotation force to the foot and ankle.
Positive tests for deltoid ligament lesion are pain medially and talus displacement. This would indicate a deltoid ligament involvement and a medial ankle sprain. Positive test results for syndesmosis injury are pain of anterior or posterior tibiofibular ligaments and interosseous membrane. This test has a high inter rater reliability with a .75 kappa coefficient, high association with other clinical tests and predicts a longer time to return to competitive sport. The external rotation stress test is a reliable test and can be effectively used clinically.16 Video Source
Conservative treatment for deltoid ligament lesion is indicated when the deep deltoid ligament bands are still intact. A literature review found that conservative treatment of stable supination external rotation(SER) ankle fractures (deep deltoid ligament intact) had a lower incidence of osteoarthritis compared with SER ankle fractures treated with surgery. Greater than 80% of these patients were asymptomatic regardless of treatment. However for unstable SER fractures (deltoid ligament ruptured) conservative treatment resulted in a higher incidence of osteoarthritis and poorer clinical outcomes compared to surgical treatment.17
Conservative treatment involves:
- External Support: removable boot and weight bearing as tolerated.10
- Symptom Management:If ankle injuries are not managed correctly during the acute phase, there is an increased risk of symptoms persisting and the development of chronic ankle instability. Once symptoms are managed, standard rehabilitation for ankle sprains can begin including range of motion, muscle strengthening, and proprioceptive training.18, 20
- PRICE (see below)
- Compression bandages
Symptom management during the acute phase:
- A review of the literature shows that protection, rest, ice, compression and elevation (PRICE) is effective in treating acute ankle sprains. PRICE is successful at managing symptoms such as pain and reducing swelling during the acute phase (24-72 hours) after injury.21
- Protection-protect the ankle from further injury by resting and avoiding activities that cause pain.
- Rest- the use of crutches will allow the ankle to rest until one can walk without pain.
- Ice-apply ice to the ankle for 15-20 minutes as often as once per hour.
- Compression- compression wraps are used to decrease swelling.
- Elevation- elevate the ankle above the level of the heart to decrease swelling.
- Cryotherapy- should be used immediately after the injury to reduce pain and inflammation. Avoid the use of heat during the acute phase for it facilitates swelling and inflammation.18
- Compression bandages- double layer tubular compression bandages or double tubigrip (DTG) has not been proven to be an effective tool to manage symptoms and may increase the need for analgesia. One study attempted to estimate the clinical effectiveness of using tubular bandages, below the knee cast, Aircast ankle brace, and the Bledsoe boot for acutely managing severe ankle sprains. The findings showed that the below the knee cast and the Aircast brace offered cost-effective alternatives to tubular bandages for acute severe ankle sprain. Those who used the cast and brace showed overall recovery at 3 months. However, there was no difference in long-term outcome. Therefore, practitioners should consider patient compliance when choosing a brace or compression bandages.19
Here is a quick list of general conservative treatment exercises (please see the PT management page for images and a more in depth discussion of interventions):
- ROM exercises: It is important to begin range of motion exercises within pain free range as soon as possible. Active and passive range of motion exercises should be used to maintain range of motion for optimal function. Range of motion should be restored before beginning training in stabilization, strength, proprioception and function. To improve or maintain ROM, stretching & joint mobs are commonly used:
- Ankle Stretches (dorsiflexion, inversion): hold for 15 -30 seconds, 5 reps, every day. It is important to begin ankle dorsiflexion stretches early due to the Achilles tendon’s tendency to contract following injury.
- Alphabet exercises: Instruct the patient to draw the alphabet, one letter at a time A-Z. This exercise encourages movement of the ankle in all planes.
- Joint mobilizations:
- Anterior-posterior joint mobs: mobilizing the ankle into restricted planes can help to regain lost range of motion.
- Joint Stabilization: Stabilization is achieved through muscle strengthening exercises, balance, and proprioception exercises.
- Isometric Exercises: Resistance can be provided by an immovable object (wall or floor), elastic bands, or manual resistance. Exercises should be held for at least 6 seconds for maximal contraction, 10 repetitions and 3 sets daily. Exercise can be performed in dorsiflexion, plantarflexion, eversion, inversion, and eventually diagonals.
- Isotonic Exercises: Resistance can be provided by weights, theraband, or gravity. Exercises should be performed for 10-20 reps, 2-3 sets and up to 2 times a day depending on intensity. Each repetition should include concentric component and slow eccentric component. Exercises include plantarflexion push downward, dorsiflexion push upward, eversion and inversion.
- Balance & Proprioception training: Once balance is established, proprioceptive exercises can be progressed by:
- Balance on even surface
- Balance with eyes closed
- Balance on balance board
- High surface balance
- High surface with eyes closed
- High surface on balance board
Surgery & post-op treatment:
There are separate procedures for the different presentations of ankle fracture with deltoid ligament lesion. Before deciding upon surgery determining whether the ankle is unstable or not is critical. The following surgical procedures are described by Hintermann et al1.
Complete acute rupture: 1 Complete rupture at the proximal portion of the deltoid ligament. Procedure involves suturing the deltoid ligament directly to the bone or using a bony anchor
Surgery for rupture of superficial deltoid ligament: 1
|Type of Sprain||Description of Injury||Surgical Procedure||Post-op Management|
|Type 1||Proximal tear or avulsion of the tibionavicular and/or tibiospring ligament.||A short longitudinal incision between the tibionavicular and tibiospring ligaments is made. The ligaments are fixed onto the medial malleolus with a bony anchor.||Foot is placed in plaster cast for 6 weeks. PT starts after cast is removed. Active/passive mobilization, ankle proprioception and ankle inversion/eversion strength training are indicated. Ankle stabilizer or orthotic is recommended for future sporting activities|
|Type 2||Intermediate tear of the tibionavicular and/or tibiospring ligament.||The torn ligament/s are divided into two flaps: deep and superficial. The deep flap remains attached distally and the proximal end is surgically anchored to the medial malleolus. The superficial flap remains attached to the medial malleolus proximally, and the distal end is surgically anchored to the navicular tuberosity.||Foot is placed in plaster cast for 6 weeks. PT starts after cast is removed. Active/passive mobilization, ankle proprioception and ankle inversion/eversion strength training are indicated. Ankle stabilizer or orthotic is recommended for future sporting activities|
|Type 3||Distal tear of the tibionavicular and/or tibiospring ligament.||Sutures are placed in the spring ligament. If the tibionavicular ligament is completely detached then it is anchored to the navicular tuberosity||Foot is placed in plaster cast for 6 weeks. PT starts after cast is removed. Active/passive mobilization, ankle proprioception and ankle inversion/eversion strength training are indicated. Ankle stabilizer or orthotic is recommended for future sporting activities|
Hintermann Techniques for Deltoid Ligament Surgical Repair2 Procedures
Chronic rupture of deep deltoid ligament:1 The tibialis posterior is used as a graft site to reconstruct the deltoid ligament. Two options for treatment include bone tendon bone grafts and passing the graft through a drill hole.
Additional Web Based Resources:
1. Fong DT-P, Hong Y, Chan L-K, Yung PS-H, Chan K-M. A systematic review on ankle injury and ankle sprain in sports. Sports medicine (Auckland, N.Z.). 2007;37(1):73-94. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17190537.
2. Hintermann B, Knupp M, Pagenstert GI. Deltoid Ligament Injuries: diagnosis and management. Foot and ankle clinics. 2006;11(3):625. Available at: http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:This+material+may+be+protected+by+copyright+law.+(Title+17+U.S.+Code).#0 [Accessed November 26, 2011].
3. Hintermann B. Medial ankle instability. Foot and ankle clinics. 2003;8:723. Available at: http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:This+material+may+be+protected+by+copyright+law.+(Title+17+U.S.+Code).#0 [Accessed November 26, 2011].
4. Lynam L. Assessment of acute foot and ankle sprains. Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association. 2006;14(4):24-33; quiz 34. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16878848.
5. Kemler E, Port I van de, Backx F, Dijk CN van. A systematic review on the treatment of acute ankle sprain: brace versus other functional treatment types. Sports medicine (Auckland, N.Z.). 2011;41(3):185-97. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21395362.
6. Lin C-F. Ankle Syndesmosis Injuries: Anatomy, Biomechanics, Mechanism of Injury, and Clinical Guidelines for Diagnosis and Intervention. Journal of Orthopaedic and Sports Physical Therapy. 2006. Available at: http://www.jospt.org/issues/id.1132/article_detail.asp [Accessed July 8, 2011].
7. Waterman BR, Belmont PJ, Cameron KL, et al. Risk factors for syndesmotic and medial ankle sprain: role of sex, sport, and level of competition. The American journal of sports medicine. 2011;39(5):992-8. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21289274 [Accessed October 29, 2011].
8. Gerber JP, Williams GN, Scoville CR, Arciero R a, Taylor DC. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot & ankle international / American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 1998;19(10):653-60. Available at: http://www.ncbi.nlm.nih.gov/pubmed/9801078.
9. Tourné Y, Besse J-L, Mabit C. Chronic ankle instability. Which tests to assess the lesions? Which therapeutic options? Orthopaedics & traumatology, surgery & research : OTSR. 2010;96(4):433-46. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20493798 [Accessed July 23, 2011].
10. Koval KJ, Egol K a, Cheung Y, Goodwin DW, Spratt KF. Does a positive ankle stress test indicate the need for operative treatment after lateral malleolus fracture? A preliminary report. Journal of orthopaedic trauma. 2007;21(7):449-55. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17762475.
11. Bekerom MPJ van den, Mutsaerts EL a R, Dijk CN van. Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures: a systematic review of the literature. Archives of orthopaedic and trauma surgery. 2009;129(2):227-35. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18953550 [Accessed September 15, 2011].
12. Gill JB, Risko T, Raducan V, Grimes JS, Schutt RC. Comparison of manual and gravity stress radiographs for the evaluation of supination-external rotation fibular fractures. The Journal of bone and joint surgery. American volume. 2007;89(5):994-9. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17473136 [Accessed September 29, 2011].
13. Schuberth JM, Collman DR, Rush SM, Ford L a. Deltoid ligament integrity in lateral malleolar fractures: a comparative analysis of arthroscopic and radiographic assessments. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons. 1960;43(1):20-9. Available at: http://www.ncbi.nlm.nih.gov/pubmed/14752760 [Accessed September 3, 2011].
14. CHEN P, WANG T. Ultrasonographic examination of the deltoid ligament in bimalleolar equivalent fractures. Foot & ankle international. 2008;29(9):883-886. Available at:http://www.ncbi.nlm.nih.gov/pubmed/18778665/
15. McConnell T, Creevy W, Tornetta P. Stress examination of supination external rotation-type fibular fractures. The Journal of bone and joint surgery. American volume. 2004;86-A(10):2171-8. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15466725.
16. Alonso A, Khoury L. Clinical tests for ankle syndesmosis injury: reliability and prediction of return to function. The Journal of orthopaedic and sports physical therapy. 1998;27(4):276-284. Available at: http://www.ncbi.nlm.nih.gov/pubmed/9549711 [Accessed December 1, 2011].
17. Gougoulias N, Khanna A, Sakellariou A, Maffulli N. Supination-external rotation ankle fractures: stability a key issue. Clinical orthopaedics and related research. 2010;468(1):243-51. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2795847&tool=pmcentrez&rendertype=abstract [Accessed October 26, 2011].
18. Wolfe MW, Uhl TL, McCluskey LC. Management of ankle sprains. American Family Physician. 2001;63(1):91-105. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19427949.
19. Cooke MW, et. al Treatment of severe ankle sprain: a pragmatic randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of three types of mechanical ankle support with tubular bandage. The CAST trial. Health Technol Assess. 2009;13(13): 1-121. http://www.ncbi.nlm.nih.gov/pubmed/19232157
20. Altizer, L. Strains and Sprains. Orthopaedic Nursing. 2003;22(6): 404-409.
21. Cohen RS, Balcom TA. Current treatment options for ankle injuries: Lateral ankle sprain, achilles tendonitis, and achilles rupture. Curr Sports Med Rep. 2003;2(5):251-254.
22. Shaw MY, et al. Ankle bracing, fatigue, and time to stabilization in collegiate volleyball athletes. J Ath Tr 2008;43(2):164–171