Anatomy
Ankle joint insideA. Ligamentum mediale/deltoideum
B. Calcaneus
C. Talus
D. Tibia
Cause
Rupture of the medial collateral ligaments of the ankle joint is much rarer than rupture of the lateral collateral ligaments of the ankle joint. The rupture occurs if the foot wiggles around (pronation), causing the inner ligaments to overstretch and rupture. In mild cases it is called a sprain/strain and in severe cases a full or partial rupture/tear.
Consequential injuries associated with ligament ruptures can include rupture of the ligaments holding the tibia and fibula together (syndesmosis rupture), fluid accumulation in the joint (traumatic synovitis), tendonitis, rupture of ligaments in the metatarsal, ankle fractures, cartilage damage inside the ankle joint (major cartilage lesions are seen in 7% of sprains) and damage to the subtalar joint (the joint between the heel bone (calcaneus) and ankle roll bone (talus)).
In some cases, ankle ligament ruptures are complicated by inflammation of the joint capsule around the ankle joint (capsulitis).
Symptoms
Sudden onset of pain on and below the medial malleolus, swelling due to bleeding, pain when walking.
Examination
Diagnosis is made on clinical examination, where in mild cases (sprains) there is minimal swelling and no discomfort with normal walking, but usually pressure soreness on the medial malleolus. The size of the swelling is not a measure of the extent of the injury. Pronounced swelling or pain should be examined by an appropriate professional to rule out, among other things, ankle fractures, especially fractures in the growth zone of the lower leg at the ankle and rupture of the ligaments between the tibia and fibula (syndesmosis rupture).
If a fracture or syndesmosis fracture is suspected, an X-ray of the ankle joint should be taken. Previous vigorous twisting of the ankle joint in the acute stage to assess the degree of looseness is no longer indicated as this does not affect the choice of treatment. Ultrasound scanning can produce internal ligaments and ligaments between the tibia and fibula (lig. tibiofibulare ant. inf.) that rupture with syndesmosis rupture and inflammation with capsulitis (Colò G, et al. 2023). Dynamic ultrasound scanning can assess ligament looseness (the ligament is stressed during simultaneous ultrasound scanning to see if the joint gap increases as a sign of ligament rupture) (Heitz PH, et al. 2024).
Treatment
The treatment of ligament injuries today is conservative (rehabilitation) (Loozen L, Veljkovic A, Younger A. 2023). In the past, many patients underwent surgery and plastering, which has largely been abandoned for uncomplicated ligament ruptures.
In cases of repeated ankle sprains and syndesmosis ruptures with significant looseness and complex injuries (fractures, multiple torn ligaments), surgery is often indicated (Corte-Real N, Caetano J. 2021).
Bandage
During rehabilitation, tape (or different types of ankle braces) is often used when running on uneven surfaces or running with rapid changes of direction. The ligaments contain nerve cells (proprioreceptors) that send information to the brain about the position of the ankle joint. Information is sent from the brain to the muscles, which are activated to keep the ankle joint in the correct position. When the ligaments are damaged, these nerve pathways don’t function optimally, increasing the risk of twisting the foot again.
The primary function of the tape is to stimulate the small nerve cells (proprioreceptors) in the skin so that they can ‘substitute’ for the temporarily damaged nerve cells in the ligaments. The function of the tape is thus not just a purely mechanical ‘stabilisation’ of the ankle joint, see tape 1, tape 2 og tape 3.
In some cases, certain types of bandages around the ankle joint can be beneficial for 5-6 weeks. Specialised bandages have been shown in some studies to reduce the risk of ligament re-injury.
Complications
If the progression is not smooth, you should consider whether the diagnosis is correct or if there are complications: rupture of ligaments between the tibia and fibula (syndesmosis rupture), ankle fracture, avulsion (avulsion), peroneal luxation, tendonitis, tendon sheath inflammation, fluid accumulation in the joint (traumatic synovitis), cartilage damage in the joint (osteochondral lesion).
If rehabilitation is handled properly, it is rare for the injury to result in a chronically loose ankle joint. If the result is a chronically loose ankle joint, intensive balance training is recommended. Neglected treatment can result in the development of flatfoot. If rehabilitation is not sufficient, bandages can be tried. If this is not enough either, surgery to tighten the ligaments can be tried (Corte-Real N, Caetano J. 2021).
Especially
Rocking board exercises 1 and 2 are important in both rehabilitation and prevention (Al Attar WSA, et al. 2022). Rocking board exercises should be performed regularly for the rest of the active sports career as a preventive measure if there is a history of ankle ligament injuries.
Start by standing on both legs on the seesaw and support with your hands on the wall. Gradually release the support with your hands and finally train with support on one leg only. You can brush your teeth morning and evening on the seesaw.
