VINOBA BHAVE UNIVERSITY

HAZARIBAG, JHARKHAND
DEPARTMENT OF PHYSIOTHERAPY

Lateral Ligaments Sprain of Ankle

Submitted by
Name : Swati Shubhra
Registration no. : BPT 1624590 / 2020
Roll no. : 210010465206
Session : 2020-2024
 ACKNOWLEDGEMENTS

I would like to express my sincere gratitude toward The Director

“PROFESSOR YASHVIR JAGGI”, Department of Physiotherapy,
Vinoba Bhave University, Hazaribagh; Jharkhand for giving me an
opportunity to work on case study.

Also, I would like to express my special thanks to my project guide

“DR.MERAJ NABI SIDDIQUI” for giving me this project work.
 CERTIFICATE

This is to certify that Ms. SWATI SHUBHRA of Registeration

no.:-BPT1624590/2020,Roll no.:-210010465206,Session
2020-2024,of Department of physiotherapy,Vinoba Bhave
University,Hazaribagh,Jharkhand has completed the case
study on the

TOPIC:- Lateral ligaments sprain of ankle

DR. MERAJ NABI SIDDIQUI PROF.YASHVIR JAGGI

PROJECT GUIDE DIRECTOR
 INDEX
1.Introduction
2.Etiology
3.Pathophysiology
4.Functional anatomy
5.Clinical features
6.clinical assessment
7.Management
8.Recent advancement in physiotherapy treatment
 LATERAL LIGAMENTS SPRAIN OF ANKLE

Introduction: -
A lateral ankle sprain is a tear or stretching of the ligaments on the
outside of the ankle, which prevent the foot from rolling inward. It is
the most common type of ankle sprain, accounting for 85% of ankle
injuries.
The lateral ligaments of the ankle are three ligaments that provide
stability to the ankle joint and prevent it from inverting.
1.Anterior talofibular ligament (ATFL)
2.Calcaneofibular ligament (CFL)
3.Posterior talofibular ligament (PTFL)

(ATFL): - This ligament runs from the lateral malleolus to the

anterior talar body. It prevents the talus from moving forward when
the foot plantarflexes.

(CFL): - This ligament runs from the lateral malleolus to the lateral
calcaneus. It helps stabilize the ankle when the heel inverts.

(PTFL): - This ligament runs from the lateral malleolar fossa to the
talus. It limits the talus from moving forward or backward relative to
the fibula and tibia.
Fig:- Lateral ligaments of ankle
ETIOLOGY :-
Lateral ankle sprain,also known as an inversion or supination ankle
sprain,is usually caused by overstretching or tearing the ligaments
on outside of the ankle.This can happen when the ankle rolls
outward while the foot turns inward,which can occur during a rapid
shift of the body’s center of mass.

SOME RISK FACTORS FOR LATERAL ANKLE SPRAINS

INCLUDE :-
*Previous ankle injury
*Weak ankle and foot muscles
*High arches
*Hypermobility
*Poor balance
*Being overweight
*Participating in sports like football,basketball
*Wearing shoes that don’t fit properly
PATHOPHYSIOLOGY :-
The ankle functions as a complex structure with contributions from
the talocrural,subtalar,and inferior tibiofibular joints.Each of these
joints must be considered in the pathophysiology of lateral ankle
sprains.
Lateral ankle sprain typically occur when the rearfoot
undergoes excessive supination on an externally rotated lower
leg,or inversion of the rearfoot.
Recurrent ankle sprain is extremely common;infact,the most
common predisposition to suffering a sprain is the history of having
a previous ankle sprain.

FUNCTIONAL ANATOMY :-
The ankle complex comprises of 3 articulations;the talocrural
joint,the subtalar joint,and the distal tibiofibular
syndesmosis.These 3 joints works to allow coordinated movement
of the rearfoot.Rearfoot motion is often defined as occuring in the
cardinal planes as follows;
Saggital plane motion (plantarflexion-dorsiflexion)
Frontal plane motion (inversion-eversion)
Transverse plane motion (internal rotation-external rotation)
Rearfoot motion,however doesn’t occur in isolation in the individual
planes,rather,co-ordinated movement of the 3 joints allows the
rearfoot as a unit about an axis of rotation oblique to the long axis of
the lower leg.
CLINICAL FEATURES :-
The clinical manifestation of lateral ankle sprain include;
*Pain : Immediate pain on the outside of the ankle
*Swelling and bruising : Swelling and bruising on the outside of the
ankle
*Tenderness : Tenderness when pressure is applied to the outside
of the ankle
*Instability : A feeling of instability or looseness in the ankle
*Difficulty in walking : Difficulty in walking or putting weight on the
affected foot
*Popping or snapping : A popping or snapping sound is heard when
the injury occurs.

OTHER SYMPTOMS INCLUDE :-

*Mild redness and heat
*Tingling ,numbness,or pins and needles sensation
*Stiffness in the ankle
CLINICAL ASSESSMENT :-
*HISTORY :-Accurate clinical assessment of the ankle injury needs
a comprehensive and organized history.The patient typically
complaints of lateral ankle swelling (local or diffuse),pain,bruising
and limited ROM.
History must also incude age,demographic
data,time since injury,exact mechanism,nature of injury,location of
pain,previous history of ankle sprain or instability,history of other
lower extremity pain or deformities,mechanical symptoms(locking
or feeling of loose bodies) and paresthesia.
*PHYSICAL EXAMINATION :- After looking for a fracture by careful
palpation of the critical anatomic check-points especially lateral
and medial malleoli,the base of the fifth metatarsal and navicular
bones,ecchymosis,edema,point tenderness,ROM,ligamentous
laxity,and muscle strength should be carefully evaluated in all
suspected ankle spains.
*The provocative tests are also important.
Anterior drawer test (ADT) and Talar tilt (inversion stress) tests are
utilized to evaluate lateral ankle instability.These tests should be
performed in comparison with the uninjured ankle.Tests are
regarded as positive in cases of increased laxity.
To rule out less common syndesmotic
injuries,provocative tests are helpful.These tests including the
squeeze test (lower leg squeeze at midcalf),crossed -leg test(asking
the individual to cross the legs with the injured leg resting at midcalf
on the other knee),external rotation stress test(concurrent external
and dorsiflexion),heel thump test(applying gentle but firm thump on
the heel with the fist)
*GRADING :-
Lateral ankle sprains are characteristically classified as grade 1,2 or
3,based on the severity of injury to the lateral ligaments.
A grading system has been introduced in which more severe grades
need longer rehabilitation for full recovery.

ANKLE SPRAIN GRADING SYSTEM:-

Grade Hem- Point Loss Decre Swelli ADT TTT1 Stress
orrhag tende- of ased ng radiogr
e rness functi total aphy
on ankle
motio
n

1 Little No No <5* <0.5c - - -

or no m
2 yes yes Some >5* >0.5 + - -
and and
<10* <2cm
3A Yes Yes Near >10* >2cm + + ADM<3
total mm

3B Yes Yes Near >10* >2cm + + ADM>

total 3mm
ADM:- Anterior drawer movement
ADT :-Anterior drawer test
TTT :-Talar tilt test
#IMAGING

*Plain radiography :- The Ottawa Ankle and Foot Rules are clinically
recommended for all acute ankle injuries.According to these
rules,plain ankle radiography is needed,if pain exists in the
malleolar zone and there is atleast one of the following signs:
1.Bone tenderness in the distal 6cm of the post.half of the tibia or
tip of the medial malleolus
2.Bone tenderness in the distal 6cm of the post.half of the fibula or
tip of the lateral malleolus;and
3.Inability of weight-bearing for 4 steps both immediately after injury
and in the physician’s office or emergency department.
*Stress radiography :- The technique is painful and needs local
anesthesia.The result is also inconclusive due to high variability.
*Ultrasound :- Ultrasound may be useful for the diagnosis of ankle
ligamentous injuries.Diagnostic accuracy of upto 95% for ATFL and
90% for CFL injuries has been reported.
*MRI :- MRI has good accuracy to detect osteochondral lesions of
the talus and determine the level of injury to the ankle syndesmotic
ligaments.

TREATMENT AND REHABILITATION

*Rest,ice,compression,and elevation
*Cryotherapy for 3-7 days is routinely used to reduce pain,minimize
swelling and bleeding due to vasoconstriction.
*Analgesic and anti-inflammatory medications :- Oral and topical
NSAIDs are commonly prescribed to decrease pain and
inflammation in the acute phase of ankle sprain.
*Acetaminophen :- Effective for pain and swelling,and ROM in the
first 2 weeks following acute sprain.
*Bracing and immobilization :- A short episode of immobilization
(Less than 10 days) with a below knee plaster cast or rigid stirrup
brace may be of added value in grade 3 sprains to decrease pain
and swelling.
*Weight bearing and walking aid :- Integrating early weight bearing
and movement has a positive influence on the reduction of swelling
and restoration of normal ROM.
*Foot orthosis :- This may have a significant positive effect in
athletes with acute ankle sprain .They considerably diminishes pain
and increases postural control after an acute ankle sprain.
*Manual therapy :- The application o manual techniques in the
rehabilitation process of acute ankle sprains may be beneficial in
pain reduction,ROM,especially dorsiflexion,stride
length,and,functional recovery.
Comon manual techniques include anterior to posterior talocrural
glides and talocrural distraction in theneutral position.
*Exercise therapy :- The use of exercise therapy is the main
component of the treatment programme.These programs can
reduce the prevalence of recurrent injuries,as well as functional
ankle instability.
*ROM exercises :- Early ROM exercises should be started as soon as
pain permits.Such a program can frequently be commenced
immediately in grade1 and 2 injuries but may need to be postponed
in a grade 3 injury.As soon as the pain permits,individuals should
begin weight-bearing and ROM rehabilitation.
However,it is better to minimize inversion and eversion in the early
stages of rehabilitation.After decreasing tenderness over the
ligament,inversion and eversion exercises should be added.
*Stretching exercises :- These exercises should be started with
open chain ankle motions for all planes and non-weight bearing
dorsiflexion stretch with upper extremity assist and progress to
standing calf stretch and generalized ankle stretching in the closed
chain.
*Strengthening exercises :- After restoration of normal ROM,the
athlete starts this phase,beginning with isometric exercises against
an immobile object in both frontal and sagittal planes.
*Neuromuscular and proprioceptive exercises :- The next phase of
rehabilitation involves neuromuscular and proprioceptive training to
restore the balance and postural control.
Early application of
neuromuscular training in the first week of injury gives rise to higher
activity levels without consequences such as increased
pain,swelling,or the rate of re-injury.
*Electrophysiological modalities :- Traditionally,these modalities
have been suggested to improve the healing process following
acute ankle sprain.
*Surgical therapy :- Surgical techniques emphasize anatomic
repair/reconstruction to regain stability while trying to minimize
complications such as limitation of joint motion and long term
development of degenerative arthritis.
 The modified Brostrom
procedure is commonly used and comprises the direct anatomic
repair o torn lateral ligaments together with reinforcement of the
inferior extensor retinaculum.

RECENT ADVANCES IN PHYSIOTHERAPY FOR LATERAL

LIGAMENT SPRAINS INCLUDE :-
*Exercise based interventions:-
Progressive exercises can improve
strength,flexibility,balance,agility,and endurance in the ankle.These
exercises can target the ligaments,muscles,and structures around
the ankle joint.
*Neuromuscular re-education:-
Proprioceptive neuromuscular facilitation exercises can improve
ankle functional outcomes.Balance training should be performed
throughout rehabilitation.
*Platelet-rich plasma (PRP) therapy :-
PRP injections may be an option for managing lateral ankle
instability.One study found that PRP injections resulted in similar
outcomes to rigid immobilization at 24 weeks,and less pain at 8
weeks.
*Other biologics:-
Bone marrow concentrate,stem cells,and hyaluronic acid are being
investigated as adjuncts to surgical and non surgical options.
Reference:- http://ncbi.nlm.nih.gov/
https://scholar.google.com/