Foot & Ankle
Acute Supination Injury - Ligament Injuries of the Foot
Supination Trauma, Sprain, Ligament Injuries, or Ligament Tears of the Foot
Ligament injuries of the ankle (inversion traumas, ankle sprains, torn ligaments) are highly common injuries that happen frequently, whether through a simple misstep in everyday life or, even more so, during a wide variety of leisure and sporting activities (see bfu accident statistics): An ankle injury is one of the most common musculoskeletal injuries of the human locomotor system worldwide.
Boldie, Sprained foot, marked as public domain, details on Wikimedia Commons
Nevertheless, at BodyLab Osteopathy and Physical Therapy, Rehabilitation, and Training in Zurich, we see different and completely varying approaches and medical treatments depending on the hospital or doctor: from casts and braces with or without walking aids to tapes, all the way to no immobilizing support and pure physiotherapeutic referrals – especially with sports doctors...
Due to the high number of injuries, a wide variety of scientific publications and studies deal with this topic. And we at BodyLab have also done some research in the literature.
As already mentioned in our blog Cruciate Ligament Injuries, different countries have their own medical boards that develop and publish guidelines for such common injuries based on the current state of science. Guidelines are recommendations designed to help therapists assess whether the wound healing process of an injury is progressing normally or not, and they analyze and recommend adequate therapeutic and treatment interventions. They provide framework information and serve as a reference.
We find the Dutch "KNGF Guideline for physical therapy in patients with acute ankle sprain" to be an important and excellent paper: in the Netherlands, patients can go directly to a physical therapist (without a doctor's referral), which means a physical therapist must know what to do and when! They must be able to rely on – and master – their differential diagnostics.
Anatomy and Function of Foot Ligaments – Capsule
The ankle joint provides the connection and thus the transfer of force from the body/lower leg to the foot/ground. It consists of two joint parts – the upper ankle joint, formed by the connection of the fibula and tibia (ankle) with the talus, and the lower ankle joint where the talus meets the calcaneus.
Most of the stability in the ankle joint is achieved through the arrangement of the bones and the capsule formation of the many ligaments. The muscles around the ankle joint originate in the lower leg and, with the exception of the Achilles tendon, are redirected via retinacula (band structures) or bone notches. Thus, the muscles do not attach directly to the ankle joint.
The joint is stabilized medially and laterally by ligaments. On the medial side, the broad deltoid ligament fans out from the inner ankle to the talus, the navicular bone (tarsal bone), and the calcaneus (heel). Anatomically, the deltoid ligament is divided into 4 parts. The main task of the deltoid ligament is stabilization against pronation (valgus position) and the inhibition of eversion. It is one of the strongest ligaments in the body.
Henry Vandyke Carter creator QS:P170,Q955620 Henry Gray creator QS:P170,Q40319, Gray354, marked as public domain, details on Wikimedia Commons
On the outside, 3 different ligaments form the lateral ligament – the calcaneofibular ligament and the anterior and posterior talofibular ligaments. They run from the outer ankle to the calcaneus and parts of the talus respectively.
Henry Vandyke Carter creator QS:P170,Q955620 Henry Graycreator QS:P170,Q40319, Gray355, marked as public domain, details on Wikimedia Commons
Based on the structural differences between the medial and lateral ligaments (width and arrangement), it is easy to see that the inner side of the ankle joint is stabilized much more strongly by passive structures. You can also feel for yourself that the foot can be moved further inward than outward.
If the "weaker" lateral ligaments are put under too much tension during a misstep or twisting of the foot, these lateral ligaments can easily be overstretched or torn.
Injuries and Injury Mechanisms
Twisting and rolling the foot inward leads to excessive movement of the foot, which usually (and first of all) affects the anterior talofibular ligament. Depending on the severity and force of the impact, this ligament can be overstretched or even torn. This can lead to further capsule injuries (since the ligaments are usually fused with the capsule), other ligament tears in the foot (e.g., bifurcate ligament), or even syndesmosis injuries (connection between the tibia and fibula). Furthermore, bone avulsions or fractures can occur.
Due to the quadrangular anatomical shape of the talus, compression injuries of the joint cartilage in the ankle mortise (tibia-fibula fork) of the upper ankle joint often occur, along with bone bruises. Twisting the talus too severely results in a high, localized load in the upper ankle joint, which also causes the patient to experience discomfort and pain on the inside of the joint.
Screening Process
The goal is to identify the problem and the injured structures, as well as to recognize red flags (severe injuries such as fractures). Do the symptoms match known clinical signs of an ankle sprain?
Is it an acute sprain from an accident? Or does the problem lie in chronic or functional instability? To detect or rule out a fracture after an acute accident, the Ottawa Ankle Rules are helpful. These have an almost 100% sensitivity (the sensitivity of a diagnostic test indicates how many diseased patients are actually identified by the test), but only a moderate (25-50%) specificity (which, in a medical diagnosis, indicates the proportion of healthy individuals who are correctly identified as not having the disease).
The Ottawa Ankle Rules state:
If the patient cannot walk four steps immediately after the injury, or
feels increased local bone tenderness along the posterior edges or tips of the malleoli (ankles) at 4 palpation points, or
feels increased bone tenderness at the navicular bone or base of the fifth metatarsal
medical contact with an X-ray is indicated.
Diagnostic Process
The goal of the physical therapy assessment and diagnosis is to use medical and other information to determine whether physical therapy can influence and change the triggering and hindering factors that led to the patient's medical health issue, as confirmed by the therapist.
The diagnostic process should result in / lead to a physical therapy diagnosis!
The therapist examines and determines the recency and severity of the injury to the capsular-ligamentous apparatus in relation to the medical history and physical assessment. The functional examination includes active tests (active mobility, can weight be put on the foot), as well as passive and palpatory tests. With the help of these, differential diagnostics should evaluate which structures are injured (muscle, tendon, cartilage, or capsular-ligamentous apparatus).
Afterward, the therapist should also be clear about which healing phase the tissue is in and whether a normal or abnormal healing process is taking place. This allows for a prognosis and provides guidance on physical therapy options.
Therapy
We recommend starting physical therapy measures as quickly as possible (within 5 days to a week).
Therapy differs based on the recency and state (wound healing phase) of the tissue, as well as the patient's symptoms.
In the acute phase (0 – 3 days after the accident), pain-relieving and swelling-reducing techniques are indicated. Depending on the level of pain, partial weight-bearing and elevating the injured foot make total sense during this time! A compression bandage for major swelling can also be considered in this initial stage. Nevertheless, the foot and toes should be actively moved without pain as much as possible.
A very important part of all treatments is also patient education and information!
Depending on the severity and healing status, further steps involve progressively resuming functionality and activity, increasing this based on pain tolerance. You start with functional exercises aimed at restoring normal range of motion, promoting ankle stability and coordination, and achieving a normal gait.
Over time, exercises are added to build foot strength and improve proprioception.
As already explained in our blog about wound healing, there is no faster healing than optimal healing! We at BodyLab have the expertise to perfectly support and guide you through injuries of the locomotor and musculoskeletal systems. This helps relieve your pain and detect or prevent delays and complications (such as infections or later deficits) early on. For an optimal, rapid, and best possible result.
Whenever you need us, we are here for you!
Your BodyLab Team, your specialists after twisting your ankle, getting you back on stable ground
Osteopathy and Physical Therapy | Rehabilitation and Training
Zurich Altstetten
References / Guidelines
KNGF-Guideline for Physical Therapy in patients with acute ankle sprain
Supplement to the Dutch Journal of Physical Therapy, Volume 116 / Issue 5 / 2006
KNGF-Flowchart for Physical Therapy in patients with acute ankle sprain / functional instability
Cover Image Credit
Harrygouvas, ANKLE SPRAIN 02b, CC BY-SA 3.0
Harrygouvas
