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Inversion Ankle Sprains

The most common type of ankle sprain occurs when the foot is inverted or falling inward. When this type of ankle injury occurs, the 3 outer ligaments, or “lateral ligaments” are at risk of injury. This can result in a tear or increased laxity of the ligament. Pain is always felt on the outside of the ankle when you weight bear particularly on walking downstairs and down a slope. After the acute phase, walking on level ground may not be painful as the ankle stability in that range is provided by the mortise configuration of the bones of the ankle and these have not been injured. This can give a false sense of security of the situation. The situation becomes clearer when that ankle becomes easily sprain again and again with lesser movements in the future. We describe this as progressive ankle instability. Ladies that wear high heel shoes may notice instability when in this type of shoe wear and at other times feel quite normal.

What are Lateral Ligaments?

• the anterior talofibular ligament (ATFL);

• the calcaneofibular ligament (CFL); and

• the posterior talofibular ligament.

What is the injury mechanism?

As the foot goes into plantarflexion (toes pointed down), the structural stability contributed by the bones (talus and calcaneous) dissociates. Therefore, more stress is put on the Lateral Ligament (especially the ATFL) and make it more susceptible to injury. Previous sprain is a predictive factor for lateral ankle sprains.

What is the available treatment?

Mild inversion ankle sprains can be treated conservatively by physiotherapy (electrotherapy for pain relief and anti-inflammation, calf muscle stretching and ankle mobility exercise for restoration of range of motion, proprioceptive exercise for balance and strength training). The patient will need to wear an ankle brace for 6 weeks to reduce instability and chance of further damage.

With appropriate rehabilitation, pain and stability can improve in 6 months or less. If the ankle remains unstable or painful, despite adequate rehabilitation, and the lateral ligaments are demonstrated to be lax, Lateral Ligament Reconstruction Surgery is indicated. The goal of surgery is to improve 80-95% of ankle stability so that the patient can return to sports.

Lateral Ligament Reconstruction Surgery

How is the surgery done?

Arthroscopic technique is used to address any intra-articular ankle pathology and an open stabilization procedure is needed to reconstruct the ligament. The hamstring tendon graft (harvested in the inner side of the same knee) is usually used to reconstruct the anterior talofibular ligament (ATFL) and calcanofibular (CFL) ligament during open stabilization. After the repair is completed the ankle is put through total range of motion to make sure that it has been maintained throughout surgery.

How long will it take to return to sports after surgery?

•  It normally takes about 6-9 months to return to competitive sports after surgery.

•  The goal of rehabilitation is to return the patient to a normal and complete level of function as soon as possible without compromising the integrity of the surgically reconstructed ankle.

•  Early exercise is encouraged. Rehabilitation guidelines are generally as follows:

• Phase I - Begins immediately after surgery and extends through approximately two weeks. Patient is encouraged to perform gentle exercise in bed and walk with ankle brace and elbow crutch(es) starting the day of surgery.
• Phase II - begins two weeks post-operatively and extends to six weeks. Patient can walk with ankle brace alone or 1 elbow crutch. Mobilization exercises are encouraged to regain full range of motion.
• Phase III - typically starts at six weeks and extends through three to four months.  Patient can walk with ankle brace alone for continued protection of the graft from stresses. Light endurance training using stationary bike, swimming and balance training can start. Patient can gradually progress to moderate resistance and endurance training to regain strength of 70-80%.
• Phase IV - begins at four to six months. Patient can begin running program and agility training, prepare to return to sports.
• Phase V - begins with return to sport, usually at six months. Patient is educated to return to sports safely. Training to maintain strength, endurance, and proprioception is prescribed to improve sports performance gradually. Sports with risks of direct blow to the reconstruction site, e.g. snowboarding and soccer are recommended to resume 12 months after surgery.