Ligament injury

Ankle ligament injuries

Lateral ligament sprains are most common

Examination

• Ottawa rules help decide who needs an X-ray
  • Ankle X-ray if there is pain in the malleolar zone and any of: tenderness over the posterior edge or tip of lateral malleolus; tenderness over the posterior edge or tip of medial malleolus; or inability to weight-bear both immediately after injury and now 
  • Foot X-ray if there is pain in the midfoot zone and any of: tenderness over the navicular bone; tenderness over base of 5^thmetatarsal; or inability to weight-bear both immediately after and now
• Other parts to examination
  • Palpate ligaments:
    • Deltoid ligament (medially)
    • Lateral ligament complex (anterior talofibular ligament, calcaneofibular ligament and posterior talofibular ligament)
  • Palpate fibula up to knee (check for associated head of fibula fracture)
  • Squeeze test – squeeze mid-lower leg to test syndesmosis (positive test is pain at syndesmosis, requires urgent orthopaedic assessment if not intact)
  • Test weight-bearing (4 steps)
  • If the patient is not in too much pain
    • Anterior drawer test (hold foot still and push lower leg anteriorly and posteriorly) – tests talofibular ligament
    • Tilt test (invert foot at ankle and compare to other side) – tests lateral ligament complex, bias towards calcaneofibular ligament
  • + distal neurovascular exam (check peroneal and sural nerves)

Generic management

• Acutely, apply an ice pack for 20 minutes
• Give patient crutches, analgesia and advice
• Advice:
  • NSAIDs
  • RICE: Rest, Ice (20 minutes four times a day), Compression (elastic bandage) and Elevation for 24 hours
  • Then mobilise and weight-bear as able (walking on it will hurt but not harm)
  • Try to fully weight-bear on it for ~ 2 minutes twice a day for a month (e.g. while cleaning teeth)
  • Physio if not better in 1-2 weeks 

Specific management

Grading of ankle ligament injuries and their management

Grade	Definition	Clinical findings	Specific management
1	Ligament stretch with microscopic tearing	Local tenderness, minimal swelling, no joint instability	Elastic compression bandage (for 2 weeks) Heals in 2-4 weeks
2	Ligament stretch with partial tearing	Local tenderness, oedema, ecchymosis, partial loss of joint motion but definite end point	Stirrup splint (for 4 weeks) Heals in 4-12 weeks
3	Complete rupture of ligament	Marked swelling, severe pain, gross ankle instability	Aircast boot (for 6 weeks)May require surgical repair Heals in 3-6 months

Knee ligament injuries

Classification

Structure damaged	Mechanism	Symptoms
Cruciate ligaments	Anterior: forced flexion, hyperextension of knee (e.g. during tackle) or rotation injury to extended knee  Posterior: tibia forced backwards, e.g. fall on object or against dashboard in road traffic accident May hear ‘pop’	Knee collapses when put weight on it Immediate pain Difficulty weight-bearing Rapidly forming haemarthrosis
Collateral ligaments	Medial: blow to lateral side of knee Lateral: blow to medial side of knee (check peroneal nerve)  Lateral ligament injuries are uncommon	Pain on inner/outer knee Immediate pain Difficulty weight-bearing May have symptoms of instability (if high grade injury)
Meniscus tears	Rotational injury to flexed knee	Immediate pain Difficulty weight-bearing Slowly forming effusion  Clicking and locking (locking limiting extension)

Examination

• Ottawa rules help decide who needs a knee X-ray: age >55; inability to weight-bear both immediately after injury and now; isolated patella tenderness; head of fibula tenderness; or inability to flex to 90˚
• Knee examination may be difficult due to swelling and patients may need to return for full examination after 1 week

General management

• Acutely, apply an ice pack for 20 minutes
• Give patient crutches, analgesia and advice
• Advice:
  • NSAIDs
  • RICE: Rest, Ice (20 minutes four times a day), Compression (elastic bandage) and Elevation for 24 hours
  • Then mobilise and weight-bear as able (walking on it will hurt but not harm)
  • Try to fully weight-bear on it for ~ 2 minutes twice a day for a month (e.g. while cleaning teeth)
  • Physio if not better in 1-2 weeks

Specific management

Grading of knee ligament injuries and their management

Grade	Definition	Clinical findings	Specific management
1	Ligament stretch with microscopic tearing	Knee stable on clinical testing	Elastic or wool & crepe bandage (for 2 weeks) Heals in 2-4 weeks
2	Ligament stretch with partial tearing	Laxity but definite end point	Knee brace (for 4 weeks, or until no laxity on examination) Heals in 4-12 weeks
3	Complete rupture of ligament	Joint opens >1cm	Medial/lateral collateral ligament: knee brace (for 6-12 weeks or until no laxity on examination) Anterior/posterior cruciate ligament: cast and surgical reconstruction
Meniscus	Damage to menisci	Knee gives way, clicks and locks	Arthroscopic repair if locked knee or knee is no better in 2 weeks

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