Table of Contents
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 nowÂ
- Foot X-ray if there is pain in the midfoot zone and any of: tenderness over the navicular bone; tenderness over base of 5thmetatarsal; 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)
- Palpate ligaments:
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 weeksÂ
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:Â blow to lateral side of knee Lateral:Â blow to medial side of knee (check peroneal nerve)Â 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 |
Now try some questions
Which is the most commonly damaged knee ligament?
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Draw a diagram of the knee with valgus and varus deformities, and another to show how valgus/varus forces can be applied.
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What is the anatomical purpose of the menisci of the knee?
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