Ankle injuries are not limited to just athletes. Even stepping off a curb incorrectly can injure your ankle ligaments. What is a ligament? What is an ankle ligament tear? Do torn ankle ligaments need surgery? What is ankle ligament surgery? Let’s dig in.
What is an Ankle Ligament Tear?
A ligament is a thick band of connective tissue that connects bone to bone. The ankle has multiple ligaments on both the inside (medial) and outside (lateral) portion of the joint that stabilize the joint The most common type of ankle ligament injury is an inversion sprain where the foot rolls inward and stretches the ligaments on the outside of the ankle (1). There are three major ligaments on the outside of the ankle that stabilize the j oint.
- Anterior talofibular ligament (ATF)
- Anterior talofibular ligament (PTF)
- Calcaneal fibular ligament (CF)
The names of a given ligament are simply the names of the two bones that it spans across. For example, ATF ligament is the ligament that connects the talus bone to the fibular bone. The ankle ligaments are susceptible to injury including strain and tears.
How Serious is a Ligament Tear?
It depends upon the severity of the tear. There are three types of ankle ligament tears:
- Partial-thickness ( the tear only involves a portion of the ligament)
- Full-thickness (tear involves entire ligament but the ligament is still intact)
- Full-thickness with retractions (tear involves entire ligament and the two edges are pulled apart).
If you have sustained a full-thickness tear with retractions, surgery is your only option. Fortunately, a large number of ankle ligament injuries are only partial-thickness, or full-thickness tears without retractions. These patients can likely avoid ankle ligament surgery. Have you sustained an ankle ligament injury and don’t know exactly what type of tear you have? This is not uncommon as the radiologist often does not comment on the specific type of ligament tear. In addition, many surgeons do not actually look at the MRI and rely on the radiologist’s report.
Almost all ankle sprains can be treated without surgery. Surgery options include repair or reconstruction of the damaged ligaments. When this is not possible a tendon from a different site is harvested and used to construct a new ligament. In this scenario, holes are drilled into the bones and the harvested tendon is laced through the holes to create the new ligament (2). The peroneal tendon is a common tendon used in ankle reconstruction.
What are the Risks of Ankle Ligament Surgery?
Risks associated with ankle ligament surgery include bleeding, infection, and surgical failure. In one study the complication rate was 29% and involved wound healing, nerve injuries, blood clots (3), complex regional pain syndrome and recurrent instability (4).
How Long is the Recovery from Ankle Surgery?
Outcomes vary on study design, the specific type of surgery, and patient demographics. In one recent study athletes who underwent lateral ankle ligament tear surgery returned to training on average at 9 weeks (5). Return to sports took longer and was 11 weeks on average. If there were other injuries such as trauma to the cartilage, return to training was longer, at 12 weeks on average, and return to sports was 15 weeks.
Are there Non-Surgical Treatment Options?
Almost all ankle sprains can be treated without surgery. There are new nonsurgical techniques that utilize a patient’s own bone marrow-concentrate cells to heal ankle ligament injuries. Bone marrow concentrate contains cells that can facilitate a local repair response by bringing other cells into the area as well as turning into ligament cells (6). The procedure is called a percutaneous ankle ligamentoplasty (PAL). At the Centeno Schultz Clinic, we started using bone marrow concentrate on ankle ligament injuries over a decade ago. Below are MRI’s before and after bone marrow concentrate treatment. On the left, the red circle identifies the anterior talofibular ligament which is crimped and loose. The MRI on the right illustrates the complete healing of the ATF ligament after PAL treatment.
The procedure involves the precise injection of PRP or bone marrow concentrate into the injured ankle ligaments. Ultrasound is used to precisely inject cells. This is a challenging procedure that your PCP or orthopedic surgeon can not perform. To watch a ultrasound-guided ankle injection please click on the video below.
Ligaments are thick bands of connective tissue that connects bone to bone. Ankle ligaments provide important support to the ankle and are susceptible to injury. There are three major types of ankle ligament injuries. The majority of ankle ligament injuries do not require surgery. Ankle ligament surgery involves either repair of the damaged ligament or reconstruction utilizing a patient’s own tendon as the new ligament. Surgical complications include wound healing, nerve damage, and blood clots. A new nonsurgical technique that utilizes a patient’s own bone marrow-concentrate cells is an effective alternative to heal ankle ligament injuries. It avoids the lengthy rehabilitation and risks associated with ankle ligament surgery.
1.Manganaro D, Alsayouri K. Anatomy, Bony Pelvis and Lower Limb, Ankle Joint. [Updated 2019 Aug 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545158/
2. Shakked RJ, Karnovsky S, Drakos MC. Operative treatment of lateral ligament instability. Curr Rev Musculoskelet Med. 2017;10(1):113-21..doi: 10.1007/s12178-017-9391-x
3. Corte-Real NM, Moreira RM. Arthroscopic repair of chronic lateral ankle instability. Foot Ankle Int. 2009;30(3):213-7. DOI: 10.3113/FAI.2009.0213
4. Barbari SG, Brevig K, Egge T. Reconstruction of the lateral ligamentous structures of the ankle with a modified Watson-Jones procedure. Foot Ankle. 1987;7(6):362-8. DOI: 10.1177/107110078700700614.
5. Yasui Y, Murawski CD, Wollstein A, Kennedy JG. Reoperation rates following ankle ligament procedures performed with and without concomitant arthroscopic procedures. Knee Surg Sports Traumatol Arthrosc. 2017 Jun;25(6):1908-1915. doi: 10.1007/s00167-016-4207-x.
5. Alsousou J, Thompson M, Harrison P, Willett K, Franklin S. Effect of platelet-rich plasma on healing tissues in acute ruptured Achilles tendon: a human immunohistochemistry study. Lancet. 2015 Feb 26;385 Suppl 1:S19. doi: 10.1016/S0140-6736(15)60334-8.
6. Ramdass B, Koka PS. Ligament and tendon repair through regeneration using mesenchymal stem cells. Curr Stem Cell Res Ther. 2015;10(1):84-8. https://www.ncbi.nlm.nih.gov/pubmed/25274564