Ankle injuries can be excruciating and can occur with sports or simple activities like stepping off the curb incorrectly, and the most common ankle injuries are to the ligaments. What are the four ligaments in the ankle? What are loose ankle ligaments? What causes chronic instability? How do you treat weak ankles? Let’s dig in.
What Are the 4 Ligaments of the Ankle?
Ligaments are thick bands of connective tissue that connect one bone to another. The ankle ligaments function to stabilize the joint and limit excessive bending and rotation. The deltoid ligament is a triangular-shaped complex located on the inside aspect (medial) of the ankle (1). The outside aspect (lateral) of the ankle has three principal ligaments: Anterior Talofibular (ATF), Posterior Talofibular (PTF), and Calcaneal Fibular ligament (CF). The ATF is the weakest lateral ankle ligament and is the most commonly injured in lateral ankle sprains (2).
Loose Ankle Ligaments: What Causes Chronic Ankle Instability?
The ankle is susceptible to injury. It is the most injured joint in sports and accounts for 10-30% of all sports injuries (3). A sprain (aka twisting the ankle) is when one or more of the ligaments is stretched or torn. Pain, swelling and bruising are common. Sprains are classified into grades 1, 2 or 3 based upon severity of the injury. Simple tasks like stepping off the curb or sports can led to ankle sprains. Ligaments stabilize the ankle joint and when sprained can lead to ankle instability. When acute ankle sprains are not identified, treated and allowed to heal chronic ankle instability can occur. 20% of acute ankle sprains develop into chronic ankle instability (4). Chronic instability is serious as it is associated with loss of cartilage, tendon injury and instability of the foot joints.
How Do You Test for Ankle Instability?
Physical examination must include assessment of both ankles. In a seated and relaxed position, the ankle is put through various stress tests to determine ligament laxity. The anterior drawer test is used to assess the integrity of the ATF whereas the talar tilt assesses the CFL (5). Performing and Interpreting these tests often times can be a challenge due pain level, swelling, body size and muscle spasm. Is there another option that is available in the office? Yes.
Ultrasound Stress Test
Under ultrasound, the ankle ligaments are identified and stress is then applied to determine whether the ligaments are loose or partially torn. The applied stress is similar to that one would experience while running and cutting. An MRI is not capable of this evaluation as it is a static test with the patient remaining still. This test is critical in the evaluation of ankle injuries.
To learn more about stress ultrasound for ankle ligament instability please click on the video below.
How Do You Treat Weak Ankles?
It depends on the type and severity of the injury. Conservative care is initial treatment of choice for most injuries and involves physiotherapy, bracing or taping, and neuromscular training (6). Surgery is often recommended for those that fail conservative treatment. Surgical options include repair or reconstruction of the damaged ligament or replacement with a graft. Like all surgeries complications can occur. In one study complication rate was 29% and involved wound healing, nerve injuries and blood clots (7). Are there non surgical regenerative options? Yes as PRP and bone marrow derived stem cells are effective in the treatment of ankle ligaments injuries (8). At the Centeno-Schultz Clinic we have extensive experience in the treatment of loose ankle ligaments and chronic ankle instability utilizing precisely guided PRP and bone marrow derived stem cells. Ligament healing occurs in three phases; Inflammation, regeneration, and tissue remodeling.
To understand the phases of ligament healing and response to PRP and stem cell injections please watch the video below.
Ligaments are thick bands of connective tissue that connect one bone to another. The ankle ligaments provide critical support and stability. There are four major ligaments in the ankle that are susceptible to injury. Chronic ankle instability can occur when acute sprains are not identified, treated and allowed to heal. Chronic instability can lead to loose ankle ligaments, loss of joint cartilage and tendon injury. Stress ultrasound provides ideal and immediate evaluation of the ligament integrity in the office. Surgery is often recommended when conservative treatment fails but has significant complications. PRP and stem cells are effective treatment options for loose ankle ligaments and chronic ankle stability and avoid the risks associated with surgery.
1.Crim J. Medial-sided Ankle Pain: Deltoid Ligament and Beyond. Magn Reson Imaging Clin N Am. 2017;25(1):63-77. DOI: 10.1016/j.mric.2016.08.003
2.Golanó P, Vega J, de Leeuw PA, et al. Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc. 2010;18(5):557-69. DOI: 10.1007/s00167-010-1100-x.
3. Hølmer P, Søndergaard L, Konradsen L, Nielsen PT, Jørgensen LN. Epidemiology of sprains in the lateral ankle and foot. Foot Ankle Int. 1994;15(2):72-4. DOI: 10.1177/107110079401500204.
4.Al-Mohrej OA, Al-Kenani NS. Chronic ankle instability: Current perspectives. Avicenna J Med. 2016;6(4):103-8. doi: 10.4103/2231-0770.191446.
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6. .McCriskin BJ, Cameron KL, Orr JD, Waterman BR. Management and prevention of acute and chronic lateral ankle instability in athletic patient populations. World J Orthop. 2015;6(2):161-71. DOI: 10.5312/wjo.v6.i2.161
7. 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.
8. Lai MWW, Sit RWS. Healing of Complete Tear of the Anterior Talofibular Ligament and Early Ankle Stabilization after Autologous Platelet Rich Plasma: a Case Report and Literature Review. Arch Bone Jt Surg. 2018;6(2):146-9.