FOOT AND ANKLE TRAUMA
Management of acute
ankle ligament injuries
Paul MC Dearden
William JE Reeve
Ian T Sharpe
Abstract
Ankle sprains are amongst the most common injuries presenting to
emergency departments in the UK. They are not one single entity
but a heterogeneous group of injuries with a wide spectrum of severity.
Most injuries will involve the lateral ankle ligament complex but it is
important to ensure injuries to the syndesmotic ligaments or the del-
toid ligaments are not missed. Missed injuries or poor management
can cause disabling consequences and may occur in as many as
40% of inadequately treated patients. This article focuses on the
basic anatomy and biomechanics of the ankle joint, common mecha-
nisms of injury, appropriate diagnostic techniques and the indications
for non-operative and operative management.
Keywords ankle sprain; conservative; deltoid; injury; instability;
lateral ligament ankle; surgery; syndesmosis
Introduction
Ankle sprains are common and make up 3e5% of all Emergency
department attendances or 5600 incidents per day in the UK.1
They most often occur following a combination of inversion
and adduction of the foot in a plantarflexed position (supination)
as the body’s centre of gravity rolls over the ankle. Injury to the
lateral ankle ligament structures may account for 16e21% of all
musculoskeletal injuries sustained during sports. Certain high-
risk sports such as basketball, soccer, running and dance have
a higher incidence, with 53% of all basketball and 29% of all
soccer injuries being sprains of the ankle lateral ligaments.2,3
Injury to the syndesmotic ligament complex or ‘high ankle
sprain’ is a less common presentation especially in isolation and
without associated fractures. Involvement of the syndesmotic
ligaments, however, is a strong predictive factor for chronic
ankle dysfunction at 6 months post-injury.4 If undiagnosed or
chronically unstable, syndesmotic injuries may lead to symp-
tomatic ankle joint arthritis.
The socioeconomic cost of ankle sprains is significant. A
quarter of patients suffering an acute ankle sprain are unable to
attend school or work for more than 7 days following injury.5
Paul MC Dearden FRCS (Trauma & Orth) BMBS BMedSci (Hons), Foot and
Ankle Clinical Fellow, Royal Devon and Exeter Hospital, UK. Conflicts
of interest: none declared.
William JE Reeve FRCS (Trauma & Orth) MBBS BSc, ST7 Registrar, Royal
Devon and Exeter Hospital, UK. Conflicts of interest: none declared.
Ian T Sharpe FRCS (Trauma & Orth), Consultant Orthopaedic and
Trauma Surgeon, Royal Devon and Exeter Hospital, UK. Conflicts of
interest: none declared.
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Please cite this article in press as: Dearden PM, et al., Management of acute ankle ligament injuries, Orthopaedics and Trauma (2018), https://
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Despite this, these injuries are often wrongly perceived as
benign. It is reported that residual symptoms of pain and/or
instability may occur in 10e40% of patients despite appropriate
conservative treatment.6
Anatomy and biomechanics
Three articulations: the talocrural, distal tibiofibular and the
subtalar joints work together in allowing coordinated movements
of the ankle and hindfoot. Motion occurs in three planes: sagittal
(flexion/extension), coronal (inversion/eversion) and transverse
plane (internal/external rotation).
Talocrural joint
The talocrural joint is formed by the tibial plafond, talar dome
and the medal and lateral malleoli forming a ‘mortise’. The
lateral malleolus is longer and positioned more posteriorly than
the medial malleolus placing the axis of rotation of the joint
through the tips of the malleoli. This means that the ankle joint,
when functioning in isolation, acts as a modified hinge with the
plane of range of movement oblique to the plane of the ground
and oblique in the transverse plane. Additionally the talus
externally rotates in relation to the tibia during dorsiflexion and
internal rotates during plantarflexion.
During weight-bearing activity, the bony anatomy of the ankle
affords stability to the talocrural joint with the talus compressed
into the mortise. The talar dome articular surface is wider at its
anterior aspect than posteriorly like the frustum of a cone. This
means as the ankle passes from plantar to dorsiflexion the talus
fits more tightly in the mortise and bony stability increases. In
the unloaded ankle joint the ligamentous and dynamic muscular
stability becomes more important with each ankle ligament
contributing a different function dependent upon the position of
the ankle joint and subsequent tension of the ligament.
Lateral ligaments: three ligaments support the talocrural joint
on the lateral side: the anterior talofibular ligament (ATFL), the
calcaneofibular ligament (CFL) and the posterior talofibular lig-
ament (PTFL) (Figure 1).
The ATFL is the weakest of the lateral ligaments with a load to
failure 2e3.5 times lower than that of the CFL and PTFL. The
ATFL is taut in plantarflexion and foot inversion and as such is the
most frequently injured. The ATFL runs as an intracapsular
structure originating 1 cm proximal to the tip of the fibular,
anterior to the fibular facet, and inserting into the neck of the talus.
The CFL takes its origin from the tip of the fibular adjacent to
the ATFL and inserts into the calcaneus just posterior to the
peroneal tubercle. The CFL forms the floor of the peroneal
sheath. The CFL is taut when the ankle is dorsiflexed.
The PTFL is the strongest of the three lateral ligaments and is
a short thick structure originating from the medial aspect of the
posterior tip of the fibula and inserts into the posterior talus. It is
only taut in extreme dorsiflexion. Due to this combination it is
rarely injured.
Medial ligaments: the medial, or deltoid, ligament is composed
of superficial and deep components. It is much stronger than the
lateral ligaments and is rarely injured in isolation. It is more
commonly injured in association with a fibular fracture. The
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 FOOT AND ANKLE TRAUMA
Figure 1 Lateral ligamentous structures of the ankle. Source: Reference 19. Reproduced with
permission from Elsevier.
superficial deltoid ligament is a fan-shaped structure originating
from the anterior colliculus of the medial malleolus and consists
of tibiospring, tibionavicular, tibiocalcaneal and superficial pos-
terior tibiotalar components. The deep deltoid arises from the
posterior colliculus and traverses horizontally to attach onto the
talus. Therefore the superficial deltoid ligaments cross two joints
and the deep deltoid only one (Figure 2).
A functional deltoid ligament limits talar abduction, pronation
and external rotation. When the deep deltoid and the ATFL are
sectioned, internal and external rotation movement of the talus is
increased. If the syndesmotic ligaments are also sectioned, the
talus will freely dislocate during external rotation.
Distal tibiofibular joint or syndesmosis: the distal fibula and
the incisura of the tibia form the syndesmosis. The interosseous
membrane runs between the fibula and tibia along their entire
lengths and stabilizes the syndesmosis. Distally, there are three
ligamentous structures: the anterior-inferior tibiofibular ligament
(AITFL), the posterior-inferior tibiofibular ligament (PITFL) and
the interosseous ligament (IOL). The AITFL is the weakest and is
the most commonly injured component. The IOL is stronger than
the AITFL and is generally injured in combination with the
AITFL. The PITFL is composed of superficial and deep portions
and acts to deepen the talocrural joint and helps to resist poste-
rior talar subluxation. The PITFL is the strongest of the syn-
desmotic ligaments and contributes the most to syndesmotic
stability. The PITFL also projects inferior to the ankle joint line
and acts to deepen the ankle mortise and protect against poste-
rior translation of the talus.
Subtalar joint
The articulation of the subtalar joint is formed between the
inferior aspect of the talus and the os calcis. The articulation is
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divided into anterior and posterior portions divided by the sinus
tarsi and the tarsal canal. The anterior portion of the subtalar
joint is formed from the anterior and middle articular facets of
the calcaneus and the talonavicular joint. The posterior aspect of
the subtalar joint consists of the posterior facet and the inferior
talar surface. The anterior portion of the joint is positioned
anterior and medial in relation to the posterior aspect. Movement
of the subtalar joint is through this axis, which is inclined
approximately 42 in relation to the plane of the ground and 23
medial to the midline of the foot.
The ligamentous support of the subtalar joint is divided into
three groups; peripheral, deep and retinacular. There are three
peripheral ligaments, calcaneofibular ligament (CFL), the lateral
talocalcaneal ligament (LTCL) and the fibulotalocalcaneal liga-
ment (FTCL). There are two deep ligaments, the cervical liga-
ment (CL) and the Interosseous ligament (IOL).
The CFL is commonly injured in association with the ATFL
during lateral ankle ligament sprains. If injured the CFL can lead
to combined instability of the talocrural and subtalar joint.
Ligament healing
During the post-injury healing response, ligaments undergo
three stages of healing with differing demands, which can be
optimized by tailoring the patients’ rehabilitation.
Stage I e inflammatory phase
The inflammatory phase of ligament healing starts at time of
injury and continues for the first 7 days. During this initial phase
there is swelling and increase in skin temperature as local
growth factors such as transforming growth factor-b1, insulin-
like growth factor and bone morphogenetic proteins are
released. These growth factors activate immune cascades that
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 FOOT AND ANKLE TRAUMA
Figure 2 Medial ligamentous structures of the ankle. Source: Reference 19. Reproduced with
permission from Elsevier.
lead to an influx of neutrophils and macrophages and stimulate
these cells to begin ingesting and removing damaged cells and
debris from the injury. Angiogenesis occurs with new vessel
formation increasing vascularity of the damaged tissue. Also, at
this stage, production of type III collagen and extracellular ma-
trix begins.
Treatment during the inflammatory phase should be aimed at
avoiding or reducing excessive swelling. Rest, ice, compression
and elevation (RICE) therapy is advocated during the first 4e5
days to reduce swelling and improve pain levels. It is postulated
that this approach helps avoid on-going injury and thus opti-
mizes the healing potential.7 During the inflammatory phase, the
use of non-steroidal anti-inflammatory drugs has been shown to
be beneficial in reducing swelling and improving pain levels.8
Stage II e proliferative phase
This phase begins at around day 7 post-injury and continues for
several weeks. During this phase, further growth factors are
released and fibroblast proliferation is initiated. The tissue
formed during the proliferative phase appears like disorganized
scar tissue with more vessels, fat cells and inflammatory cells
than a normal ligament and with a predominance of disorganized
type III collagen. It is at this stage of the healing response (days 5
e21) that healing ligaments are at their weakest.
Early mobilization has been proposed as a beneficial approach
during the proliferative phase of ligamentous healing. Controlled
stress on the healing ligament during functional active range of
movement promotes proper collagen fibre orientation. The early
movement protocols should avoid inversion movements, which
can cause excessive strain and the formation of excess weaker
type III collagen. This said, studies indicate that a short period of
immobilization (maximum 10 days) in a semi-rigid brace or
below knee plaster cast is actually beneficial and speeds return to
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walking when compared to patients treated with no immobili-
zation or soft support/compression bandages only.9
Stage III e maturation phase
Gradually, as the proliferation phase continues and merges into
the maturation phase, collagen deposition becomes more
organised and orientated in line of the fibres of the normal lig-
ament. Collagen type III fibres are replaced with more type I fi-
bres and the ligament gains strength. Maturation and
remodelling can continue for months or years after injury. It is
during remodelling that collagen and matrix components are
turned over and opportunity for adaptation to functional de-
mands can occur. If remodelling is inadequate, the potential for
the ligament to heal at incorrect tension or to fail under sub-
normal loads arises.10
Predisposing anatomical factors
Several anatomic factors have been suggested as causing a pre-
disposition to ankle sprains. Individuals with a varus hindfoot
are higher risk for ankle sprains. With the hindfoot in varus, the
ground reaction force is more medial, generating supination
torque. This supinating force places the ATFL under stress. Also,
inversion at the subtalar joint locks the transverse tarsal joint and
reduces the ability of the foot to dissipate stress and places
further forces across the ankle ligaments.
The ATFL and CFL act to stabilize the ankle joint at different
points in the ankle range of movement due to the orientation of
their individual courses. In certain individuals it is suggested that
an increase angle between the ATFL and CFL (normal range
between 70 and 140 ) causes for a window of instability to be
created where neither of the ligaments are taut and the ankle is
therefore unstable.
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 FOOT AND ANKLE TRAUMA
Where dorsiflexion is limited by a tight Achilles tendon the
ATFL is placed under increased stress during greater periods of
the gait cycle and is therefore at greater risk of injury.
Mechanism of injury
Injuries to the ankle lateral ligaments ankle sprains are the most
frequent and occur as a result of inversion of the foot and ankle.
Supination and adduction of the plantarflexed foot is the most
common mechanism. There may also be excessive external
rotation of the lower leg during heel strike. The lateral ligaments
often fail sequentially with ATFL most commonly injured fol-
lowed by ATFL and CFL in combination. It is possible for isolated
failure of the CFL to occur and may play a role in subtalar
instability.
Syndesmotic ligament injuries are often referred to as ‘high
ankle sprains’. These injuries are most commonly accepted to
occur following an injury mechanism where external rotation
occurs through the foot and ankle with the ankle dorsiflexed and
foot pronated. This causes external rotation of the talus within
the ankle mortise. The fibular also externally rotates and is
forced posteriorly and laterally. The sequentially ligamentous
failure occurs with the AITFL first, followed by the deep deltoid
complex or a medial malleolar fracture. If the energy is high,
failure of the interosseous ligament, fibular fracture and finally
the PITFL may occur.
Medial ankle ligament injuries occur following pronation,
eversion, supination and external rotation or abduction mecha-
nisms. Significant isolated medial ankle ligamentous injuries are
rare. Superficial deltoid is most often injured and has a good
prognosis, as the ankle remains rotationally stable. If both su-
perficial and deep ligaments are injured there is almost always
associated injury to the ankle or fibula.
Classification
Terminology is important when describing ankle ligament injury.
The term ankle sprain is often used interchangeably to describe
any injury from minor stretch of the ligament to complete rupture
with instability. Many grading systems exist to describe injury to
the lateral ankle ligaments based on anatomic location, mecha-
nism, and stability or severity of injury. Most useful lateral lig-
ament injury classifications grade ankle ligament injuries based
on severity of injury and aid management planning.
Grade I injury e Mild stretching of the ligament causing
tearing of fibres. No laxity
Grade II injury e Moderate injury with moderate pain and
swelling. Functional limitation with weight-bearing and mild
to moderate laxity
Grade III injury e Severe injury with complete rupture of
ligament accompanied by marked pain, swelling and hae-
matoma. Markedly impaired function in weight-bearing and
marked laxity.
Clinical presentation
Arriving at the correct diagnosis is essential if appropriate man-
agement of the patient’s ankle sprain is to be instigated. If left
undiagnosed and untreated, lateral ankle sprains may lead to late
symptoms in up to 40% of patients. There are no pathognomonic
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features of the history or the injury mechanism that enable the
clinician to make a precise diagnosis or grade the injury. Features
of the history such as hearing a snap or crack do not correlate
with the anatomical location of the injury or its severity. In
general terms, those patients who sustain low-grade sprains
(grade I and II) are often able to continue weight-bearing and
have swelling that develops slowly, often several hours after
their injury. Those patients with complete ruptures (grade III)
report more immediate swelling and early appearance of
bruising. Higher-grade injuries are likely to prevent patients from
being able to continue their activities or weight-bear.
At time of injury it may be impossible to make an accurate
assessment of the grade of the injury due to patient discomfort.
Delayed physical assessment, 4e5 days post-injury, once the
severity of pain has reduced remains the gold standard.7 Location
of swelling, haematoma and pain on palpation over the affected
ligament are key features.
Lateral ligament injury
Tenderness over the ATFL combined with haematoma has a
positive predictive value for ATFL injury. There may be tender-
ness over the syndesmosis in up to 40% of patients despite there
being no injury to the AITFL. This is likely due to an anterior
capsular tear. Medial tenderness may also be present in 60% of
patients with lateral ligament injury. Instability of the ATFL
should be looked for by performing an anterior drawer test. This
is performed with the patient sitting, knee flexed and the ankle
plantarflexed 10e20 . The examiner stabilizes the tibia with one
hand whilst attempting to translate the ankle forward with the
other hand (Figure 3). A positive anterior drawer, combined with
tenderness and haematoma over ATFL has 98% sensitivity for
identifying ATFL injury and an 84% specificity.
Syndesmosis
Local tenderness over the syndesmosis and distance of tender-
ness from the ankle joint are positive predictive features of a
syndesmotic injury with pain more proximal to the ankle joint
correlating to more severe injury. Special tests include the fibular
translation test and the Cotton test, both of which have been
recommended by the European Society of Sports Traumatology.
Fibular translation is performed by grasping the fibula between
two fingers and translating it anterior or posteriorly (Figure 4).
Pain accompanying an increased degree of translation in com-
parison to the uninjured side is suggestive of injury. The Cotton
test is described as applying medial and lateral translational
forces to the talus with the ankle in a neutral position (Figure 5).
A positive test is increased mediolateral translation accompanied
by pain.
Deltoid
As isolated deltoid injuries are rare it is important to formally
examine the entire length of the fibula, the lateral ankle liga-
ments and the syndesmosis to rule out lateral injury or high
fibular fracture (Figure 6). Once excluded, formal examination of
the medial ligaments for pain on palpation and presence of
bruising may suggest isolated deltoid injury. Delayed examina-
tion with lateral talar tilt test or anterior drawer in external
rotation may be helpful but the specificities are not known. Stress
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 FOOT AND ANKLE TRAUMA

Figure 3 Anterior drawer test.

Figure 6 A weight-bearing anteroposterior radiograph of a patient with

combined medial deltoid and syndesmotic instability. Note the
undisplaced high fibula fracture (circled in red).

radiographs and manipulation under anaesthetic may be useful if

for other reasons the patient needs to be taken to theatre.

Figure 4 Fibula translation test for syndesmotic instability.
Figure 5 Cotton test for syndesmotic instability.
Imaging
Standard anteroposterior (AP), mortise and lateral ankle X-rays
should be requested if the patient meets Ottawa ankle fracture
criteria. These images help to rule out fracture and may
demonstrate diastasis of the ankle syndesmosis, avulsion frac-
ture or widening of the medial clear space. Comparative weight-
bearing and non-weight-bearing AP views are requested in the
investigation of suspected syndesmotic injury as increase in
tibiofibular clear space greater than 6 mm on weight-bearing
with associated pain is suggestive of syndesmotic instability.
However, it is not possible to grade severity of injury with any
accuracy using plain radiographs alone and subtler, low-grade
injuries may not be picked up at all.
Stress radiographs may prove useful if viewed in combination
with comparative views of the uninjured side. Little to no
consensus exists of cut off values for degrees of translation for
‘abnormal’ or positive tests
Ultrasound examination is highly sensitive and specific in
identifying ligamentous injury around the ankle and identifica-
tion of injury to the peroneal tendons. However, with the now
widespread availability of MRI, it has almost become redundant
in the investigation of acute ankle ligament injury.
MRI is a highly useful diagnostic tool due to its excellent
sensitivity (93e96%) and specificity (100%) in visualizing ankle
ligament injuries. The high numbers of patients presenting with
all grades of ligament injury prohibits the routine use of MRI in

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Please cite this article in press as: Dearden PM, et al., Management of acute ankle ligament injuries, Orthopaedics and Trauma (2018), https://
doi.org/10.1016/j.mporth.2018.09.003
 FOOT AND ANKLE TRAUMA
diagnosis of acute ankle sprain. However, MRI also has the
ability to identify not only injury to the ankle ligaments, but to
the chondral surfaces of the ankle and hindfoot joints, tendinous
structures and subtle bony injuries. Therefore, its use should be
reserved for use in those patients with persisting symptoms or if
there is suspicion of chondral injury in the acute setting.
Management
Lateral ligament injuries
Non-operative: several randomized control trials have demon-
strated superior outcomes following appropriate non-operative
management when compared to no treatment.11 The non-
operative management of grade IeIII lateral ankle sprains
should be considered as the current standard of practice.
RICE therapy is generally the treatment of choice during the
acute inflammatory phase of ligament injury (days 1e5). How-
ever, there is insufficient evidence to support its efficacy.12 The
use of non-steroidal anti-inflammatory medications has been
demonstrated to be effective in the acute management of ankle
sprains with benefits outweighing the adverse effects of these
drugs.8
Whilst early functional treatment appears to provide favour-
able outcomes in comparison to long-term immobilization (4e6
weeks), a short period of initial immobilization in a below knee
cast or removable boot (<10 days) has been shown to be of
benefit.13 Following initial RICE treatment and immobilization,
protection of the healing ankle lateral ligaments against inversion
is recommended. This aims to avoid excess type III collagen
formation during the proliferation phase. The type of immobili-
zation: tape, elastic bandages, tubular support, lace-up or semi-
rigid ankle brace is a matter for much debate and investigation
with little evidence to support their ability to reduce reinjury
rates. Petersen et al in the systematic review of 2013 concluded
that for all grades of injury, a semi-rigid ankle brace should be
recommended to protect against inversion.
Functional neuromuscular exercise comprising ankle range of
movement, proprioceptive balance board training, muscle
strengthening and activity-specific training can be used following
initial immobilisation in acute ankle sprains. This can be a
formal physio supervised programme or self-directed home
therapy with improved function and return to activity. There is
also evidence that, following balance training, lower re-injury
rates are seen.9
Operative: the role of surgical management of acute ankle liga-
ment injury is only minor. Most authors agree that non-operative
treatment should be recommended.
Recently, a Cochrane review of acute surgical ligament
reconstruction in lateral ligament injuries has been conducted.
This review suggested that acute surgical ligament reconstruction
has advantages including reduced recurrence rate of ankle injury
in those treated. The review also identified improved functional
(subjective) and mechanical (objective) instability compared to
non-surgical treatment and a reduced rate of chronic ankle
problems. On the other hand there was limited evidence for
longer recovery times, higher incidence of stiffness and impaired
ankle mobility and more complications in the surgically treated
group. Overall the Cochrane review concludes that there is
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insufficient evidence to determine the effectiveness of surgical
management over non-operative treatment due to low quality of
the trials analysed and a lack of long-term outcome data.14
More recent prospective randomized controlled trials with
long-term follow-up comparing operative to non-operative
management demonstrated no difference in clinical scores be-
tween the two groups. Lower re-injury rates in the surgical group
were demonstrated long term by Pihlajamaki et al.15
Surgery should not be entirely ruled out as it has advantages
in certain instances. Namely, the management of the elite athlete
with lateral ankle ligament grade II or grade III injury. The
advantage of surgical repair in these patients is that following
surgical repair there is an improved objective instability
demonstrated by talar tilt on stress radiographs or positive
anterior drawer. As increased subjective instability is a strong
predictor of future ankle sprains, proposed benefits of surgical
management of an acute high-grade sprain in an athlete is the
reduced risk of further injury and reduced time out of competi-
tion. If surgery is to be considered, an anatomic repair such as a
Brostro€m-Gould procedure with or without synthetic augmenta-
tion, followed by a programme of supervised range of movement
and proprioceptive exercise is suggested.7 The role of non-
anatomic repair or reconstruction in the acute ankle lateral lig-
ament injury setting is now only historical.
Syndesmotic injuries
Non-operative: low-grade syndesmotic injuries, that is, those
without instability should be treated non-operatively. Non-
operative management should comprise of initial RICE therapy
together with non-weight-bearing immobilization in cast or
removable boot for 1e2 weeks. This should be followed by re-
turn to weight-bearing in a functional brace, physiotherapy
directed ankle mobilization and strength training. When pain
free weight-bearing and range of movement has been achieved,
neuromuscular and proprioceptive training should begin and
continue until fully recovery is achieved. If there is no evidence
of instability, non-operative management of syndesmotic injury
can be expected to achieve good results.4
Operative: where instability of the syndesmosis is demonstrated
the management should be operative. Management goals include
anatomical restoration of the fibula within the incisura of the
tibia and maintenance of this reduction whilst healing of the
ligaments occurs. Surgical fixation can be performed by a num-
ber of techniques including syndesmotic screw fixation, suture
button dynamic fixation or AITFL repair. No technique has been
proven to be superior. Indirect reduction using a tibiofibular
clamp with the ankle in neutral position to avoid over reduction
has been recommended although there is controversy as to
whether over reduction of the syndesmosis is possible in the
absence of fractures.
Screw fixation is probably the most common technique.
Screw diameters of smaller than 4.5 mm are recommended to
avoid fibular fracture. Two screws placed 2e3 cm proximal to
the ankle joint line provide more stability than a single screw.
Three cortices fixation reduces risk of screw breakage but four
cortices fixation is more rigid, provides greater resistance to loss
of reduction during treatment and allows greater ease of implant
retrieval if a screw breaks.
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 FOOT AND ANKLE TRAUMA
Suture button fixation has been shown to have slightly infe-
rior stability when compared to screw fixation but with some
advantageous increase in motion.16 A prospective randomized
control trial of suture button versus screw fixation demonstrated
higher ankle scores in the suture button group although not
reaching statistical significance.17 This study did however
demonstrate improved ankle range of movement in those treated
with suture button. Although an additional proposed benefit of
suture button fixation over screws is reduced implant compli-
cations and need for removal, there is evidence to suggest that
implant complications may be higher than expected.18
Deltoid ligament injuries
Superficial deltoid ligament injuries should be managed non-
operatively with a protocol similar to that utilised in acute
lateral ligament injuries.4 Injuries to both superficial and deep
components of the deltoid ligament are almost always associated
with other injuries that may require surgical management. Most
opinion on the non-operative management of complete deltoid
rupture is based on the successful results seen in the non-
operative management of the deltoid ligament component in
surgical stabilisation of ankle fractures. Infolding of the deltoid
ligament is a cause of persistent widened medial clear space and
difficulty in adequate reduction in ankle fracture management
but little evidence exists to suggest that this can occur in isolated
deltoid injury.
Conclusions
Acute ankle sprains are not one single homogenous entity but a
range of different anatomic injuries with a spectrum of severities.
The initial management should be guided following careful
assessment with thorough clinical examination and appropriate
imaging. Focused non-surgical management with initial non-
weight-bearing immobilization followed by neuromuscular and
proprioceptive rehabilitation is the most appropriate manage-
ment of all grades of lateral ankle ligament injuries.
Stable syndesmotic injuries should also be treated with such a
focused non-operative technique. The unstable syndesmotic
injury should be treated with acute or subacute stabilization
using an appropriate implant of the surgeons’ choice. In cases of
suspected isolated medial ligament injury it is important to rule
out fibular fracture or syndesmosis injury, as these are more
likely to co-exist.
The consequence of missed injury or inadequate management
can be severe with chronic pain, instability and posttraumatic
osteoarthritis, which could have potentially been avoided. A
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1 Doherty C, Delahunt E, Caulfield B, et al. The incidence and
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2 Ekstrand J, Gillquist J. Soccer injuries and their mechanisms: a
prospective study. Med Sci Sports Exerc 1983; 15: 267e70.
3 Garrick JG, Requa RK. Role of external support in the prevention
of ankle sprains. Med Sci Sports 1973; 5: 200e3.
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Please cite this article in press as: Dearden PM, et al., Management of acute ankle ligament injuries, Orthopaedics and Trauma (2018), https://
doi.org/10.1016/j.mporth.2018.09.003
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