Brief overview
- Symptoms: Pressure pain, swelling and bruising (if vessels are damaged), gait difficulty.
- Treatment: Acute treatment according to the PECH rule (rest, ice, compression, elevation), conservative treatment with physiotherapy, surgery.
- Course and prognosis: With early treatment and careful training usually good, with non-treatment and in severe cases often late consequences such as instability in the joint.
- Examination and diagnosis: palpation and joint function tests, X-ray and ultrasound examination, magnetic resonance imaging (MRI) or computed tomography (CT).
- Causes and risk factors: inward twisting of the foot in sports or traffic accidents; risk factors include certain sports with high stress on the ankle and abrupt changes in direction, as well as insufficient training and previous injuries
- Prevention: Warm up sufficiently before sport, muscle training, supportive bandages or tapes, suitable and flat footwear (for sports shoes with a high shaft).
What is a torn lateral ligament?
In the case of a torn lateral ligament (lateral ligament rupture), the ligament lying on the outside of a joint is either partially (ligament tear) or completely torn. This form of ligament tear occurs mostly in the upper ankle joint and is one of the most common sports injuries here. The lateral ligaments are involved in about 85 percent of ankle or ankle joint injuries.
On the knee, for example, there is also an external ligament that sometimes tears in injuries or falls, but this is much less common.
Women are more often affected by a torn external ligament of the foot than men. While in young people the outer ligament tear often occurs in isolation, in older people it is often accompanied by a fracture of the outer ankle (the distended lower end of the fibula). In children, the injuries are mainly in the area of the growth plate of the bone.
Anatomy – Ankle external ligament
The main function of the upper ankle joint (OSG) is to raise and lower the forefoot. Several ligaments stabilize the joint, including the external ligament (ligamentum collaterale laterale). This consists of three different ligament parts:
- Ligamentum talofibulare anterius: connects the anterior edge of the lateral malleolus to the talus (one of the tarsal bones)
- Ligamentum talofibulare posterius: connects the inside of the lateral malleolus with the talus bone
- Ligamentum calcaneofibulare: connects the outer ankle to the calcaneus
In the case of an external ligament tear, the weak talofibulare anterius ligament is most frequently affected. In about 20 percent of cases, this ligament tears, as does the calcaneofibulare ligament. The strongest of the three ligaments, the ligamentum talofibulare posterius, tears only rarely. All three ligaments tear only in cases of strong force.
How do you recognize a torn lateral collateral ligament?
Those affected sometimes perceive a torn lateral ligament in the upper ankle as a palpable crack. Often, stepping with the injured foot is no longer possible, which means corresponding gait difficulties. Sometimes the affected person only walks with a limp. Severe swelling develops at the ankle joint. The area of the torn ligament is painful from pressure. If smaller vessels are also injured, the area turns bluish and a hematoma develops.
What is the therapy for a torn lateral collateral ligament?
In most cases, it is not necessary to operate on a torn outer ligament. It has been shown that even with many more severe injuries to the external ligament apparatus, a functionally good result can be achieved without surgery.
Immediate action
The acute measures for a torn lateral collateral ligament are based on the PECH rule (rest, ice, compression, elevation): It is best to interrupt sporting activity, elevate the ankle, cool it (for example with ice or cold water) and apply a pressure bandage (against the onset of swelling). If necessary, painkillers such as ibuprofen are helpful against the pain.
Conservative therapy
As a rule, functional treatment is carried out with a special orthosis (ankle splint), which the affected person ideally wears for up to six weeks. It prevents a renewed twisting of the ankle. In the first week, it is advisable to completely relieve the foot (with the aid of forearm crutches); this is followed – depending on the pain – by a gradual increase in the load. If the ligament rupture is not very severe, stabilization with a firm bandage instead of a splint is often sufficient.
Taping is usually not sufficient at the beginning of the treatment, but is quite supportive in the course. It is recommended that users who are as experienced as possible apply the tapes. Some people experience skin irritation from the tapes, which is why they are often only suitable for a limited treatment period.
Consistent immobilization is almost only necessary in cases of considerable pain. A plaster splint is used only rarely and for a few days. After that, the described protection against renewed twisting with splints is usually sufficient.
Operation
Only in a few cases is a torn lateral ligament to be treated surgically. In the following situations, the doctor would consider surgery:
- External ligament tear of all three ligaments
- Additional cartilage/bone damage
- Complete instability of the joint
- Axis deviation of the joint
- Severe cases of chronic instability
- Failure of conservative therapy
- External ligament rupture in professional athletes
Depending on the severity of the ligament rupture, there are various surgical procedures to treat the (an)torn ligament. Either the ligament can be sutured (in the case of a central rupture) or the doctor applies a ligament replacement by inserting part of a tendon from the body. If the ligament is torn close to the bone, the doctor usually tries to fix it back to the bone (reinsertion).
The advantages of surgical intervention are a lower recurrence rate of the external ligament tear and a reduction in joint instability. However, there is some surgical risk even with this seemingly minor procedure.
After an operation, the doctor usually immobilizes the ankle joint in a splint for one to two weeks. This is followed by functional aftercare, also with an orthosis or a so-called stabilizing shoe. Rehabilitation takes about three to four months in total.
Physiotherapy
Regardless of the type of treatment, experts advise starting physiotherapy measures early after a torn lateral collateral ligament. The goal is to strengthen the muscles in the ankle area to better stabilize the joint. Balance training (for example on the wobble board) is also useful. In the course of training, the load is increased until the pain-free full load is reached. Supporting bandages usually facilitate training and later return to sport.
How long does it take to heal from a torn lateral collateral ligament?
There are rarely complications after an external ligament tear. The prognosis is usually very good. As a rule, the doctor prescribes physiotherapy treatment after an external ligament rupture to promote healing. The rehabilitation period is about four to twelve weeks, depending on the severity of the rupture and the type of therapy. The natural repair processes in the tissue sometimes take up to a year.
The duration of healing depends on the individual’s general state of health as well as the type of strenuous activity and can therefore not be precisely determined. Experts advise those affected to refrain from sports for about the first two months after tearing the lateral collateral ligament, especially those that place particular stress on the lateral collateral ligaments. Residual symptoms such as a tendency to swelling can last for several months in some cases, but usually disappear completely.
Rarely, a torn lateral collateral ligament is followed by joint stiffness or long-term joint wear (osteoarthritis). If the initial pain does not subside, an ankle impingement or (overlooked) shear fracture should be considered. Impingement involves the entrapment of soft tissues such as ligaments.
Within one year of the injury, there is approximately twice the risk of a recurrence of a torn lateral collateral ligament compared to the average population. Instability can sometimes be corrected with consistent physical therapy. In up to 40 percent of cases, mechanical instability remains, which then necessitates surgery.
How do you diagnose a torn lateral collateral ligament?
If a torn lateral collateral ligament is suspected, orthopedists, trauma surgeons or sports physicians are the contacts of choice. First, the doctor talks to the patient to obtain important information about the symptoms and the course of the injury. To do this, he asks the following questions, among others:
- How did the injury happen?
- Where is the pain localized?
- Can you still stand on the affected foot?
- Did you have to stop the activity you were doing before the injury?
- Have you already had an injury to this foot?
The doctor then examines the affected foot in detail. As with any injury, he first checks whether the blood flow, motor function and sensitivity of the foot are intact. Already during the examination, a clear swelling and a hematoma at the ankle joint are usually noticeable in the case of a torn lateral collateral ligament.
Malalignment of the foot often indicates a bony injury. However, deviations of the joint position are also possible with a sole outer ligament tear.
If the sufferer feels a pressure pain under the outer ankle when palpating the foot, this indicates a torn outer ligament. A pressure pain on bone points, on the other hand, indicates a bone fracture.
Already the combination of pressure pain and hematoma make an outer ligament injury very likely.
Special tests check the function of the outer ligament. The so-called drawer test is used to test the stability of the upper ankle joint. To do this, the doctor tries to push the foot forward with the knee bent and the tibia fixed. In this way, instability can be determined in a side-to-side comparison (talus advancement). Another test is the inversion stress test, which is used to detect a calcaneofibular ligament tear.
With a torn lateral ligament, the ankle joint can often be opened laterally, with an increased O-position compared to the uninjured ankle joint on the other foot.
Because there are a variety of muscles, tendons and ligaments in the foot, the external ligament examination also considers alternative diagnoses, such as an Achilles tendon tear.
Imaging
Imaging is not always necessary. For example, an X-ray examination clarifies whether there are bony injuries in addition to the outer ligament tear (such as a bony ligament tear). Sometimes the doctor takes so-called held images. In this case, he fixes the foot in a certain position in order to examine the opening of the upper ankle joint and indirectly detect a torn lateral ligament.
An ultrasound examination (sonography) is particularly suitable for checking the stability of the ankle joint. Doctors usually use this technique only in individual cases.
For further diagnosis, a computer tomography (CT) or a magnetic resonance imaging (MRI) is sometimes used, although these procedures are only used in certain cases and less frequently. However, an MRI examination is particularly good at identifying a torn lateral collateral ligament and other injuries, especially those to the connective tissue.
What causes an outer ligament tear?
A torn lateral collateral ligament occurs when the foot twists outward, for example, while walking or running. In everyday life, uneven or slippery ground, stairs or curbs increase the risk of twisting the foot and injuring yourself.
Athletes usually twist their ankles as a result of uncontrolled movements, when colliding with an opponent or when landing after a jump. The risk of a torn lateral collateral ligament is particularly high in sports with frequent changes of direction, short sprints and quick stopping movements, for example in soccer, tennis and volleyball. There is also an increased risk of spraining the foot so severely during skateboarding or ballet dancing that the ligament tears.
Risk factors for an external ligament tear include poor training condition, weak muscles, contractures or shortening of muscles, tendons or the joint capsule. Nerve damage resulting in poor perception of foot and joint position also increases the risk for an external ligament tear. Lack of experience playing a sport poses a risk, but at the same time, high-performance athletes are particularly at risk. Excess weight and high heels also favor an outer ligament tear.
In rare cases, injuries to bone or cartilage occur in addition to the torn ligament.
Can a torn lateral ligament be avoided?
Doctors recommend that athletes warm up sufficiently before exercising to prevent a torn lateral collateral ligament. Avoid one-sided stress. Compensatory gymnastics or a balance sport helps build supportive muscles (especially around the ankle). For those prone to twisting and tearing ligaments, sports bandages or tapes may help support the ankles. Shoes with a sturdy high shank also protect against an outer ligament tear.
Avoid shoes with very high heels or do not wear them for long periods of time. Otherwise, the ligaments will shorten in the long run and tear more quickly under stress.
