Case Study:
Rupture of Anterior Talofibular Ligament
Presented by: Dr John Negrine
History: A 25-year-old female treads on an uneven footpath and twists her ankle. She feels a pop.
The ankle swells dramatically she is able to limp home.
On examination: The ankle is globally swollen. She is maximally tender anterior to the distal fibula. She has a restricted range of motion in the ankle and subtalar joints. Her lateral ligaments stability is difficult to assess because of guarding.
Investigations: She has had a plain x-ray which did not show any evidence of fracture. She had in addition an ultrasound (or an MRI scan) which suggested a “complete full-thickness rupture of the anterior talofibular ligament” and an injury to the calcaneofibular ligament.
Question: Is this a serious injury? Does this need urgent surgery? Does this need urgent specialist referral?
Answer: At least 400 people injure their ankles in Sydney every day. The most common injury is a rupture of the anterior talofibular ligament with or without an injury to the calcaneofibular ligament.
This is called a “sprained ankle”. The acute injury does not need surgery. As medical students we were all taught that an ankle injury needs “RICE” = “rest, ice, compression and elevation” this still holds true.
Investigations: She has had a plain x-ray which did not show any evidence of fracture. She had in addition an ultrasound (or an MRI scan) which suggested a “complete full-thickness rupture of the anterior talofibular ligament” and an injury to the calcaneofibular ligament.
Question: Is this a serious injury? Does this need urgent surgery? Does this need urgent specialist referral?
Answer: At least 400 people injure their ankles in Sydney every day. The most common injury is a rupture of the anterior talofibular ligament with or without an injury to the calcaneofibular ligament.
This is called a “sprained ankle”. The acute injury does not need surgery. As medical students we were all taught that an ankle injury needs “RICE” = “rest, ice, compression and elevation” this still holds true.
Once the swelling goes down and the patient is able to mobilise some form of splint which allows controlled movement such as an airstirrup is helpful for 3 to 4 weeks to allow the ligaments to heal. A boot which immobilizes the ankle in this situation is not recommended in my opinion as it causes joint stiffness, muscle wasting and increases the risk of DVT.
Physiotherapy is very useful to re-educate proprioception, decrease swelling, strengthen the peronei and restore weight bearing.
The majority of patients with this regime will get better. Patients in the past have been randomised to surgical or nonsurgical treatment for the acute injury and the results are similar and therefore we do not operate on the acute injury.
A small percentage of patients with this regime will be unstable in the long-term and can be treated with an ankle ligament reconstruction at a later date. This is distinctly in the minority.
Take home message: A complete rupture of the anterior talofibular ligament is the same as a sprained ankle. It does not need surgery acutely.
Dr John Negrine
Physiotherapy is very useful to re-educate proprioception, decrease swelling, strengthen the peronei and restore weight bearing.
The majority of patients with this regime will get better. Patients in the past have been randomised to surgical or nonsurgical treatment for the acute injury and the results are similar and therefore we do not operate on the acute injury.
A small percentage of patients with this regime will be unstable in the long-term and can be treated with an ankle ligament reconstruction at a later date. This is distinctly in the minority.
Take home message: A complete rupture of the anterior talofibular ligament is the same as a sprained ankle. It does not need surgery acutely.
Dr John Negrine
