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Multi-Ligament Ruptures of the Ankle


Almost immediate effusion / haemarthrosis after severe inversion or eversion or hyper-extension/flexion sprain, sometimes complicated by direct impact from a block tackle, which is common in contact sports.


This injury may cause ruptures of anterior talo-fibular and fibulo-calcanear ligaments in combination with deltoid or syndesmosis ligament ruptures or posterior capsule injuries with or without fracture of the ankle.


In the acute phase there is haemarthrosis and or bruising if the capsule has torn. There is tenderness on palpation over the affected ligaments. There is often a combination of positive tests, such as positive anterior drawer and talar tilt tests, combined with positive reverse talar tilt and syndesmosis tests. Often gross multidirectional laxity can be identified.


X-ray must be undertaken to rule out fracture but may be normal. MRI may miss the ligament injuries in the initial phase, due to extra- and intra-articular bleeding. This injury must be investigated through the mechanism of injury, the forces involved and clinical signs.


In the acute phase RICE, crutches and non-weight-bearing exercise should be advised until the extent of the injury is determined. Initial rehabilitation aims to control and reduce swelling to allow a thorough examination of the joint. Early arthroscopy and examination under anaesthesia is sometimes indicated, with or without surgical stabilisation of the affected ligaments. The deltoid and lateral ligaments often heal without surgery and can be dealt with at a later stage if symptoms persist. These injuries can take the athletes out from sport for 12 to 26 weeks. Occasionally they may need bracing or strapping during the first weeks after the return to sport. These injuries are often combined with intra-articular cartilage injuries that increase the need for early surgical intervention.


Preferably refer to orthopaedic surgeon directly after injury for detailed investigations and treatment.


Immobilisation of the ankle in a non-weight-bearing boot is indicated for a number of weeks, with or without stabilising surgery. Therefore exercise must maintain general fitness of the rest of the body, before specific training of the injured leg can be allowed. Core stability exercises must be done whenever weight bearing is allowed.


Monitor decrease of clinical symptoms and signs. Normal clinical laxity tests of the ankle should result. Full strength, RoM and proprioception, compared with other leg should be expected. Functional ankle scores and core stability must be tested at the end of an often long rehabilitation period before resuming full sport.


Extra-articular injuries such as dislocation of peroneus tendons or fracture. Clinical picture, X-ray and MRI will differentiate.


Good-Poor. This can be a careerthreatening injury.

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