What are the treatment options for a ligamentous tear?

Treatment Options for Ligamentous Tear

Functional treatment with support and exercise therapy is the preferred treatment method for ligamentous tears, particularly ankle sprains, as it provides better outcomes compared with immobilization. 1

Diagnosis of Ligamentous Tears

Before initiating treatment, proper diagnosis is essential:

Physical Examination Findings

• Key findings associated with severe (grade III) ligamentous tears include:
  • Swelling
  • Hematoma
  • Pain on palpation
  • Positive anterior drawer test (for ankle lateral ligament tears)
  • When all four findings are present, 96% of patients have a lateral ligament rupture 1

Imaging Studies

• MRI is the most comprehensive imaging modality for ligamentous tears, evaluating all anatomic structures including bone marrow 1
• CT arthrography has the highest sensitivity (nearly 100%) and specificity for detecting scapholunate and lunotriquetral ligament tears 1
• Ultrasound can be useful for dynamic evaluation when symptoms are only present during specific movements 1
• Delayed physical examination (4-5 days post-injury) is most reliable for assessing ligament damage severity 1

Treatment Algorithm for Ligamentous Tears

Immediate Management (First 72 hours)

1. PRICE Protocol (Protection, Rest, Ice, Compression, Elevation) 1

   • Elevate the injured area
   • Protect with a compressive device
   • Apply ice to reduce edema and decrease pain
   • Rest for up to 72 hours to allow ligaments to heal

2. Pain Management

   • NSAIDs can improve pain control, decrease swelling, and allow more rapid return to activity 1
   • Caution: NSAIDs may suppress the natural healing process 1

Subsequent Treatment (After 72 hours)

For Grade I-II Tears (Partial Tears):

1. Functional Support

   • Use of ankle brace or tape for 4-6 weeks 1
   • Ankle braces show greater effects compared with other types of functional support 1
   • Treatment with any real ankle support is more effective than compression bandage or tubigrip 1

2. Exercise Therapy

   • Initiate early exercise therapy programs consisting of neuromuscular and proprioceptive exercises 1
   • These programs reduce the prevalence of recurrent injuries and functional instability 1
   • Associated with quicker recovery time and enhanced outcomes 1

3. Manual Mobilization

   • Can provide short-term increase in joint range of motion 1
   • Decreases pain when combined with exercise therapy 1
   • Most effective when combined with exercise therapy 1

For Grade III Tears (Complete Ruptures):

1. Functional Treatment First

   • Despite good clinical outcomes of surgery, functional treatment is still preferred as not all patients require surgical intervention 1
   • 60-70% of individuals with lateral ankle sprains respond well to non-surgical treatment 1

2. Surgical Consideration

   • Reserve for patients with chronic instability who have not responded to comprehensive exercise-based physiotherapy 1
   • May be preferred for professional athletes to ensure quicker return to play 1
   • Surgery is superior at decreasing recurrent sprains but has risks of longer recovery times, ankle stiffness, impaired mobility, and complications 1

Special Considerations

• Short period (<10 days) of immobilization may help decrease pain and edema in acute lateral ligament injuries 1
• After any immobilization period, functional treatment should be commenced 1
• Avoid compression stockings beyond the acute phase 1

Pitfalls and Caveats

1. Avoiding Prolonged Immobilization

   • Immobilization for more than 10 days leads to less optimal outcomes 1
   • Prolonged immobilization can lead to loss of proprioception and formation of inelastic scar tissue 2

2. Preventing Recurrent Injuries

   • Exercise therapy has shown significant preventive effect for recurrent sprains 1
   • Ankle braces are effective for both first-time and recurrent sprains 1

3. Addressing Ligamentous Adhesions

   • Adhesions form after approximately 6 weeks of immobilization 2
   • Patients with adhesions may complain of pain and swelling after exertion 2
   • Treatment options include deep friction, manipulation, or shockwave therapy combined with stretching exercises 2

4. Monitoring for Complications

   • Be aware of potential complications from surgical treatment including ankle stiffness and impaired mobility 1
   • NSAIDs may have side effects and can potentially suppress natural healing 1

By following this evidence-based approach to ligamentous tears, focusing on functional treatment with appropriate support and exercise therapy, patients can achieve optimal outcomes with reduced risk of recurrent injury and long-term complications.