What is the appropriate treatment for a ligament injury below the medial malleolus?

Treatment of Ligament Injury Below the Medial Malleolus

Functional treatment with early mobilization using a semirigid ankle brace is the definitive treatment approach for medial ankle ligament injuries, avoiding immobilization beyond 10 days. 1

Initial Assessment and Diagnosis

Rule out fractures first using the Ottawa Ankle Rules before proceeding with ligament-specific treatment 1:

• Order radiographs if pain on palpation at the posterior edge or tip of the medial malleolus, inability to bear weight immediately after injury, or inability to walk four steps 1
• The Ottawa Ankle Rules have 86-99% sensitivity and 97-99% negative predictive value for excluding fractures 2

Delay definitive ligament assessment until 4-5 days post-injury when the anterior drawer test achieves optimal sensitivity (84%) and specificity (96%) for evaluating ligament integrity 1, 2, 3

Acute Phase Treatment (First 3-5 Days)

Implement RICE protocol with early weight-bearing 1:

• Rest, ice, compression, and elevation for 3-5 days maximum 1
• Apply a semirigid ankle brace immediately as the most cost-effective functional support option 1, 2
• Allow early weight-bearing as tolerated to facilitate faster return to work and daily activities 1

Avoid prolonged immobilization as it leads to worse outcomes compared to functional treatment 1:

• If immobilization is used to control severe pain or swelling, limit to maximum 10 days, then transition to functional treatment 1
• Compression stockings beyond the acute phase provide no benefit 1

Active Rehabilitation Phase (After Day 5)

Begin exercise therapy combined with continued brace support 1:

• Commence active range of motion exercises after the initial 3-5 day rest period 1
• Progress to strengthening and proprioceptive training 4, 5
• Continue wearing the semirigid brace during activities for protection 1

Add manual joint mobilization if ankle dorsiflexion is restricted 1:

• Manual mobilization combined with exercise therapy produces superior outcomes compared to exercise alone 1
• This combination decreases pain and improves short-term range of motion 1

Special Considerations for Medial Ligament Injuries

Assess for associated deltoid ligament injury patterns 6, 7:

• Medial ankle ligament injuries (deltoid complex) can lead to chronic instability and post-traumatic osteoarthritis if undertreated 6
• Look for medial tenderness, bruising, or swelling which indicates higher instability risk 1, 8
• Consider stress radiographs or MRI if clinical examination suggests complete deltoid rupture or persistent instability 6

Weight-bearing radiographs are critical for stability assessment 1, 8:

• Medial clear space >4mm indicates instability and may require surgical consultation 8
• This measurement is particularly important for medial-sided injuries as it reflects deltoid ligament competence 8

When Conservative Treatment Fails

Reserve surgical intervention for chronic instability after comprehensive conservative treatment 1, 6:

• 80-90% of ligament injuries respond to functional treatment 4
• Surgery is indicated only for patients with persistent pain and instability after completing a full exercise-based physiotherapy program 1
• For medial ligament injuries, primary repair using suture anchor fixation can be performed if sufficient tissue remains 6
• Reconstruction with autograft or allograft is necessary when tissue quality is inadequate 6

Critical Pitfalls to Avoid

Do not treat all medial ankle injuries as simple sprains 8, 6:

• Failure to recognize associated deltoid ligament disruption leads to chronic instability 8
• Medial-sided injuries have higher risk of instability compared to lateral sprains 6

Do not use rigid immobilization as primary treatment 1:

• Functional treatment leads to faster return to work and activities compared to immobilization 1
• Prolonged immobilization increases risk of stiffness and delayed recovery 1

Do not perform stress testing in the acute phase 1:

• Stress radiographs are painful and have limited diagnostic value acutely 1
• Wait 4-5 days for optimal physical examination accuracy 1, 3

Expected Outcomes

Anticipate 10-20% of patients will have residual symptoms 4:

• 5-33% experience persistent pain and instability at 1 year 2
• 3-34% develop recurrent ankle sprains 2
• Early aggressive functional treatment reduces these complications 1, 2