Lateral ligament rupture in the upper ankle joint

Lateral ligament injuries of the upper ankle joint (OSG) are one of the most common ligament injuries of the musculoskeletal system and particularly affect people who are active in sports. Although lateral ligament ruptures often lead to persistent instability, post-traumatic osteoarthritis, and significant impairment of athletic performance if treated inadequately, this lesion is often considered a “minor injury” by both those affected and those treating them. Data show that only about half of all those affected undergo further diagnostic testing after an OSG sprain [1].

Prevalence, injury patterns, and clinical relevance

The incidence of lateral ankle sprains in the general population is approximately one injury per 10,000 people per day, with the lateral ligament structure affec­ted in 85 % of cases. Young adults aged 15 – 35 are particularly affected. This rate is significantly higher in physically active populations, particularly in sports with a high jumping and pivoting load profile, such as basketball, handball, volleyball, and soccer [2 – 4]. The classic injury pattern, consisting of a combination of supination / inversion trauma with combined plantar flexion, often leads to a tear of the lateral capsular ligament apparatus at the upper ankle joint (USG). The most common injury (approx. 85 %) is to the anterior talo­fibular ligament (ATFL), followed by the calcaneofibular ligament (CFL) (52 – 75%) and, less frequently (< 10 %), the posterior talofibular ligament (PTFL).

The lateral capsular ligament apparatus of the OSG not only serves as a stabilizer against anterior talar translation and inversion in the upper ankle joint. The anterior and posterior fibulotalar ligaments, together with the anterior and posterior portions of the deltoid ligament, form a firm ligamentous ring in the transverse plane of the malleolar fork (Fig. 1). Injury to the lateral structures thus leads to complex rotational instability. Epidemiological data show that 20 – 40 % of patients develop persistent symptoms such as pain, impingement syndromes, and functional and structural chronic instabilities after initial ankle sprain [5]. In athletes, a recurrence rate of up to 34 % has been reported if no targeted neuromuscular and proprioceptive rehabilitation is performed [6]. The risk of a repeat ankle injury is five times higher after a lateral ligament rupture [7]. Long-term clinical studies show that even seemingly “simple” lateral ligament ruptures significantly increase the risk of post-traumatic ankle osteoarthritis, especially in cases of residual instability or incomplete rehabi­litation. Microinstabilities and repeated subtle sprains lead to chondral damage, which can result in degenerative joint destruction [5, 6]. 

Fig. 1 Transverse view of the upper ankle joint. The deltoid ligament (D) forms a stable ligamentous ring together with the posterior tibiofibular ligament (PTL) and anterior tibiofibular ligament (ATFL) (LLC = lateral malleolus, MLC = medial malleolus). Rupture of the LFTA leads to a break in continuity with rotational instability in the upper ankle joint.

Diagnosis

Clinical examination forms the basis of the diagnosis. Targeted systematic palpation of the typical pain points (LFTA, LFC, anterior syndesmosis, peroneal tendons), the anterior drawer test, and the talar tilt test (inversion test) are used to test mechanical joint stability. Immediately after the acute event, swelling, pain, and muscle guarding significantly limit the informative value of these tests. A reevaluation after 3 – 4 days, as advocated by Niek van Dijk, enables a much more reliable assessment with improved diagnostic sensitivity and specificity [8].

Conventional X-ray diagnostics are not indicated if a fracture is not suspected. In particular, static images of the ankle joint do not provide reliable information in the acute injury situation. Ultrasound has proven to be a diagnostic tool for imaging ligament continuity, hematoma extent, and joint effusion volumes. Radiological studies have shown that the sensitivity of sonographic examination is significantly higher than that of MRI for imaging ruptured LFTA (94 – 100 vs. 67 – 87) and LFC (94 vs. 40 – 47) [9]. The specificity is approximately equivalent. Ultrasound thus enables rapid and cost-effective confirmation of the diagnosis and prompt initiation of treatment. Magnetic resonance imaging (MRI) remains indicated in cases of complex injury patterns, suspected concomitant pathologies such as osteochondral talus lesions, syndesmotic injuries, or in the absence of clinical improvement [10].

Conservative therapy and functional treatment concept

According to S2k guideline 187 – 025, conservative therapy is considered the gold standard for lateral ligament rupture without accompanying injury, provided that there are no complete ruptures of all three lateral ligaments with pronounced mechanical instability.

The main therapeutic goals are rapid pain reduction, edema reduction, restoration of physiological joint mobility, and regaining active-dynamic stability while minimizing the recurrence rate. Instead of complete immobilization and relief, early functional therapy with a semi-rigid ankle orthosis, which limits inversion and supination and reduces plantar flexion, is considered the standard. Several studies show that early functional treatment with early mobilization in the orthosis, full weight-bea­ring after pain and swelling have subsided, and accompanying physical therapy leads to a significantly faster return to sport, less muscle atrophy, and less joint stiffness than prolonged immobilization [11, 12]. Modular ankle orthoses have been available on the market for several years. The underlying concept of this treatment is the gradual reduction of the orthosis’s stabilization from the acute stage to the rehabilitation phase, adapted to the ligament healing phases. Modular systems allow for initially higher lateral guidance in the acute phase with a gradual reduction in stability over time, which supports early functional mobilization while protecting against renewed inversion trauma. This is intended to support improved alignment of the collagen fibrils in the regenerated tissue as well as improved proprioceptive stimulation [13].

Proprioceptive and neuromuscular training – the focus of recurrence prevention

Proprioceptive and neuromuscular training is the most essential component of rehabilitation, as functional instability is not exclusively structural, but is also caused by disturbed afferent feedback and delayed peripheral muscle response patterns. Randomized controlled trials (RCTs) [3, 12, 14, 15] show that 8-12-week progressive proprioceptive programs (wobble board, balance pad, standing on one leg on unstable surfaces) reduce the recurrence rate of sprains by 35 – 41 % and significantly improve functional stability scores. Meta-analyses [16, 17] of more than 30 RCTs combined show a significant reduction in the risk of re-rupture by 39 – 47 % through structured sensorimotor training (level 1a evidence). The S2k guideline 187 – 025 recommends starting proprioceptive training as early as week 2 – 3 after the trauma, i.e., already in the orthotic treatment phase, with a progressive increase until week 12. The focus is on balance exercises, agility skills, reactive changes of direction, and sport-specific jump-landing sequences for high-level athletes. Effective exercises include standing on one leg on an unstable surface, the Star Excursion Balance Test (Fig. 2), lateral hop tests, and multi­directional jumps with defined landing patterns [18].

Biological regenerative adjuvants: PRP, hyaluronic acid, and ESWT

The use of platelet-rich plasma (PRP) in ligament ruptures aims to increase local growth factor concentrations to optimize ligament healing. Initial clinical studies report some positive effects on pain and subjective stability [19 – 21]. However, the current data are heterogeneous. Large-scale RCTs specifically on acute lateral OSG ligament ruptures are limited. The S2k guideline did not issue a strong recommendation for PRP in acute ligament injuries. Hyaluronic acid injections are mainly used to modu­late intra-articular inflammatory processes in soft tissue after an outer ligament rupture. Individual studies report faster pain reduction and a quicker return to sports [21, 22]. There is currently no consistent evidence of a benefit in accelerating ligament healing or reducing recurrent instability. At most, a complementary role may be considered in cases of associated chondral lesions. Preclinical models have demonstrated improved ligament regeneration, angiogenesis, and matrix remodeling with extracorporeal shock wave therapy (ESWT). No clinical data are available for this therapeutic measure in acute lateral ligament rupture, so there is no evidence-based recommendation. ESWT can be used as a selective option for reducing pain and swelling.

Conclusion

Consistent early functional therapy with adequate 6-week orthotic treatment, structured physical therapy, and intensive proprioceptive training form the main pillars of treatment. Proprioceptive training in the early phase and after removal of the orthosis is an essential factor in preventing functional instability and re-rupture.

Literature

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Autoren

Dr. med. Mellany Galla

» Fachärztin für Orthopädie und Unfallchirurgie sowie zertifizierte Fußchirurgin
» Leiterin Fußzentrum Helios Klinikum Hildesheim & Fußspezialistin Hannover, Privatpraxis für Fuß- und Sprunggelenkchirurgie
» Ehem. Präsidentin und Ehrenbeirat der Gesellschaft für Fuß- und Sprunggelenkchirurgie e.V. (GFFC)
(Stand 2026)