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  • Writer's pictureSteven Kent

My Scan Says I've RUPTURED My ATFL - Is it a Big Deal?

The short answer is NO. One of the most common referrals to an orthopaedic foot & ankle surgeon is for a rupture or injury to the ATFL and/or CFL ligaments of the ankle. Often this has been reported on an ultrasound or MRI scan. In many cases, the patient has rolled their ankle a number of weeks before and it is actually feeling better, hence they are often a bit puzzled about how they can feel better but have an injury to ligaments in their ankle.

The reason why many patients feel so good is because they have suffered a simple LOW ANKLE SPRAIN. This is the most common musculoskeletal reason for why people present to emergency departments. The majority of patients recover from this injury quite well and generally don't need surgery.

How Does The Injury Happen?

The injury involves you rolling the foot toward the midline of the body, with the big toe pointing towards the sky and stretching of all the structures on the little toe (lateral) side of the ankle. You can see the ATFL & CFL ligaments in green on the diagram below.

Drawing of  bones and ligaments of the ankle with ATFL & CFL
Drawing of the bones of the Ankle with the ATFL & CFL (Lateral ligments) marked in GREEN
Ligaments and bones shown on a real ankle with ligaments marked
Bones & ligaments of the ankle drawn on a real life ankle

The mechanism for how you suffer a LOW ANKLE SPRAIN is shown below. The large arrow shows the area of the ankle that is STRETCHED during the injury.

Mechanism of Low Ankle Sprain
The Position of the Ankle When a Low Ankle Sprain Is Sustained

If the Ligaments are RUPTURED do I need to see an ORTHOPAEDIC SURGEON?

No. Don't get me wrong we love seeing patients and referrals. However, any injury to the ATFL and/or CFL, whether that is reported as stretched, sprained, or RUPTURED is essentially along the spectrum of what orthopaedic surgeons would deem a LOW ANKLE SPRAIN. If we saw all of these sprains we would have little time to see anyone else! The good news with these types of sprains is that while the ligaments will scar and likely remain lax, the body compensates for them quite well and in the majority of cases there are no long-term effects. That includes those patients that have a reported RUPTURE on the scan. A good doctor, physiotherapist, or orthopaedic surgeon that sees you a few weeks after the injury with a report of such an injury will send you to physiotherapy and ask you to return if there is no ongoing improvement, particularly in relation to stability of the ankle. A small number of patients will have ongoing instbility to the ankle despite physiotherapy or continued pain as a result of another injury sustained at the time of the sprain. These patients are the ones that may require surgery, but they are the EXCEPTION not the rule. These are the patients that will require an orthopaedic surgeon, usually 2-3 months after the injury.

What Types of Sprains Do You Worry About?

I worry about any LOW ANKLE SPRAIN that is not showing improvement after 6-8 weeks. This might indicate that you have sustained damage to another structure in your ankle at the time of the sprain. If your ankle still feels quite painful or feels unstable despite 6-8 weeks of physiotherapy, then this is generally the time to consider seeing an orthopaedic surgeon.

I also worry about patients that do NOT have a LOW ANKLE SPRAIN, and have sustained a more sinister sprain known as a HIGH ANKLE SPRAIN. A high ankle sprain will have an injury to structures known as the AITFL (not to be confused with the ATFL of a low ankle sprain), IOL and/or PITFL It is a more sinister injury and can result in long-term ankle pain or dysfunction. High ankle sprains will tend to be tender over a different area (marked in red on the diagram below) and have the opposite injury pattern to a LOW ANKLE SPRAIN. The typically occur when the ankle is in eversion or external rotation (where the toes move in a clockwise position away from the body). For more information on high ankle sprains (otherwise known as syndesmosis injuries) take a look at our blog on the injury here.

Areas of pain for syndesmosis injury
A diagram showing the area which is typically tender in a High Ankle Sprain (in red) & a Low Ankle Sprain (in green)

What Are the Take Home Messages?

*A low ankle sprain should ideally be sent to a physiotherapist for rehabilitation prior to an orthopaedic referral (unless another injury is suspected)

*Low ankle sprains generally only require surgery if there is an associated injury or ongoing instability to the ankle despite 2 months of physiotherapy.

*If a High Ankle Sprain is suspected, early referral to an orthopaedic surgeon is recommended

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