Background & Etiology
The foot has over 30 joints, which are held together by connective tissues. Ligaments are one type of connective tissue, which is made of collagen and attaches bone to bone. On the outside (lateral) side of the ankle there are three major ligaments, there are several more ligaments on the inside (medial) side of the ankle joint.
The ligaments in the ankle extend into the foot and play a critical role in the range of motion of the lower extremity. Ligaments in the foot include the plantar calcaneonavicular ligament, the deltoid ligament, the long plantar ligament, and the plantar calcaneocuboid ligament.
A sprained foot is a common condition, which can happen to anyone in a variety of different situations. A sprain is a condition where the ligaments become stretched, and can either be slightly torn or completely torn. It is most common at the midfoot and first metatarsalphalangeal joint (Turf Toes).
Foot Sprains occur when the foot twists, rolls or turns beyond its normal range of motion. Common causes of foot sprains include:
- Landing hard on the foot on an uneven surface
- Stepping onto an uneven surface
- Stepping down at an angle
- Participation in athletic activities such as snow boarding, windsurfing, horseback riding, ballet dancing, and competitive diving.
Common signs and symptoms of a foot sprain include:
- Pain in a particular area of the foot often in the metatarsal area.
- Swelling along the bottom of the foot in a band like fashion
- Difficulty weight bearing on the foot
- Deep ache in foot
When the ligaments of the foot become stretched too far, they can become partially or completely torn. A ligament tear is a serious injury, which may require surgery to repair.
Causes of Ligament Tears
- A traumatic injury, particularly when the foot is turned either toes in or toes out.
- A fall or step where the foot is planted on an uneven surface
Grades of Foot Ligament Damage
There are three grades of foot ligament damage, which range from mild to more severe conditions.
- Grade I: Slight stretching of the ligaments, with mild damage to the actual fibers of the tissue through micro tearing. These injuries are typically treated with rest and guided exercises, in addition to stretching and strengthening activities.
- Grade II: The partial tearing of the ligament, accompanied by abnormal laxity of the ligaments in the foot. This condition is typically treated by immobilization, followed by stretching and strengthening exercises.
- Grade III: A complete tear of the ligament, that results in severe instability of the joints in the foot. Typically this condition is treated by immobilization, possible surgical reconstruction of the ligaments, and subsequent physical therapy.
In response to foot ligament injuries, one should initiate the RICE protocol of Rest, Ice, Compression, and Elevation in addition to the following:
- Rest to avoid aggravating the injured joint and ligament with excessive activity.
- Immobilization to keep the ligament from being stressed any further and promote healing in the correct position. Depending on the severity of the injury the foot may be immobilized for a period of time.
- Ice to reduce inflammation and pain for the first 48-72 hours. Do not apply directly over skin and use ice intermittently during the day. Apply the ice for 20 minutes at a time. Do not apply any form of heat during this period.
- Contact your physician medical provider for complete diagnostic evaluation of the injury and follow up care.
- Physical Therapy may be indicated to treat and rehabilitate this injury for Grade I-III injuries.
- Grade III injuries may require surgical repair of the injured ligament.
Physical Therapists are professionals, educated and trained to administer interventions. As stated in The Guide to Physical Therapist Practice interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis, and the goals of the patient or client.
Initial treatment will be focused on protecting the ligament, reducing pain and swelling, as well as restoring motion. As the physical therapy program progresses, strengthening, flexibility, and aerobic exercises, in addition to technique and proprioceptive training to protect the foot and ligament will be added in an effort to restore normal activity level.
Grade I-II injuries may start off with immobilization to protect the ligament and joint. Physical therapy will be progressed based on the individual’s symptoms, with the removal of the immobilizing device and initiation of a stretching, strength and functional rehabilitation program.
Grade III injuries may require surgery, especially if other structures (like other foot ligaments or tendons) are involved. Repair or tightening of the ligament may be necessary. Physical therapy will focus on restoring motion, strength and function based on the physician’s post-operative protocol. Full return to activity will depend on:
- Restoration of pain free full range of motion
- Patient ambulating independently without a limp
- Objective muscle strength in the 90% range
Physical Therapy Interventions
Common physical therapy interventions for this condition include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, deep friction massage and joint mobilization by a physical therapist to regain mobility and range of motion of the foot.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strength to protect and stabilize the foot and affected ligament.
- Neuromuscular Reeducation (NMR) to restore stability, begin retraining the lower extremity chain and improve movement technique and mechanics (running, jumping and cutting) in use of the involved foot in daily activities.
- Modalities that can include use of ultrasound, electrical stimulation, ultrasound, ice, cold laser and others to decrease pain and inflammation at the foot and ligament.
- Home program includes strengthening, stretching and stabilization exercises as well as instructions to help the person perform daily tasks and advance to the next functional level.
Following an injury to the ligaments of the ankle one should seek a full evaluation from a physician or health care provider. Treatment may consist of the following:
- Clinical evaluation including a physical exam, X-rays and MRI in more severe Grade III injuries
- Use of ice and immobilization to stabilize and rest the joint
- Anti-inflammatory medication and pain medication as needed
- Progression to a brace if indicated
- Referral to physical therapy to progress rehabilitation following a period of immobilization.
- Surgery may be indicated in Grade III injuries or cases involving damage to other foot structures secondary to instability.
The prognosis for these injuries when cared for correctly is good. Time frames vary with the severity of the injury. As a general rule, ligament density and incidence of instability play a role in how quickly these injuries heal. Grade I and II may take 4-8 weeks while Grade III injuries will require 3-4 months.