Ligaments injuries: symptoms, diagnosis and treatment

By Cristiano Antonino On Nov 11, 2022

Ligaments are the fibres that bind bones together. They are made up of very strong fibres, but if subjected to too high a load, they can be injured

How can ligaments be preserved and what are the symptoms of a ligament injury?

Skeletal ligaments are strong fibrous ribbons, stretched as bridges between adjoining bones, that ‘bind’ bones together, thus being, like the joint capsule, among the fixation means of mobile joints.

This means that they guide and limit our movements, preventing trauma and excessive stress from damaging the joints and causing them to lose their normal connection to each other.

They therefore perform a very important primary stabilising function, but also have a considerable proprioceptive role.

In fact, at ligament level, there are numerous nerve receptors that, together with the proprioceptive structures present at the level of muscles, tendons and capsules, constantly inform the central nervous system (CNS) about the condition of the locomotor system, so that it can intervene by regulating muscle tone, posture, balance, coordination and the activity of the different muscle groups according to the different situations in which we find ourselves.

When we perform a physiological movement, therefore, the muscles by activating themselves move the bones, but they can only do so within the limits allowed by the articulation and the fixation means that tend to preserve the integrity of the different anatomical structures not only mechanically but also thanks to the control of the CNS.

Why can ligaments be injured?

Like all other structures of the locomotor apparatus, ligaments also have their own characteristics of resistance to trauma and stress, being able to oppose applied forces only within certain limits.

Limits dictated, in particular, by their fibrous structure that makes them very resistant but not very elastic and therefore not very deformable under the action of high loads.

In fact, they are 70/80% made up of type 1 collagen fibres, which are extraordinarily resistant to traction against a completely negligible elongation (5%), while only a small percentage of them are made up of elastic fibres that are very extensible but not very resistant.

Their length can, in fact, increase by up to 150% under a particularly low load (which explains why ligaments react well to stretching), but at high loads, these fibres break suddenly, as their strength is about 5 times less than that of collagen fibres.

How ligaments are injured

Being very strong but not very elastic structures, ligaments, when subjected to rapid stretching caused by forces that exceed the maximum tensile strength of their fibres, first stretch, then tear and finally rupture.

Injuries can be of different degrees depending on the extent of the trauma:

Grade 0: there is a joint trauma in which no anatomical damage to the ligaments is observed.

Grade 1: there is a minor trauma that causes ligament distraction (damage at the microscopic level, without interruption of continuity).

Grade 2: there is medium trauma that causes partial rupture of the ligament with disruption of some fibres.

Grade 3: there is severe trauma causing complete rupture of the ligament.

What are the injury mechanisms?

Injury forces capable of damaging ligaments usually develop in joint traumas, such as sprains and dislocations, where the joint is stressed beyond the normal limit of motion or in planes other than those of physiological movement.

For example, in the knee joint, the ligament that is most frequently injured is the anterior cruciate ligament, which ruptures essentially due to distortion-type trauma in knee flexion.

It can happen, therefore, that the foot remains stuck to the ground while the knee performs a rotational movement in which the tibia rotates externally, or that a direct trauma to the side of the knee causes it to stress in valgus.

At the level of the ankle, on the other hand, the ligaments that are most frequently injured are those of the lateral compartment and more specifically the anterior peroneal-astragalic ligament.

And even in this case, it is essentially a distortional trauma that causes the ligament injury.

It can happen, in fact, that due to a pothole or a slip, or on impact after a jump or in rapid changes of direction, the foot in its contact with the ground undergoes an abrupt inversion trauma, thus making a movement in varus, supination and plantar flexion that exceeds the physiological limits allowed by the joint.

In these traumas, the first ligament to be affected is the anterior peroneal-astragalic ligament, but in more violent traumas, the peroneal-calcaneal and posterior peroneal-astragalic ligaments may also be affected.

In the shoulder, on the other hand, dislocations of both the scapulohumeral joint and the acromioclavicular joint are much more frequent.

In these injuries, the rupture of the fixation means results in the complete and permanent loss of the relationship between the two joint heads.

Low-energy traumas, such as accidental falls, or high-energy traumas, such as motorbike accidents, in which the humeral head is forced outwards by a lever action or is otherwise forced to the maximum degrees of movement so that the ligaments fail, can cause dislocation of the shoulder.

Dislocation of the acromioclavicular joint, on the other hand, is mostly caused by falls on the shoulder in adduction, during which the acromion is pushed downwards.

In this case, depending on the extent of the trauma, there may be a distraction of the acromioclavicular ligaments in mild traumas, a rupture of the acromioclavicular ligaments with acromioclavicular subluxation in severe traumas, and dislocation with complete rupture of all acromioclavicular and coraco-clavicular ligaments in severe traumas.

Other injuries may be caused by repetitive submaximal stresses that result in micro-ruptures of the ligament followed by inflammatory reactions and sometimes calcifications in the affected ligament tissues.

What are the symptoms of a ligament injury?

If the trauma that caused the ligament injury was a medium or severe sprain, one will complain of pain, evoked by palpation at the site of the capsular ligament injury.

The joint will begin to swell due to intrarticular effusion or extrarticular haemorrhagic extravasation and a feeling of laxity and instability may be perceived if the ligamentous lesion was complete.

If, on the other hand, the injury was caused by a dislocation, then the pain will be accompanied by a defensive attitude of the limb with almost complete inability to perform any type of active or passive movement.

And if the affected joint is superficial, an alteration of its normal anatomical profile may also be noted.

How is a ligamentous lesion diagnosed?

The anamnestic collection and the objective examination alone may raise the suspicion of a ligamentous lesion, which can, however, be confirmed, if necessary, by the use of other instrumental investigations such as CT or MRI.

X-rays, on the other hand, should always be taken to exclude the concomitance of possible fractures or alterations of normal joint relationships.

What is the most suitable treatment?

Usually, ligament injuries are treated conservatively.

This is because ligaments are quite vascularised and have a fairly good reparative capacity, so surgery is only resorted to in special situations.

For example, the treatment of the anterior cruciate ligament is surgical because this ligament never heals spontaneously but rather tends progressively to die and atrophy.

Reconstruction of the ligament is therefore resorted to once the acute phase has resolved, and the middle third of the patellar tendon, the gracilis and semitendinosus tendons, cadaver grafts and artificial ligaments can be used for this purpose.

For the treatment of the ligaments of the lateral compartment of the ankle, a conservative approach is preferred, whereby the PRICE protocol (protection, rest, ice, compression, elevation) is followed immediately after the injury in the acute phase.

Currently, it is preferred to immobilise the joint with braces or functional bandages as opposed to total immobilisation with a plaster boot in order to reduce the risk of complications such as joint stiffness and to promote better tissue repair.

The surgical solution is only necessary in the case that the injury is at the level of the ligament insertion with detachment of a bone fragment that must be reinserted if the fracture has a surgical indication or if there is a significant diastasis of the distal tibioperoneal syndesmosis.

The treatment of acromioclavicular injuries is also mostly conservative with protection of the limb in the arm pouch for 2-3 weeks, while only the most serious dislocations require surgery.

And even for the shoulder, after the dislocation has been reduced, conservative treatment is followed whereby the joint is immobilised in order to promote healing of the injured ligament structures.

Why is physiotherapy important?

In the case of a ligament injury, rehabilitation is extremely important and this is because the physiotherapist, knowing the reparative processes and using the appropriate tools, can positively influence the healing process of the injured ligament, which usually requires rather long recovery times ranging from 4-6 weeks for moderate injuries to 6 or more months for complete ruptures treated with surgery.

In the acute phase, which is the phase immediately following the ligament injury, an inflammatory reaction is triggered, which manifests itself externally, as we have already mentioned, with pain, swelling and functional impotence, but which corresponds internally to the activation of cellular, chemical and vascular processes.

There is in fact a vasodilatation that brings inflammatory cells to the site of injury with the task of removing dead tissue, while stimulating the synthesis of repair tissue.

This is therefore a very delicate phase in which the physiotherapist must intervene with the aim of controlling inflammation and facilitating healing and can do so by applying the PRICE protocol, maintaining the integrity of the soft tissues and joints through an appropriate dosage of passive movements in the pain threshold and making use of anti-inflammatory and analgesic physical therapy such as Tecar, laser therapy, hyperthermia, ultrasound, etc.

In the subacute phase of repair and healing, on the other hand, the signs of inflammation progressively diminish until they cease, while the synthesis and deposition of collagen becomes more intense, although it is still immature and fragile and therefore easily damaged.

In this phase, the physiotherapist knows that by applying the appropriate mechanical stresses he can promote the correct functional alignment of the newly-formed fibres, so he will have to dose the exercises and movements stimulating the healing of the still weak tissue, without injuring it.

To avoid the formation of adhesions and to promote the mobilisation of the ligament, the physiotherapist then has at his disposal various massage techniques also supported by the use of DA.MA TOOLS that allow mobilisation of the tissue in all directions by dosing the force.

In the chronic phase, on the other hand, there is no longer any sign of inflammation, the newly formed scar tissue continues to strengthen and restructure, the collagen fibres become thicker and reorient themselves in response to mechanical stress.

In this phase, the physiotherapist must draw up a progressive exercise programme, not only in terms of strength and endurance, but also from a proprioceptive point of view, in order to restore the stabilising and proprioceptive functions of the ligament and enable the patient to resume functional and work activities.

What is the advice for people with ligament injuries?

Ligament injuries, like many other types of injuries, must therefore be treated wisely, leaving nothing to chance.

And so it becomes essential to rely on the expert hands of a physiotherapist to help restore the specific functions of the ligament while avoiding the onset of any other complications.

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