Ligament, muscle, tendon ruptures: general information

Ruptures of ligaments, muscles and tendons are possible. There are minimal (grade I), moderate and severe (grade II) ruptures and a complete rupture (grade III). Grade III ligament damage can cause joint instability and is differentiated from grade II using load tests. A complete rupture of the tendon disables muscle function. Treatment for all ruptures includes analgesics, immobilization and, for some cases of grade III ligament and tendon damage, surgery.

Ligament injuries are common in the AC joint, PIP joint, knee, and ankle; tendon ruptures are common in the knee extensors and Achilles tendon. Certain muscle ruptures are also common. Ligament, muscle, and tendon ruptures cause pain, tenderness to palpation, and usually swelling. Grade II ruptures are especially painful with contraction. Complete rupture of ligaments often results in joint instability. If a tendon is completely torn, the muscle is unable to move a limb segment because it is not actually attached to the bone. The tendon defect may be palpable.

Bedside stress testing involves passively abducting the joint in the direction opposite to its natural direction (stress) to detect instability; this differentiates grade II from grade III ruptures. Since muscle spasm during a severely painful injury may mask instability, it is necessary to wait until the muscles relax to the maximum and repeat the test, slightly increasing the load each time. The results of the examination are compared with the opposite, normal limb. In grade II ruptures, the test is painful and joint opening is limited. In grade III ruptures, the pain during testing is less, since the ligaments are completely torn and do not stretch, and joint opening is less limited. In severe muscle tension, the test should be performed after injection of a local anesthetic, systemic analgesia or sedation, or several days after the spasm has resolved.

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Treatment of ligament, muscle and tendon ruptures

Treatment of all ruptures includes rest, cold, compression, and elevation of the limb, and, if necessary, analgesics. For grade I ruptures, early activation treatment is most effective. For moderate grade II ruptures, immobilization with a sling or bandage for several days is often used. For severe grade II injuries and some grade III ruptures, immobilization is maintained for several weeks, sometimes with a plaster cast. For most grade III ruptures, surgical treatment is indicated.

Acromioclavicular joint injuries. The typical mechanism is a fall with support on the shoulder or abducted arm. In severe ruptures of the coracoclavicular ligament, the clavicle is displaced anteriorly from the acromial process. Treatment is immobilization (e.g., with a sling) and early mobilization. Surgical treatment is indicated for some severe ruptures.

Ulnar collateral ligament injury (hunsman's finger). Typical mechanism is lateral abduction of the thumb. Stress test involves radial abduction of the thumb, local anesthesia is required. Treatment is thumb immobilization with a splint. If the maximum possible abduction is more than 20°, compared to the thumb on the healthy side, then surgical treatment is indicated.

Ankle ligament injuries. The most important ligaments for joint stability are the powerful deltoid ligament (medial), the anterior and posterior portions of the talofibular ligament, and the calcaneofibular ligaments (lateral). The injury is very common, usually occurs when the foot is turned inward (inversion) and is accompanied by a rupture of the lateral ligaments, usually starting with the anterior talofibular ligament. Severe grades II and III injuries often lead to chronic joint malalignment and instability, which predisposes to additional tears. Ankle ligament injuries cause pain and swelling, which is greatest on the anterolateral surface. A grade III tear often causes more diffuse swelling and tenderness (sometimes this area takes on an egg-shaped form).

Radiography is performed to rule out significant fractures in the following cases:

• age >55 years;
• inability to bear weight on the leg immediately after injury plus inability to take 4 steps during the first examination;
• pain in the bone along the posterior edge and at the top of both ankles.

The anterior ankle drawer test assesses the stability of the anterior talofibular ligament, which helps differentiate grade II from grade III lateral tears. The patient sits or lies supine with the knees slightly flexed. The examiner uses one hand to prevent the lower leg from displacing forward, while the other hand grasps the back of the heel and pulls it forward. Treatment for grade I injuries includes rest, ice, compression, elevation, and early weight-bearing. For grade II injuries, this treatment is supplemented by immobilization of the ankle in a neutral position with a posterior splint, with activation after a few days for moderate tears and later for severe tears. Grade III injuries may require surgical treatment. If grade II cannot be differentiated from grade III (eg, due to muscle spasm or pain), an MRI may be performed or immobilization may be tried for a few days, followed by reexamination.

In rare cases, when the foot is twisted, a rupture of the deltoid ligament is possible, often in combination with a fracture of the head of the fibula.

Achilles tendon injuries. The typical mechanism is dorsiflexion of the foot, especially if the Achilles tendon is tight. Compressing the calf with the patient prone weakens passive plantar flexion of the foot. Partial tears are often undiagnosed. Complete tears are usually treated surgically. Treatment of partial tears and some complete tears involves immobilization of the ankle with a posterior splint in plantar flexion for 4 weeks.