Deltoid Ligament Strain
THE CLINICAL SYNDROME
The deltoid ligament is susceptible to strain form acute injury due to sudden overpronation of the ankle or to repetitive microtrauma to the ligament from overuse or misuse, such as long distance running on soft or uneven surfaces. The deltoid ligament is exceptionally strong and is not as subject to strain as the anterior talofibular ligament. The deltoid ligament has two layers; both attach above to the medial malleolus. A deep layer attaches below to the medial body of the talus, with superficial fibers attaching to the medial talus and the sustentaculum tali of the calcaneus and the navicular tuberocity.
SIGNS AND SYMPTOMS
Patients with strain of the deltoid ligament will complain of pain just below the medial malleolus. Plantar flexion and eversion of the ankle joint will exacerbate the pain. Often, patients with injury to the deltoid ligament will note a “pop” followed by significant swelling and the inability to walk.
With deltoid ligament strain, patients may notice a "pop" followed by significant swelling.
On physical examination, there will be point tenderness over the medial malleolus. With acute trauma, ecchymosis over the ligament may be noted. Passive eversion and plantar flexion of the ankle joint will exacerbate the pain. Coexistent bursitis and arthritis of the ankle and subtalar joint may also be present and confuse the clinician picture.
Initial treatment of the pain and functional disability associated with deltoid ligament strain should include a combination of the nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 inhibitors and physical therapy. The local application of heat and cold may also be beneficial. Avoidance of repetitive activities that aggravate the patient’s symptomatology, as well as short-term immobilization of the ankle joint, may also provide relief. For patients who do not respond to these treatment modalities, the following injection technique may be a reasonable next step.
It is estimated that approximately 25,000 people will sprain an ankle every day. Although viewed as benign by the lay public, ankle sprains can result in significant permanent pain and disability. The described injection technique is extremely effective in the treatment of pain secondary to the deltoid ligament strain. Coexistent arthritis, bursitis, and tendinitis may also contribute to medial ankle pain and may require additional treatment with more localized injection of local anesthetic and methylprednisolone acetate. The use of physical modalities including local heat as well as gentle range of motion exercises should be introduced several days after the patient undergoes this injection technique for ankle pain. Vigorous exercises should be avoided because they will exacerbate the patient’s symptomatology. Simple analgesics and nonsteroidal anti-inflammatory drugs may be used concurrently with this injection technique.