You could be going about your business when suddenly you lose your footing and next thing you know you are on the ground, grabbing your ankle and in pain. There is no break but wow does it hurt. The ankle swells and is painful to walk on and after getting it checked out, it turns out a simple trip has caused ligament damage, sometimes irreparable.

Our ligaments connect our bones to each other. You know how it goes; your knee bone is connected to your leg bone; your leg bone is connected to your ankle bone……and so on. Well it is ligament that is this connection. Ligaments also known as articular ligament, articular larua, fibrous ligament, or true ligament, and are made of connective tissue.

Connective tissue is made of cells and extracellular matrix (proteins and ground substance located between the cells and fibres) and is one the most profuse and widely dispersed tissue of the body. It comes in various forms depending on its function.

Ground substance is a shapeless, gel-like, translucent substance made of carbohydrates and proteins known as mucopolysaccharides, or glycoaminoglycans (GAGS).

The Function of Ligaments

Ligaments bind, strengthen and support other body tissue, protect and insulate. They are (bundles) of fibrous capsules usually consisting of dense, irregular connective tissues (mostly fibres of collagen) that allow flexibility and movement.

The considerable strength of a ligament is resistant to stretching, preventing dislocation of the joint.

Ligaments are viscoelastic, allowing for resistant strain or tension ito be applied but returning to original shape when strain is removed.
However, they cannot return to their original shape when extended past a certain point or for a prolonged period of time.

Two major types are:

• White ligament which is rich in collagenous fibres (sturdy and inelastic)
• Yellow ligament is rich in elastic fibres (tough but allow elastic movement)

Joints

Ligaments at joints form a capsular sac, enclosing the articulating bone ends and providing a lubricating membrane, the synovial membrane. Some structures include a synovial lined pocket, called a bursa. Ligaments can clasp around or across bone ends in bands, allowing a variable degree of movement. Ligament secure areas between bones, such as the ribs, restricting unsuitable movement.

Ligament Injury

Sprains

A sprain is a forcible pulling or twisting of a joint that stretches, or even tears its ligament, but does not dislocate the joint.

This can happen when the ligament is stressed greater than its normal capacity. Strains may also damage tendons, muscles blood vessels and nerves. Swelling and pain are a result of chemicals being released by damaged cells and bleeding. Common areas of sprains are lower back and ankles.

Dislocations

These need to be repaired as soon as possible to reduce the damage to the ligament from being left in an extended position, not being able to return to its original shape. This can result in reduced support around a joint, allowing for dislocations occurring more easily or frequently in future.

Tears

Ligament injuries can range from mild injury where only a few fibres are torn, to complete tear of the ligament (which can lead to joint instability).

Ligament tears are graded as:

• Grade I – pain but no laxity on stressing the joint
• Grade II – pain with increased laxity but with an end point
• Grade III – there may or may not be pain but there is a gross joint laxity without any firm end point

Hypermobility

Some people have more flexible ligaments allowing for them to extend there joints further than most. This is commonly known as double-jointedness.

Repair

Ligaments generally cannot be repaired naturally. Damaged ligaments can lead to unstable joints and long term, the joint instability may lead to osteoarthritis in the joint. Not all ligament damage needs to be surgically repaired, but it may be necessary if the joint is unstable. All musculoskeletal injuries require rehabilitation, even if surgery has been performed. This will enable a return to activity in the shortest period of time.

Acute Ligament Sprain Management

Apply First Aid – Rest, ice, compress and elevate

Grade I and II can benefit from electrotherapeutic modalities, joint mobilization and soft tissue massage

Grade III – may require bracing or surgery to repair or reconstruct

For all tears – Muscle strengthening, proprioceptive training and functional training

• Muscles will atrophy rapidly following an injury due to inactivity, pain, inflammation and immobility. This means less muscle endurance. Muscle conditioning/strengthening will allow the muscle to gain strength, power, endurance and re-education.
   
• Proprioception is the general term used to describe nerve impulses originating from the joints, muscles, tendons, bones and associated deeper tissue. These impulses are transmitted to the central nervous system to provide the necessary information about joint position, motion, pressure and vibration. Damage can cause impaired nerve transmission resulting in decreased co-ordination, balance and the correct joint position sense. This can result in the joint ‘giving way’ even when doing normal activity. When proprioceptive training is begun early there can be a reduced rate of reoccurring injury. Proprioceptive training involves exercises through a rehabilitation program as soon as possible
   
• Functional Training – This is begun when a reasonable level of strength, power, endurance and proprioception has been achieved and its aim is to return to normal, usual activity and sport.

Nutrition

The most important nutritional consideration during reduced muscle activity is to avoid nutrient deficiencies. Deficiencies of energy, vitamins, minerals and macronutrients—predominantly protein—will weaken wound healing and worsen loss of muscle and tendon mass and function.

Protein

Protein is the building block of the body. Not only can it help repair tissue damage it is also important in injury prevention. By maintaining or increasing daily good quality protein intake can reduce the loss of muscle mass and strength during recovery from injury. Protein can also help with satiety and weight gain whilst normal activity is restricted. Include in your diet meat, fish, eggs, dairy, soy, legumes and nuts. Or consider protein shakes high in amino acid complex. It is best to include protein at every meal through-out the day, rather than just in the evening for the best results.

Fibre. Include fibre-rich foods for a feeling of fullness and satiety. This will help stop added weight gain from inactivity. This means vegetables, fruit, legumes and whole grains. Fresh fruits and vegetables can help with vitamins and minerals too.

Essential Vitamins and Minerals

Vitamin C. Ligaments are made from collagen and vitamin C helps make collagen. Not only that, vitamin C can help with inflammation and is a powerful antioxidant that will aid recovery. Include kiwi fruits, citrus, berries, tomatoes, mangoes and broccoli. Or supplement.

Zinc. Zinc is a component of many enzyme processes in the body and is particularly important for wound healing. Meat, fish, shell fish, pumpkin seeds, seeds, nuts and wholegrains.

Omega 3. Helps reduce inflammation. Even though we need a certain amount of inflammation to enable repair, too much can inhibit this process. Include fish, walnuts, flaxseeds and chia seeds or fish oil.

Other important nutrients include:

Calcium – Bones, teeth, nerve-signaling and muscle contraction

Vitamin D – Needed for absorption of calcium

Magnesium – an essential mineral for connective tissue health and repair

Silica - When the body's tissues are damaged, silica is one of the major materials used to aid in repair.

Collagen – the major structural component of the body

Arginine – amino acid for wound healing

Glutamine – major amino acid lost in injury. It can support collagen production, help with inflammation and repair.

Glucosamine – your body makes this for creating connective tissue in the body – ligaments, tendons and cartilage. It is in the fluid surrounding joints. Supplementing may help recovery

Curcumin – from turmeric has antioxidant properties, can aid in repair and reduce inflammation

Bromelain – a substance found in the core of pineapple is very beneficial for any tissue repair

In acute conditions or if you find you are not recovery quickly it may be best to supplement with good quality vitamins to aid repair.

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References

Tortora, Gerald J and Derrickson, Bryan 2006 Principles of Anatomy and Physiology 11th edition, John Wiley and sons, Inc, USA

https://www.britannica.com/science/ligament

Khan, Karim and Bruker, Peter; 1997; Clinical sports medicine; Mc Graw Hill publishing, Australia

Substantial skeletal muscle loss occurs during only 5 days of disuse. https://www.ncbi.nlm.nih.gov/pubmed/24168489/

Strategies to maintain skeletal muscle mass in the injured athlete: nutritional considerations and exercise mimetics. https://www.ncbi.nlm.nih.gov/pubmed/25027662

Nutritional Support for Exercise-Induced Injuries https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4672013/

Dietary protein distribution positively influences 24-h muscle protein synthesis in healthy adults. https://www.ncbi.nlm.nih.gov/pubmed/24477298/

Optimising foods for satiety  https://www.sciencedirect.com/science/article/pii/S0924224414002386

Response to trauma and metabolic changes: posttraumatic metabolism https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4379844/