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Ankle Sprains: Avoiding the Route to Chronic Pain

Updated: Dec 5, 2023


Ankle sprains, especially inversion sprains, constitute 40% of sports injuries. Inversion sprains account for 85% of these, while medial ankle sprains, linked to fractures, are less common but significant. This is due to the lateral malleolus extending further down than the medial malleolus, ensuring inside ankle stability. Untreated sprains can lead to chronic pain, re-injury, and complications like osteoarthritis. While some seem to recover, insufficient rehabilitation risks recurrence.


Although some seem to recover naturally, without proper rehabilitation, they're vulnerable to re-injury. Recent research on Athrogenic Muscle Inhibition (AMI) indicates that recurrent sprains can impact muscle activity across the leg, not just the ankle.


Article Index:


Introduction

Examination & Diagnosis

Treatment

Exercise

Conclusion & References

 

Ligamentous Architecture


Let's embark on a journey through the intricate ligamentous architecture of an ankle sprain.


The exterior portion of the ankle, the lateral side, owes its steadfastness to a trio of ligaments. Say hello to the Anterior Talofibular Ligament (ATFL), the Calcaneofibular Ligament (CFL), and the Posterior Talofibular Ligament (PTFL).

In the wake of an inversion sprain, where the ankle does an inward pirouette, the ATFL is usually the first casualty. With ligaments typically named for the bones they marry, the ATFL is a bridge between the talus bone of the ankle and the fibula, the leg's lower limb's supporting actor. The ATFL's starring role is to keep the ankle, or the talus, from straying forward.

If the stage is set for a severe ankle sprain, the CFL might also join the cast of the injured. The CFL is the bridge builder between your heel bone, known as the calcaneus, and the fibula. In contrast to the ATFL, the CFL stands as a bastion of resilience, more injury-resistant.


Movements where the foot bows down (plantar flexed) and takes a sideward roll (inverted) might harm both the ATFL and CFL. If both these ligaments falter, the ankle could be left with significant instability.


The PTFL, playing the part of the strongest ligament in the lateral complex, rarely falls victim to injury unless a full-blown ankle dislocation, or talus, is the script.

A new character frequently appearing on the sprain stage is the "High Ankle Sprain," or the syndesmotic ligament complex. This injury involves a tear in the ligament and connective tissue sandwiched between your shin bones, the tibia and the fibula. This is a grave injury that might require the surgeon's intervention.


 

Beyond Ligaments: Unraveling the Kinetic Chain of Ankle Sprains


Ankle sprains are not just a ligamentous affair but also a turbulent saga involving connective tissues, tendons, muscles, and nerves. Grasping the full breadth of these injuries, seen predominantly in lateral ankle sprains and high ankle sprains, paves the way for effective therapeutic intervention and sprain deterrence in the future.


Tendons: When an inversion sprain strikes, the Peroneal Tendon often finds itself in the line of fire. As recovery unfolds, this tendon may drift from its usual residency, manifesting in a condition termed subluxation. Pinpointing and rectifying this misalignment during healing is vital to promote optimal recuperation.


Muscles: The spotlight falls on the Peroneus Brevis and Peroneus Longus, the twin muscles that are implicated in ankle sprains repeatedly. Lateral ankle sprains often come paired with longitudinal tears of the Peroneus Brevis. At the same time, the Peroneus Longus may display signs of altered activation due to muscle constraints that take root following ankle instability. Overlook these restrictions, and you pave the path for recurrent injuries. Functionally, these twin muscles roll the foot outwards at the tarsal joint and flex the foot downward at the ankle.

Retinaculum: Picture the retinaculum as a secure belt of connective tissue; its role is to keep the peroneal tendons firmly in place. A tear in this safety belt can spark a snapping sensation in the lateral ankle. In severe cases, retinaculum tears might defy standard manual therapy, requiring a surgeon's expertise.


By delving into the anatomy of these injuries, we can lay the foundation for a holistic, impactful treatment plan for ankle sprains. This approach propels the healing process, minimizing the risk of future sprains.


 

Ankle and Foot Examinations


The crux of diagnosing and tending to injuries like ankle sprains lies in thoroughly examining the ankle and foot. A complete evaluation introduces a trio of tests: orthopedic, neurological, and vascular, each casting its spotlight on diverse facets of the injury.


Orthopedic tests delve into the world of bones, muscles, and ligaments, pinpointing the precise areas that warrant attention. Neurological tests stand guard over nerve function, ensuring no derelictions go unnoticed. Vascular assessments, on the other hand, keep a keen eye on blood circulation, the lifeline essential for healing.


To bring these examination procedures into sharp focus and underscore their significance in effectively navigating ankle sprains and allied conditions, we've curated a series of demonstration videos. We hope these visual guides help deepen your understanding of these crucial processes.


Effective Ankle and Foot Examination This video uses orthopaedic test to evaluate some of the most common ankle and foot conditions we see in clinical practice. These conditions include Ankle Sprains (inversion sprain), Cuboid Syndrome, Talar Dome Lesions, 5th Metatarsal Fracture, Syndesmosis damage, Achilles Tendon Tendinopathy, Morton's Neuroma, 2nd Metatarsal Stress Fracture, Plantar Fasciitis, and Bunions.


Lower Limb Neuro Examination


The lower limb neurological examination is part of the overall neurological examination process and is used to assess the motor and sensory neurons which supply the lower limbs. This assessment helps to detect any impairment of the nervous system. It is used both as a screening and an investigative tool.


Peripheral Vascular Examination - Key Points


A peripheral vascular examination is valuable for ruling out signs of vascular-related pathology. The detection and subsequent treatment of PVD can potentially mitigate cardiovascular and cerebrovascular complications. In this video, we review some common procedures we perform in daily clinical practice.


Imaging


Imaging plays a vital role in diagnosing and evaluating the extent of ankle sprains, providing a clear insight into the underlying anatomy and any potential damage. Initially, X-rays are commonly used to rule out fractures and assess the alignment of the ankle joint. Ultrasound can provide real-time imaging of the soft tissues around the ankle, aiding in the identification of ligament tears or tendon abnormalities. In more severe or complex cases, an MRI may be employed to provide a detailed view of both soft and hard tissues, including any damage to ligaments, tendons, or cartilage. Together, these imaging modalities contribute to a comprehensive understanding of the injury, which is crucial for devising an effective treatment plan.


 

The Acute Stage


In the face of an ankle sprain, your first line of action should be to curb the swelling in the region. A prompt response can be your ticket to a speedy recovery. Fast action might mean a shorter healing timeline, while dawdling could extend your discomfort.

Hence, in the wake of the sprain - the immediate phase - keep the RICE protocol at the forefront of your mind: Rest, Ice, Compression, and Elevation!

  • Rest: In this primary phase, it may be necessary to relieve the injured ankle of all weight-bearing, often with the aid of crutches. However, I stand by the conviction that reintroducing weight-bearing at the earliest opportunity is crucial to catalyze healing. A cautious return of weight-bearing stress may help trim the recovery duration. The perfect timing for this? At the earliest comfort, but without haste! Mind you, rest remains equally vital.

  • Ice: Applying an ice pack for spans of 20 to 30 minutes, repeated 4 to 5 times daily, can help temper the swelling. As a rule of thumb, we usually discourage icing beyond 72 hours post-injury.

  • Compression: Compression, commonly executed with an ACE wrap, assists in dampening swelling and bleeding. In the event of a Grade 3 sprain, it's advisable to wear a brace consistently until your ankle can bear weight comfortably.

  • Elevation: Lifting the affected area can help in further easing swelling and bleeding.

Post "RICE" protocol execution, it's imperative to bring motion back to the ankle at the earliest possible juncture. Depending on the injury's severity, patients may be guided to perform gentle ankle rotations or, if able, to 'draw' the alphabet using their feet. Light calf stretching and employing a stationary bicycle could also be beneficial.


Ankle Exercises - Acute Injury

Here are examples of ankle mobilization exercises after an ankle injury. These exercises are often combined with RICE: Rest, Ice, Compression and Elevation. These exercises are only for the acute stage of injury to increase fluid exchange and eliminate waste by-products.


 

Manual Therapy: A Key to Ankle Sprain Recovery


Manual therapy holds a pivotal position in the healing and warding off of ankle sprains. By fostering enhanced blood flow, oxygenation and channeling vital nutrients to the injury site, it accelerates healing. Moreover, it aids in flushing out the waste products that usually pile up post-injury. This becomes particularly vital when treating ligaments, infamous for their meagre blood supply.


The following videos offer glimpses into how the MSR treatment system takes the reins in addressing varied facets of ankle sprain recovery. These examples underscore the compelling merits of manual therapy and the specific effectiveness of the cohesive MSR system in propelling recovery and forestalling future ankle sprains.


Rehab Ankle Sprains - Exercise and Treatment

Without appropriate treatment and rehabilitation, a severely injured ankle may not fully heal and could lose its stability. This loss of stability could, in turn, result in chronic ankle pain, recurrent sprains, gait imbalances, osteoarthritis, and a path of ongoing dysfunction. In this video, Dr. Brian Abelson and Miki Burton RMT show you effective ways of addressing this common condition.


MSR - 7 Point Ankle & Foot Mobilization

Improving joint mobility is critical if you are going to address the body's full kinetic chain effectively. In this video Dr. Abelson demonstrates some very effective MSR procedures for doing just this.




Nerve Entrapments and Ankle Sprains


An ankle sprain, especially a lateral ankle sprain (inversion sprain), can also impact nerves. Attending to these nerve-centred complications is key to a successful healing journey.


Superficial Peroneal Nerve: This nerve stands vulnerable to traction injury amid a lateral ankle sprain. Certain MSR (Motion Specific Release) methodologies have been tailor-made to liberate the peroneal nerve should it become ensnared in the injury. Proper management of this nerve trauma can foster a more efficient recovery journey.


Peroneal Nerve Release:

In this video Dr. Mylonas demonstrates some of the common MSR procedures we us in releasing nerve entrapments of the peroneal nerve.




 

Treatment Frequency


The frequency of manual treatment is tailored to the severity of ligamentous injury. Mild injuries often require less intensive therapy, allowing for an early transition to self-managed care. Moderate injuries demand a more structured approach to navigate through healing phases and initiate rehabilitation.


Most hamstring injuries do not require surgery. Surgical intervention is generally reserved for severe instances, like in cases where a hamstring tendon has been entirely detached from the bone. The susceptibility to hamstring injuries can escalate due to several elements: advancing age, inadequate muscle flexibility or strength, fatigue, and a history of previous injuries to the muscle.



Grade 1 Tear (Mild):

  • Initial: 2 times per week

  • Duration: 1-2 weeks, transitioning to home exercises and self-management

  • Approximate Total Appointments: A total of 3 to 6 appointments, encompassing 2 to 4 initial treatment sessions followed by 1 or 2 follow-up appointments, depending on patient response.


Grade 2 Tear (Moderate):

  • Initial: Weekly to bi-weekly visits

  • Duration: 2-4 weeks, then tapering off as symptoms improve and home exercises progress

  • Approximate Total Appointments: 3 to 8 appointments, comprising weekly to bi-weekly visits over a span of 2-4 weeks, followed by 1 or 2 follow-up appointments, depending on patient response.


Surgical Cases


Most hamstring strains don't require surgery. In severe cases, post-operative rehabilitation begins with managing pain and swellinge. Early rehabilitation introduces weight-bearing and basic exercises. Intermediate rehabilitation advances strengthening and normalizes walking. Late rehabilitation intensifies strength training and introduces sport-specific exercises. Finally, a gradual return to full activities commences.


 


Exercise


Upon surpassing the acute phase of a lateral ankle sprain, embarking on a rigorous rehabilitation regimen is the next step. This program should encompass three pivotal components: enhancing flexibility and mobility, reinforcing muscular strength, and honing balance along with proprioception. Each element is vital for a successful recovery and in averting future injuries.


  • Flexibility and Mobility: Reacquiring the ankle's range of motion and suppleness is fundamental to reestablishing its normal functionality. This may necessitate specific stretching exercises tailored to your individual needs and the severity of your injury.

  • Strengthening: Augmenting the strength in the muscles surrounding the ankle aids in providing support and stability to the joint. Personalized exercises based on your unique circumstances will be crucial in preventing recurrent sprains.

  • Balance and Proprioception Training: This facet of rehabilitation is key in retraining the body's awareness of position and movement (proprioception), which may be disrupted post ankle sprain. Balance exercises are geared towards restoring this awareness, thereby reducing the risk of future incidents.


Although the following exercises serve as potential components of a rehabilitation plan, it's imperative to acknowledge that the exact routine will be meticulously tailored to each individual, factoring in the severity of their injury.


Rehab Ankle Sprains - Exercise and Treatment

Without appropriate treatment and rehabilitation, a severely injured ankle may not fully heal and could lose its stability. This loss of stability could, in turn, result in chronic ankle pain, recurrent sprains, gait imbalances, osteoarthritis, and a path of ongoing dysfunction. In this video, Dr. Brian Abelson and Miki Burton RMT show you effective ways of addressing this common condition. (Exercises start at Time Code 08:45)

Improve Your Balance - Exercises for Beginners

Balancing exercises are essential components of both Rehabilitation and Sports Performance training. These exercises should not be overlooked, as they can enhance one's ability to stabilize the body during functional movements. Incorporating simple balance exercises into a progressive training program can improve balance and prevent injuries.


Improve Your Balance - Advanced Exercise

Balance exercises can be of great benefit to people of any age. Balance exercises improve your ability to control and stabilize your body's position. Balance exercises greatly reduce injury risk, rehabilitate current injuries, or increase your sports performance. This exercise routine should only be performed after doing the beginner series for several weeks.


 


Conclusion


Ankle sprains, notably inversion types, are a common sports injury due to the ankle's anatomical structure. The recovery journey begins with understanding the injury's kinetic chain and initiating a rehabilitation program. Essential to this program are exercises aimed at improving flexibility, strength, and balance. Manual therapy further accelerates healing by enhancing blood flow and addressing any accompanying nerve complications, crucial for treating ligaments known for their limited blood supply.


The treatment frequency, tailored to the injury's severity, plays a pivotal role in recovery. A structured approach, transitioning from manual therapy to self-managed care, is employed to navigate through healing phases. This approach, coupled with a deeper understanding of the ankle's biomechanics, aids in restoring functionality and minimizing the risk of future sprains. Through precise therapeutic interventions and a well-planned rehabilitation regimen, individuals can work towards a successful recovery post ankle sprain.


 

DR. BRIAN ABELSON DC. - The Author


Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.

 


Revolutionize Your Practice with Motion Specific Release (MSR)!


MSR, a cutting-edge treatment system, uniquely fuses varied therapeutic perspectives to resolve musculoskeletal conditions effectively.


Attend our courses to equip yourself with innovative soft-tissue and osseous techniques that seamlessly integrate into your clinical practice and empower your patients by relieving their pain and restoring function. Our curriculum marries medical science with creative therapeutic approaches and provides a comprehensive understanding of musculoskeletal diagnosis and treatment methods.


Our system offers a blend of orthopedic and neurological assessments, myofascial interventions, osseous manipulations, acupressure techniques, kinetic chain explorations, and functional exercise plans.


With MSR, your practice will flourish, achieve remarkable clinical outcomes, and see patient referrals skyrocket. Step into the future of treatment with MSR courses and membership!

 

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  3. Fukuhara T, Sakamoto M, Nakazawa R, et al. Anterior positional fault of the fibula after sub-acute anterior talofibular ligament injury. J Phys Ther Sci 2012; 24(1): 115-117.

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