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Ankle Sprains: Sidestepping the Path to Chronic Pain

An ankle sprain, which involves the tearing of the ankle ligaments, is responsible for about 40% of all athletic injuries. Interestingly, 40% of those who suffer an ankle sprain also experience recurring symptoms.

Inversion sprains, which affect the outside (lateral side) of the ankle, make up 85% of all ankle sprains. They're the type of injury most runners experience. In contrast, medial ankle sprains (located on the inside of the ankle) are less common and typically result from fractures or other traumatic incidents.

When an ankle is severely injured, inadequate treatment and rehabilitation can prevent it from healing completely, leading to reduced stability. This instability may cause chronic ankle pain, recurrent sprains, imbalanced gait, osteoarthritis, and an ongoing pattern of dysfunction.

The reason inversion sprains are so widespread can be traced back to our uneven anatomy. The bone on the lower outside of the ankle (lateral malleolus - distal fibula) extends further down than the bone on the inside (medial malleolus – fibula), providing the inside of the ankle (medial side) with greater stability than the outside (lateral side).

Although most ankle sprains seem to resolve completely without rehabilitation, they're actually more prone to further injury if not treated properly.

Recent research indicates that individuals with a history of recurrent ankle sprains exhibit decreased muscle firing activity in the ankle, knee, and hip when performing tasks, a phenomenon known as Athrogenic Muscle Inhibition (AMI). This suggests that an ankle sprain's impact isn't limited to the local area but can extend throughout the entire leg.


Let's delve into the ligamentous anatomy of an ankle sprain.

The outside part of the ankle, or the lateral side, gains its stability from a combination of three ligaments. These include the Anterior Talofibular Ligament (ATFL), the Calcaneofibular Ligament (CFL), and the Posterior Talofibular Ligament (PTFL).

When an inversion sprain occurs, which is when the ankle turns inward, the most frequently injured ligament is the ATFL. Ligaments are typically named based on the bones they connect. In this instance, the ATFL links the talus bone in the ankle to the fibula, a long bone in the lower leg. The primary role of the ATFL is to prevent the forward displacement of the ankle, or the talus.

In cases of a severe ankle sprain, another ligament, the CFL, might also sustain damage. This ligament bridges your heel bone (the calcaneus) and the fibula. Compared to the ATFL, the CFL is more robust and less likely to suffer injury.

Movements where the foot is pointed downwards (plantar flexed) and rolled out (inverted) can potentially harm both the ATFL and CFL. Significant instability in the ankle can arise if these two ligaments are damaged.

The PTFL, the strongest ligament in the lateral complex, is seldom injured, except in instances of a complete ankle dislocation (talus).

There's also a sprain known as a "High Ankle Sprain" (syndesmotic ligament complex) that's becoming increasingly common. In this type of injury, the ligament and connective tissue between your shin bones (the tibia and fibula) get torn. This injury is serious and may necessitate surgical intervention.


More Than Ligaments - The Kinetic Chain of an Ankle Sprain

Ankle sprains can result in damage to various structures, such as connective tissues, tendons, muscles, and nerves. A comprehensive understanding of these injuries, commonly seen in lateral ankle sprains and high ankle sprains, is essential for effective treatment and prevention of future sprains.

Tendons: In inversion sprains, the Peroneal Tendon is often injured, and during recovery, it may displace from its normal position, a condition known as subluxation. It's crucial to address this issue during the recovery stage of an ankle sprain to promote proper healing.

Muscles: Peroneus Brevis and Peroneus Longus are two muscles frequently involved in ankle sprains. Longitudinal tears of the Peroneus Brevis are commonly associated with lateral ankle sprains, while the Peroneus Longus may exhibit altered activation patterns due to muscle restrictions that form after ankle instability. If not addressed, these restrictions could predispose individuals to recurrent injuries. Both muscles function to evert the foot at the tarsal joint and plantar-flex the foot at the ankle.

Retinaculum: The retinaculum is a band of connective tissue that secures the peroneal tendons in place. A tear in the retinaculum can cause a snapping sensation in the lateral ankle. Severe retinaculum tears might not be suitable for standard manual therapy and may require surgical intervention.

Understanding the complexities of these injuries allows for the development of a comprehensive, effective treatment plan for ankle sprains. This facilitates faster recovery and reduces the risk of future sprains.


Ankle and Foot Examinations

Ankle and foot examinations play a vital role in diagnosing and managing injuries like ankle sprains. A comprehensive assessment includes orthopedic, neurological, and vascular tests, each focusing on different aspects of the injury.

Orthopedic tests evaluate bones, muscles, and ligaments, identifying specific areas of concern. Neurological tests ensure nerve function is intact, while vascular examinations check blood circulation, crucial for healing.

We've included demonstration videos to help you better understand these examination procedures, emphasizing their importance in effectively addressing ankle sprains and related conditions.

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 over all 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 a valuable tool used 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 go over some of the common procedures we perform in daily clinical practice.


Managing An Ankle Sprain

The Initial Phase

Right after an ankle sprain, your priority should be to minimize swelling in the area. Swift initiation of treatment often leads to a quicker recovery. Addressing the injury promptly can result in a relatively short healing period, while neglecting it may prolong your discomfort.

Therefore, in the immediate aftermath of the sprain - during the initial phase - remember to follow the RICE protocol: Rest, Ice, Compression, and Elevation!

Rest: In the initial stage, it might be necessary to completely offload the injured ankle, often using crutches. However, I believe it's essential to reintroduce weight-bearing as soon as it's feasible to expedite healing. The careful reintroduction of weight-bearing stress can potentially shorten recovery time. The right time to do this? As soon as you can, but without rushing! Remember, rest is equally important.

Ice: Applying ice for 20 to 30 minutes, 4 to 5 times daily can help reduce swelling. Generally, we advise against icing beyond 72 hours post-injury.

Compression: Compression, typically achieved with an ACE wrap, helps mitigate swelling and bleeding. If you have a Grade 3 sprain, a brace should be worn continuously until you can bear weight on your ankle.

Elevation: By raising the injured area, you can further reduce swelling and bleeding.

After implementing the "RICE" protocol, it's crucial to reintroduce motion to the ankle at the earliest opportunity. Depending on the injury severity, the patient might be advised to perform gentle ankle circles or, if capable, to 'write' the alphabet with their feet. Gentle calf stretching and using 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 get rid of waste by-products.


Manual Therapy For Ankle Sprain Recovery And Prevention

Manual therapy plays a significant role in both the recovery from and prevention of ankle sprains. It promotes faster healing by enhancing blood flow, oxygenation, and the delivery of crucial nutrients to the injured area, while also aiding in the removal of waste products that tend to accumulate following an injury. This is particularly vital in the treatment of ligaments which are typically characterized by poor blood supply.

An integral part of effective manual therapy is the use of Motion Specific Release (MSR). Contrary to a single technique, MSR is a diversified treatment system that draws upon multiple perspectives to address both soft tissue and joint dysfunction. It integrates a range of techniques and approaches to offer a personalized, holistic treatment strategy tailored to the patient's unique needs and conditions.

The following videos will provide examples of how we utilize the MSR treatment system to address different aspects of ankle sprain recovery. These examples highlight the profound benefits of manual therapy and the particular effectiveness of the integrated MSR system in promoting recovery and preventing 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 effectively address the body's full kinetic chain. In fact, we greatly reduce the effectiveness of any myofascial treatment if we don’t also address restrictions in joint mobility.

Nerves and Ankle Sprains: Delving Deeper

Nerves can also be affected during an ankle sprain, particularly in the case of lateral ankle sprains (inversion sprains). Addressing nerve-related issues is vital for successful treatment and recovery.

Superficial Peroneal Nerve: This nerve is at risk for traction injury during a lateral ankle sprain. Specific MSR (Motion Specific Release) procedures are designed to release the peroneal nerve if it is involved in the injury. Proper treatment of this nerve injury can aid in a more effective recovery process.

Peroneal Nerve Release: Peroneal nerve injuries are the most common peripheral nerve injury in the lower extremity. The majority of these injuries occur in the region of the fibular head (common peroneal nerve). To address such injuries, MSR procedures may be employed, focusing on releasing the peroneal nerve to improve function and promote healing. Click on the Video to see MSR procedures demonstrating peroneal nerve release techniques.


Navigating Post-Acute Recovery from an Ankle Sprain

Once the acute stage of a lateral ankle sprain has subsided, it's critical to initiate a rehabilitation program. This program should involve three key components: enhancing flexibility and mobility, strengthening the affected muscles, and honing balance and proprioception. Each of these aspects plays a crucial role in a successful recovery and the prevention of future injuries.

Flexibility and Mobility: Regaining range of motion and flexibility in the ankle is paramount to restoring normal function. This may involve specific stretching exercises tailored to your individual needs and the severity of your injury.

Strengthening: Building strength in the muscles surrounding the ankle aids in providing support and stability to the joint. These exercises can be customized to your unique circumstances and will be crucial in preventing recurring sprains.

Balance and Proprioception Training: This element of rehabilitation is essential to retrain the body's sense of position and movement (proprioception), which can be disrupted after an ankle sprain. Balance exercises help to restore this awareness, thereby reducing the risk of future injuries.

While the following exercises are potential components of a rehabilitation program, it's important to note that the exact regimen will be specifically tailored to each individual and 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 are great at reducing injury risk, rehabilitating current injuries, or increasing your sports performance. This exercise routine should only be performed after doing the beginner series for several weeks.


In Conclusion: Your Ankle Sprain Recovery Journey

Navigating through an ankle sprain can be a complex and daunting journey. From understanding the anatomy of your injury to effectively managing its acute stage, and finally, onto a carefully structured rehabilitation plan, every step is pivotal in your recovery.

Embracing a holistic approach is key to fostering a full and speedy recovery. This includes adopting the RICE protocol promptly after the injury, seeking professional manual therapy such as Motion Specific Release (MSR) when necessary, and adhering to a rehabilitation program that promotes flexibility, strength, and proprioceptive balance.

Remember, your body is interconnected through the kinetic chain, where the health of one part can significantly impact the others. Therefore, while focusing on your ankle, do not neglect the health and functionality of the surrounding structures, as these too can influence your overall recovery.

While the journey to recovery may seem long, don't be discouraged. With patience, dedication, and the right approach, you can overcome this setback and restore your ankle's health, function, and resilience, preventing further sprains and ensuring a return to your active lifestyle.

Always consult with healthcare professionals when dealing with an ankle sprain to ensure you're getting the most appropriate and effective treatment for your unique situation. Remember, each injury and individual is different; what works best for you will depend on various factors, including the severity of your sprain, your overall health, and specific lifestyle factors.

In the end, the goal is not just to heal, but to emerge stronger, with a more resilient and capable body that's ready for whatever challenges lie ahead.