An Approach To Lower Ankle Sprains

The ankle, like the wrist, incorporates two large long bones that are connected by small ovoid bones that provide proper biomechanical movement of the tendons as they attach to the distal structures of the fingers and toes. The ligaments are like fasteners attaching one larger bone to a smaller bone providing stability that allows movement, but limits excessive movements.

The ligaments are strategically situated.  They provide stability to the joints within functional movements.  In the ankle, these functional movements are the dorsi and plantar flexion and extension, as well as, inversion and eversion. These ligaments attach to the tibia and fibula and insert into the calcaneal and talar bones that create the mortis of the ankle joint. Ligaments are thick and have no blood supply. On the other hand, muscles, nerves, arteries, veins, and lymphatics are well vascularized as they perform functional physiological tasks within these movements. These structures rely on stable bone positions that are maintained by the ligaments.

Since the ligaments have no blood supply when they sprain or tear, they are not the major source of bleeding. However, when forceful mass trauma occurs to the joints, ligaments do sprain and may possibly tear away at their bony attachments.  As a consequence of forceful trauma, the tendons and their secondary muscle tendons that spasm to tighten the joint and lend support to the instability.

Our body’s musculoskeletal system has two main sensors that indicate excessive pressure and tension.  The pressure sensor at the joints is called Golgi tendon apparatus. The tension sensor within the muscle is termed a muscle spindle. These sensors within the muscles and tendons provide the reflexive protective mechanisms to protect the muscle from over-extension and forced joint trauma.

In trauma, ice is used to control the initial histamine inflammatory swelling the body creates to protect itself. The ligaments do not swell to any degree, as they have no vascular or lymphatic supply. The swelling occurs outside the joint space in the vicinity of the myofascial structures.  This physiologic swelling is the natural response of the body surrounding the area injured with fluid.

Once ice is provided, physical compression to the area stabilizes the tendons and muscles, as well as, physically decreases the inflammatory response. This limits the amount of fluid that is able to expand within the capsule or the fascial structures around the joint.

The goal of correcting joint sprains is to compress the new instability towards themselves such as to decrease the secondary muscular tendinous inflammatory process.

Myofascial tendon systems have a complex sensory system that responds to expanding pressure and the length changes. By re-positioning the bones and shortening the muscles tendinous length, one can reduce the inflammatory swelling, thereby, minimizing the expansion of the joints.

When ligaments are sprained or torn, the attachments at the bone are strained. The body’s response for minimal displacement is to increase fluid, which allows lubrication in order that bones do not rub against themselves causing friction.

Elevation of the limb reduces the congestion of the lymphatics and vascular supply as a result of musculoskeletal tightness and secondary third spacing of fluid outside the joint. Reviewing the process of icing, wrap compression and elevation gives us the basis of the initial treatment components of the sprained joint. The final component is to rest the joint thereby minimizing further inflammation and swelling. These four components make up the acronym of RICE being rest, ice, compression and elevation in the initial management of joint injuries.

In my experience, joint injuries are managed well in the acute phase utilizing RICE. Unfortunately, many athletes as well as non-athletes continue to have problems of swelling and pain in the joint and loss of functional endurance with walking, running, jumping, climbing stairs, or ascending and descending slopes. With activity, secondary swelling occurs when there are malalignments in the musculoskeletal biomechanical model of the joint. This occurs commonly in athletes who develop ankle sprains and must rely on repeated taping of their joints which is turn minimizes flexibility and increases frictional forces in the subtalar joint.

My approach to treating ankle sprains is to identify the ligaments that were over-stretched which will help describe the mechanism of injury--whether it is anterior or posterior or side-to-side. Once these specific ligaments are identified, in all probability, the subtalar bone shift has occurred causing malalignment and increased tension of the tendinous structures that overly these ligaments and joint.

My approach to correcting lower ankle sprains is to identify the ligaments that are sprained and bring the joint back upon itself, in the direction of these ligaments, as if closing a hinge.  This eliminates any instability, but more importantly reduce secondary tightness of the tendons and joint receptors. Initially, the injured person would assist me with an active contraction back upon the hinge of the ligaments that are involved in order to activate contraction of overlying musculotendinous structures.

The initial voluntary contraction toward the ligaments should continue up to a 60- second time period while the affected joint reassures itself that no trauma is likely to occur, thus minimizing tension across the ankle. After these 60 seconds, the therapist asks the person to relax, then applies passive pressure with compression upon the joint so that the surrounding tendons also relax. At the two-minute period there is a window of opportunity that allows for manual repositioning of the subluxed subtalar bones with secondary repositioning of proper muscular tendinous alignment.

After two minutes, a gentle tug is done quickly in the opposite direction from the hinged joint that allows the subtalar mortis to realign itself back to its physiological anatomical position, which then allows for healing and restoration of normal function. In the event that the first try is unsuccessful or partially successful, after a few minutes a second try and third try can be performed in the hopes of providing subtalar realignment of the bones.

Often with proper realignment, a popping noise can be heard during the retraction process, which indicates that the fluid pressure is released and the fluid is transformed into an audible sound of pressure release.

Frequently in my experience, I have noted that athletes who were unable to bear weight through the joint or were required to wear supportive footwear or splinted boots are able to put more pressure and flex the joint with functional use instantly following this release technique. As of yet, I have had no complications or adverse consequences to this technique.

Should you have any further questions regarding this article, please direct your questions or comments to "Ask the Doctor" section.

Copyright © 2004 - 2010 Taras V. Kochno, M.D.  All Rights Reserved
Board Certified in Physical Medicine and Rehabilitation

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