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
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
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 - 2012Taras V.
Kochno, M.D. All Rights Reserved
Board Certified in
Physical Medicine and Rehabilitation