What to do about that Sprained Ankle
Ankle sprains by definition is a sprain to ligaments (not muscles or tendons) in the ankle. Ankle sprains in modern day athletics are common. They make up 30% of all sports related injuries. Ankle sprains occur most when lots of jumping, running, and quick changes in direction are involved. These actions put a lot of force into the foot and ankle. If an ankle sprain occurs, then there is an 80% chance that another ankle sprain will occur. With that being said, it is important to try to prevent ankle sprains in the first place, and even more important when an ankle sprain occurs.
Grades of Injury
Tendons and muscles (sometimes bones-depending on severity) are often injured in conjunction with the injury to the ligaments. There is a grading system to determine the severity of the ligament sprain in the ankle, ranging from grade 1 (least severe) to grade 3 (most severe). A grade 1 sprain means that there was some stretching or slight tearing of the ligaments. Mild tenderness, stiffness, and swelling can occur, but the ankle should feel stable and someone can walk with minimal pain.
Grade 2 sprains involve an incomplete tearing of the ligaments, which there is moderate pain, stiffness, and swelling. The ankle can be walked upon because it should still be stable, however, it is painful to walk on the ankle. Bruising often occurs, and all that means is that blood vessels, like capillaries and venules, were stretched to the point they burst and leaked blood into the extracellular fluid (which gives bruising that dark blue/purple color). The most severe grade is grade 3, and that is a complete tearing of the ligament and causes a lot of instability in the ankle. There is severe swelling, bruising, and pain, which makes walking difficult, and should avoided immediately after the injury.
Inversion and Eversion
80% of all ankle sprains are inversion, meaning that the foot rolls in and down (plantar flexion with supination and inversion) which affects all structures on the outside of the ankle. Potentially, there could be three ligaments involved in an inversion ankle sprain, it all depends on the way the ankle rolled in as well as how severe. The anterior talofibular ligament (ATFL) is the most commonly injured of the three lateral ligaments, while the calcaneal fibular ligament (CFL) is the next most common, and then the posterior talofibular (PTFL).
Other neuromusculoskeletal findings that are commonly found with inversion ankle sprains is the talus being subluxated superior, the fibular head subluxated posterior, and the ipsilateral os coxa flexed (posterior superior iliac spine is posterior, medial, and inferior). Along with those findings, the ipsilateral gluteus maximus is neurological shut off (usually through reciprocal inhibition of the iliopsoas), the Q angle increases which means the knee is in a more valgus position, and the fibularis (peroneal) muscles are strained.
With eversion ankle sprains, it’s the medial structures of the ankle that are affected. It’s the deltoid ligament that is affected during the eversion ankle sprain, however, there are sometimes other ligaments involved, like the plantar calcaneonavicular ligament (depends on severity and the way the ankle was sprained). As far as associated neuromusculoskeletal finding with eversion ankle sprains, there isn’t as many since they aren’t as common. The only major one is muscle strains of the tibialis anterior and posterior.
High Ankle Sprains
High ankle sprains are another thing to look at when determining the extent of an ankle injury. The difference between an inversion/eversion ankle sprain and a high ankle sprain is the ligaments involved. Inversion/eversion ankle sprain ligaments were previously stated, but the high ankle sprain involves the fibrocartilaginous ligament between the distal tibia and fibula. The most common mechanism for this is an “impact” injury, where the person lands on the ground and the distal tibia and fibula separate, which causes the sprain. A common neuromusculoskeletal finding associated with high ankle sprain is a sprain of the superior extensor retinaculum of the ankle, which is another ligament. One function of the superior extensor retinaculum is to keep the distal tibia and fibula together, so when there is tenderness of the retinaculum there is an indication of a high ankle sprain.
Ankle sprain treatment varies on severity, as well as how acute or chronic the ankle sprain is. Generally, adjusting any subluxations, using instrument assisted soft tissue massage (IASTM) and lasering strained muscles, kinesiology taping, and mechanical loading/proprioceptive rehabilitation is used for the majority of ankle sprains in my clinic (even acute ankle sprains). Nutritional therapies are also ustilized, especially for acute ankle sprains. Anti-inflammatory compounds and herbs (boswellia, turmeric, ginger, quercetin, fish oil, magnesium, selective pro-resolving mediators [SPMs], passionflower, lemon balm, valerian, cayenne) in conjunction with enzymes away from food (trypsin, chymotrypsin, bromelain) help reduce inflammation and clean up “cellular debris” from the acute ankle sprain. Inflammation and the inflammatory cascade is necessary for the healing process, so it needs to be modulated by previously stated nutrients at the appropriate level (not too much or too little), rather than being shut off completely by certain chemicals/compounds and increasing recovery time. Since inflammation is a chemical process, dealing with inflammation needs to be dealt with chemically and not by icing. All icing does is decrease blood flow to the area, which inhibits nutrient rich blood to get to the area for healing and slows the removal of lymph (which is the fluid that causes the swelling). The other aspects of the PRICE model should be followed.
Every ankle sprain should be evaluated by the appropriate medical professional, because every patient is different as well as every ankle sprain. Ruling out the most serious complications of an ankle sprain (broken bones for example) is important for the healing process.
About the Author
Dr. Eric Johnson, Doctor of Chiropractic and Diplomate of the American Clinical Board of Nutrition as well as owner of Functional Wellness and Chiropractic Center in Madison, WI, is a functional medicine doctor that identifies root causes of pain and/or dysfunction. His systems-based, not symptoms-based, approach is a comprehensive, holistic approach that helps identify mental, chemical, and physical stressors that are underlying numerous health conditions. If you are in the Madison, Middleton, Verona, Waunakee area and looking to not only feel better, but live better, contact Dr. Eric at (608) 203-9272.
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