Of all the sports injuries that have occurred, lateral ankle sprains are the most common. Representing approximately 40% of all sports injuries, these occur mainly among basketball athletes (53%), soccer (29%), running and ballet/dancing1-2. Approximately 10% of emergency room visits are ankle sprains. In the United States this represents 30,000 sprained ankles a day!3
Three-quarters of these involve the lateral ankle ligaments, the Anterior Talofibular ligaments (ATF), the Calcaneofibular ligament (CF) and the Posterior Talofibular ligament (PTF) (see Figure 1)4. The most common structures that are damaged are the lateral ligaments caused by forced plantar flexion (pointed foot) and inversion (bottom of the foot inward) as the weight of the body moves forward (see Figure 1)5. The Anterior Talofibular ligaments and Anterior Calcaneofibular ligaments are most often injured. Ankle sprains happen to both women and men equally. When the sprain is treated quickly, 80% of acute ankle sprains will recover completely with conservative treatment, while 20% may develop mechanical or functional instability leading to chronic ankle instability6-7. This instability is mainly caused by a decrease in mechanoreceptors (sensory neurons sensitive to mechanical deformations). Instability could quickly lead to degenerative changes on the medial side of the ankle due to an imbalance when applying weight8. Given these major consequences, it’s important to treat any ankle sprain as quickly as possible.
How do chiropractors diagnosis this?
Basic x-ray images can be taken after an acute sprain in order to eliminate the possibility of a fracture. The Ottawa ankle rule was established by Stiell and Greenberg to guide professionals on “when should one take ankle x-rays?” This guide has reduced emergency department costs by $3 million annually. CT or magnetic resonance imaging (MRI) aren’t typically indicated for acute ankle sprains, except when additional injuries are suspected.
The classification “lateral sprains” is divided into three grades according to severity and associated ligament damage. This classification guides the chiropractor in administering the right treatment.
Classification of the injury and clinical presentation9
|Injured ligaments||Clinical presentation|
|Grade 1||Stretching of the anterior talofibular ligament.||Light swelling and pressure. Minimal difficulty with range of motion and applying body weight.|
|Grade 2||Complete tear of the ligament (anterior talofibular +/- calcaneofibular ligament).||Moderate tenderness and swelling
Decreased range of motion and increased difficulty in applying body weight
|Grade 3||Complete tear of ligament (anterior talofibular and calcaneofibular ligament, + / tearing of the capsule +/- talofibular posterior ligament tearing||Generalized swelling, bruising Pressure in the anterolateral capsule, anterior talofibular and calcaneofibular ligaments. Instability occurs when applying body weight.|
What is the treatment?
As with all types of injuries, it’s clear that prevention is key. It’s controversial whether wearing an ankle brace or support prevents ankle sprains.
For grade I and II sprains, an intensive conservative treatment is indicated. This would consist of a short resting period with immobilization, compression, elevation and the application of ice followed by adapted taping. In these cases, rehabilitation may vary according to the frequency of treatment. For a grade I it should take about 8 days and 15 days for a grade II7. Functional rehabilitation varies according to the stages of cellular healing. At first, the acronym RICE (rest, immobilization, compression and elevation) is used to reduce inflammation and edema in order to promote future healing1. The ligaments must then be protected for a few weeks during the healing and proliferation phase. During this period, the fibroblasts invade the area and form collagen fibers. Taping or an orthosis is recommended to decrease the chances of the talus sliding 1(very important bone in the ankle). About 3 weeks after the injury, the collagen fibers mature becoming scar tissue. Stretching exercises will then be necessary to allow the collagen fibers to reorient themselves and thus reduce the chances of rigidity. In general, after 6 to 8 weeks post-injury, the fourth stage of healing allows the patient to regain maximum strength and return to normal activities.
However, the athlete should remember that it will take 6 to 12 months for the injured ligaments to completely heal. In practice, it’s very common to see these stages accelerate for the athlete who follows the exact guidelines. Rehabilitation treatment focuses on increasing ankle mobility and proprioception. Stationary cycling and swimming can be very helpful in increasing range of motion. Strengthening should only begin after applying one’s normal body weight and painless range of motion is felt. Treatment is focused on increasing proprioception, for example, by using the tilt board to increase balance and neuromuscular control. For a grade III injury, treatment is less standardized and in some rare and serious cases may require surgery.
Through their specialized undergraduate doctor training, a chiropractor is able to accurately diagnose a sprained ankle. They are able to determine whether your pain can be improved by a chiropractic treatment program or if you need to be referred to another healthcare professional. If the cause of your pain is neuro-musculoskeletal, your chiropractor can help you. Through various manual therapy techniques, the chiropractic approach will aim to reduce pain and restore mobility to the affected joint. By addressing such a problem with a global approach, the chiropractor makes sure to reduce pain, restore the biomechanics of the region and prevent the reoccurrence of painful episodes. The chiropractor will also promote muscle relaxation through muscle and soft tissue work. Finally, your chiropractor will be able to give you advice that will play an important role in your rehabilitation.
1 Balduini FC, Vegso JJ, Torg JS, et al. Management and rehabilitation of ligamentous injuries to the ankle. Sports Med. 1987 Sep-Oct;4(5):364-80.
2 Colville MR. Surgical treatment of the unstable ankle. J Am Acad Orthop Surg. Nov-Dec 1998;6(6):368-77.
3 Berlet G, Anderson RB, Davis W. Chronic lateral ankle instability. Foot Ankle Clin. 1999;4:713-28.
6 Harrington KD. Degenerative arthritis of the ankle secondary to long-standing lateral ligament instability. J Bone Joint Surg Am. Apr 1979;61(3):354-61.
7 Keith W. Chan, M.D., Bryan C. Ding, M.D., and Kenneth J. Mroczek, M.D., Acute and Chronic Lateral Ankle Instability in the Athlete, Bulletin of the NYU Hospital for Joint Disease 2011; 69 (1):17-26.
8 Jarvinen MJ, Lehto MU. The effects of early mobilisation and immobilisation on the healing process following muscle injuries. Sports Med. Feb 1993;15(2):78-89.
9 Vaes P, Duquet W, Handelberg F, et al. Objective roentgenologic measurements of the influence of ankle braces on pathologic joint mobility. A comparison of 9 braces. Acta Orthop Belg. Jun 1998;64(2):201-9.