Chiropractic and Ankle Instability

Ankles play an important role in body mechanics. They help to support a person's entire body weight and therefore are mostly injured. Ankle injuries are among the most common of the bone and joint injuries and can arise frequently from trauma, such as a car accident, motorcycle accident, slip and fall accident, bicycle accident, construction accident, industrial accident or recreational injury. They are particularly common in sports such as basketball, soccer, hiking, volleyball, ice skating, or other activities performed on uneven surfaces.

The most common ankle problems are sprains, strains and fractures.

If you have ever twisted your ankle, you might still have some weakness, which could still be causing problems. The most common injury to the ankle is turning it in, such as when wearing high heels and turning it over by stepping on a stone or off the edge of a curb. This is a common ankle sprain.

Occasionally the end of the bone on the outside of the ankle breaks, but more often the ligaments of the ankle on the front and side get torn and produce massive swelling and bruising. It can take 4 to 6 weeks to recover from the immediate injury, but the ligaments very rarely repair satisfactorily and often become full of scar tissue, which is not elastic. This increases the likelihood of rolling over again and several further sprains.

Such repeated traumas will influence the mechanics of the ankle and cause problems in the joint and the structures above, such as the knee and spine. These usually tend to become obvious after jogging or long walks, especially on uneven ground, but as the symptoms may be in a distant joint, you do not necessarily think of that old ankle injury being the origin of it. Chiropractic treatment can help to prevent chronic and recurrent problems. Your chiropractor will, by careful case history and examination, be able to discover the cause and remedy it accordingly.

Strains vs. Sprains:

Strain is the most common type of ankle injury and refers to soft tissue damage to the muscles, tendons and ligaments around the ankle joint that results from forcible contraction or overstretching in response to a quick twist, or pull. Damage is usually limited to muscular or tendinous structures. Ligaments are injured when more than normal stretching force is applied and this happens most commonly when the foot is turned inward or twisted. In the case of muscle or tendon strain, it occurs at the weakest point where the muscle is attached to the tendon. Symptoms for an acute muscle strain may include pain, swelling, bruising, muscle spasm, loss of strength, and limited range of motion.

Uncomplicated ankle strains are classified as:
    1.    Mild – Little or no swelling or tear.
    2.    Moderate – Partial tearing of muscle tissue with inflammation.
    3.    Severe – Complete tearing of a muscle group.

Sprains are acute overstretching injuries that affect ligaments, thick bands of cartilage that attach bone to bone. They occur in response to a forceful movement to a joint causing a mild ligamentous stretch to a partial or complete tear of a ligament or joint capsule. Sprains can result from trauma such as a fall or outside force that displaces the surrounding joint from its normal alignment. Bruising, swelling, instability, and painful movement are common symptoms experienced after a sprain occurs.

Uncomplicated ankle sprains are classified as:
    1.    Mild – Slight hemorrhage of capsular fluids.
    2.    Moderate – Partial tearing of the ligaments with edema (swelling).
    3.    Severe – Complete tearing of ligaments with edema (swelling).

Unfortunately, one of the consequences of a moderate to severe sprain is re-occurrence. This is due to scar tissue which can lead to ligamentous changes causing the joint to become biomechanically unstable. Anyone who has ever severely sprained an ankle knows this. It is typically that same ankle that gets sprained in the future.

Fracture of the ankle is most often caused by the ankle rolling inward or outward. The most common symptoms are pain and swelling; the affected area can also feel tender. If the fracture is more complex, it may be visible as the bone may have broken the skin.

When To Seek Treatment for a Sprain or Strain:

• You heard a “popping” sound when the injury happened
• You have severe pain and cannot put any weight on the injured joint.
• The area over the injured joint or next to it is very tender when you touch it.
• The injured area looks crooked or has lumps and bumps that you do not see on the uninjured joint.
• You cannot move the injured joint.
• You cannot walk more than four steps without significant pain.
• Your limb buckles or gives way when you try to use the joint.
• You have numbness in any part of the injured area.
• You see redness or red streaks spreading out from the injury.
• You injure an area that has been injured several times before.
• You have pain, swelling, or redness over a bony part of your foot.

Chiropractic Care for Ankle Injury:

A chiropractor can help align the bones of the foot and be more specific with soft tissue techniques that will help the ankle recover. By using the chiropractic adjustment to return spinal segments to their normal mobility and by using physical therapy to help the supportive tissues (muscles, tendons, & ligaments), chiropractic physicians help the injured areas return to normal function. An ongoing exercise program may be implemented to help rebuild and strengthen the muscles and ligaments surrounding the ankle. Pills do not correct the damage to soft tissues and other systems that can lead to future pain. Only a chiropractic treatment is the best solution to prevent chronic and recurrent problems after an ankle injury.

Taking an detailed history, examination and x-ray (if indicated to rule out fracture) are important first steps before chiropractic ankle sprain treatment can begin. If there is a fracture present, usually of the large bony bump on the outside of the ankle (called the lateral malleolus) or a bone on the very side of the foot (head of the fifth metatarsal), then casting of the ankle by an orthopaedist is recommended. If a ruptured ligament is found, referral for surgery will likely be recommended.

The pain and swelling associated with a sprained ankle have been shown to respond well to conservative Chiropractic care. The most important point of ankle sprains is the rehabilitation that occurs after the swelling has subsided and the ligament is healed.

The most effective treatment for an ankle sprain/strain in the absence of fracture or ligament rupture which may require surgical intervention, or 6-8 weeks post-surgery or casting, is not only the gradual resumption of activities but chiropractic rehabilitation. There are various physiological therapeutics and treatment modalities that have been found to be most effective in reducing the amount of time it takes to heal. Low-level laser photo biostimulation (LLLT), ultrasound and electro-muscle stimulation combined with conservative chiropractic care management has been shown to be effective in treating the pain associated with a stress fracture of the lower extremity and boost the injured tissue healing response. The more important aspect of the treatment is in finding out why the injury occurred in the first place and removing that problem so the injury does not resurface again in the future.

If you or someone you know is needlessly suffering from ankle pain, call Advanced Healthcare Inc. and have Dr. Pisarek design a customized treatment protocol that will have you on the road to living and playing pain free today!

To facilitate normal quick healing if there is no fracture contraindication to physical treatment, the first treatment is focused on reducing the inflammation, swelling and pain. Sprain and strain of ligaments and tendons treatment is done using the standard R.I.C.E. ankle sprain treatment method: Rest, Ice, Compression Bandage, Elevate. Usually more than one tissue is injured and unfortunately the treatment of one (eg. a fracture) may contraindicate the treatment of another (eg. ice on the sprain, or adjusting the talus). Fracture will always take precedence. The talus can always be adjusted once the fracture has healed. Following this, the talus bone can be gently mobilized. This is not usually particularly painful, and can be done with a standard chiropractic technique. Restoring the normal biomechanics enhances the normal healing time.

A Specific Treatment and Exercise Rehabilitation Program:

1. If the patient cannot bear weight on the injured ankle after a Grade 2 or Grade 3 sprain, and there is tenderness extending around the lateral malleolus, a fracture of the lateral malleolus bone must be ruled out with x-rays before treatment begins.
2. After ruling out a fracture of the ankle, weight bearing on the injured ankle should commence as tolerated with or without crutches. An ankle support should be worn to protect the ankle from twisting in.
3. Steps to minimize swelling are very important. The patient is instructed on ice therapy: 20 minutes on and 1 hour off, with reapplication as tolerated. Prescribed non-steroidal anti-inflammatory drugs are often useful as well.
4. Adjustments to the joints in the ankle and foot, soft tissue procedures applied to the muscles surrounding the ankle, and ultrasound/electric muscle stimulation combined therapy would be utilized to free up soft tissue motion and joint motion and decrease healing time.
5. Range of motion exercises are necessary for proper re-strengthening of the joint area. These exercises involve eversion, dorsiflexion, and plantarflexion. Stationary cycling, while stressing dorsiflexion and plantarflexion of the ankle, can maintain cardiovascular conditioning as well as restore range of motion.
6. Resisted rubber band or tube exercises are quite effective and are used to stretch the achilles tendon, strengthen the muscles that evert the ankle (peronei muscles), and strengthen the muscles on the front of the leg that dorsiflex the foot (tibialis anterior and extensor muscles) (Figures 8A, 8B, and 8C below). Heel raises can strengthen the posterior calf muscles.
7. Proprioception training, retraining neurological responses of the muscles, is done with the wobble board and balance disc cushion (Figures 8D & 8E below). The slide board and jumping rope are also useful proprioceptive training devices.
8. When the patient can walk without a limp, it is usually acceptable to start straight-ahead running. The patient may progress to more advanced agility drills as stability and confidence in the ankle increases.
9. Injured athletes can return to play when they can conduct full active and passive range of motion of the ankle; when the strength of the injured ankle is comparable to the non-injured ankle; when they can conduct the movements of their particular sport with minimal or no pain; and when and they are psychologically prepared to participate in their sport.
10. If conservative measures fail, surgical correction should be considered

Prevention:

You can take steps to ensure that you won’t suffer from an additional ankle sprain. It is important to avoid “running ahead” of the healing process, so follow your chiropractor's directions fully. Many re-injuries of the ankle come from asking for maximum performance of the joint too soon. The pain and swelling associated with ankle sprains often goes away before the ligaments are healed and this leads the patient to believe that they are ready to return to usual activity when they actually are not.  

An ongoing exercise program may be implemented to help rebuild and strengthen the muscles and ligaments surrounding the ankle. Your chiropractor may recommend daily exercises to promote range of motion in the ankle. These exercises may include resistance exercises with tubing and wooden “wobble” boards for balance. It is also common for your chiropractor to recommend custom-made flexible orthotics to provide a firm foundation for your feet and to promote long term healing while minimizing recurrences of the ankle injury. 

Below is a sample ankle sprain/strain exercise rehabilitation program: