A Comprehensive Manual Therapy

Treatment Guide for

Ankle Sprain

by: Dr. Joe Muscolino ©2017 Learnmuscles.com

© Learnmuscles.com Page 1
 A Comprehensive Manual Therapy
Treatment Guide for Ankle Sprain
Introduction to ankle sprain

MEDIAL AND LATERAL VIEWS OF THE LIGAMENTS OF THE ANKLE JOINT. PERMISSION: JOSEPH E.
MUSCOLINO. KINESIOLOGY: THE SKELETAL SYSTEM AND MUSCLE FUNCTION, 3ED. (ELSEVIER), 2017.

© Learnmuscles.com Page 2
The ankle joint is located between the talus and the distal ends of
the tibia and fibula. It is a uniaxial joint that allows only sagittal plane
(or near sagittal plane) motions of dorsiflexion and plantarflexion.
Frontal and transverse plane motions of the foot do not occur at the
ankle joint, rather they occur at the subtalar joint (located between the
talus and calcaneus).

An ankle sprain is a traumatic injury that results in tearing of ligaments

of the joint. The ankle is the most commonly sprained joint in the
human body; and the most common type of ankle sprain is an inversion
sprain in which ligaments on the lateral side of the ankle joint are
overstretched or torn. As with all joint sprains, ankle sprains are usually
divided into three categories based on the degree of severity: Grade 1
is a mild sprain; Grade 2 is a moderate sprain; and Grade 3 is a severe
sprain or complete rupture.

Causes of ankle sprain

The cause of an ankle joint sprain is motion that is beyond the normal
range of motion of the joint. At the end of range of motion, ligaments
are pulled taut, trying to stabilize the bones and prevent dislocation. If
the motion is excessive, the ligaments can be overstretched and torn.

By far, the most common type of ankle sprain is when the foot moves
excessively into inversion. Foot inversion occurs at the subtalar joint,
but if the range of inversion exceeds the subtalar joint’s ability to
invert, the tensile pulling force of inversion will then be experienced at
the ankle joint itself. If this motion is strong enough, it will exceed the
ability of the laterally placed ligaments of the ankle joint to restrain
inversion and they will be overstretched and torn. These three lateral
ligaments are the anterior talofibular, calcaneofibular, and posterior
talofibular ligaments. As their names imply, the anterior talofibular
ligament is located the most anteriorly; the posterior talofibular

© Learnmuscles.com Page 3
ligament is located the most posteriorly, and the calcaneofibular
ligament is in the middle between the other two.

An ankle sprain usually occurs due to stepping on uneven ground,

resulting in the foot falling into inversion. Because inversion sprains
usually occur when a person is walking or running, the momentum of
body weight moving forward often results in not only inversion of the
foot, but also plantarflexion. This focuses the tension force of the
stretch to the more anteriorly located anterior talofibular ligament.
Indeed, the anterior talofibular ligament is the most commonly
sprained ligament in the human body.

A further causative factor of an inversion ankle sprain is laxity

(“weakness”) of the lateral ligaments of the ankle joint. Ironically, once
the ankle joint has been sprained into inversion, because the sprain
results in overstretching/tearing of the lateral ligaments, they become
more lax and less able to prevent ankle joint inversion in the future.
Therefore, once a client/patient has experienced an inversion sprain of
the ankle joint for the first time, it is more likely that further inversion
sprains will occur in the future. Each successive sprain further weakens
the ligaments, further increasing the susceptibility of the joint to
continuing inversion sprains.

Similarly, weak musculature can also contribute to the occurrence of an

ankle sprain. Musculature can assist ligaments in restraining excessive
motion at a joint. If the eversion muscles of the foot are weak, they are
less able to limit inversion, increasing the likelihood of an inversion
sprain. The muscles of eversion are the fibularis longus, brevis, and
tertius, and the extensor digitorum longus. (The fibularis muscles were
formerly known as the peroneus muscles.)

Note: It is extremely rare for the ankle joint to be sprained into

eversion because the lateral malleolus of the fibula extends farther

© Learnmuscles.com Page 4
distally than the medial malleolus of the tibia, limiting eversion range of
motion compared to inversion. Another factor that limits eversion is
the ligament structure of the ankle joint. The ligament complex on the
medial side of the ankle joint is stronger than the ligament complex on
the lateral side. This further limits foot eversion, making an eversion
sprain even less likely.

Signs and symptoms of ankle sprain

When an inversion ankle sprain is acute, the typical signs and
symptoms are pain and swelling (inflammation) in the lateral ankle
near the lateral malleolus. Pain will usually be worst when standing and
weight bearing on the injured foot. The degree of pain and swelling is
usually correlated with the severity of the sprain. Maximal tenderness
is usually located over the ligament that is most severely sprained
(torn); most often this is the anterior talofibular ligament located distal
and slightly anterior to the lateral malleolus. The injured ligament(s)
will be tender when palpated.

THE USUAL POSITION OF AN ANKLE SPRAIN: INVERSION AND SOME PLANTARFLEXION OF THE FOOT AT
THE ANKLE JOINT. PERMISSION: JOSEPH E. MUSCOLINO.

© Learnmuscles.com Page 5
Pain and swelling usually lessen as the ankle sprain becomes chronic.
Most conditions are considered to be chronic once six months have
passed since the initial injury. However, because it is difficult to avoid
weight-bearing use of the injured side ankle, healing can take a very
long time. For this reason, ankle inversion sprains, especially moderate
or severe ones, sometimes require a year or more, for the pain and
swelling to fully subside. Even once the overt pain is gone, the injured
area often remains tender to touch.

Because the inversion ankle sprain results in stretched/torn lateral

ligaments, chronic instability of the ankle joint usually results, and the
injured ankle joint will display increased inversion range of motion
permanently into the future.

Occasionally, if the ankle sprain is severe enough, pain and swelling

may occur on the medial side of the ankle joint because the excessive
inversion motion results in the bones on the medial side of the ankle
jamming into each other. Further, due to the excessive inversion
motion that occurs during the sprain, pain may also be present in the
lateral leg due to strain of the eversion musculature (fibularis
longus/brevis/tertius and extensor digitorum longus).

Assessment/Diagnosis of ankle sprain

Assessment/diagnosis of an inversion ankle sprain of the ankle joint is
based on verbal history as well as visual inspection, palpation, and
range of motion (ROM) evaluation during the physical examination.

During verbal history, ask the client/patient to describe the position of

the foot when the ankle sprain occurred; this can be helpful toward
assessing which of the lateral ligaments was sprained. If the foot was
sprained into pure inversion, the calcaneofibular ligament will most
likely sustain the majority of the damage. Most commonly, because the
client/patient is usually moving forward when the sprain occurs, the
© Learnmuscles.com Page 6
foot will also turn into plantarflexion along with the inversion and the
anterior talofibular ligament will sustain the majority of the damage.
Less commonly, if the foot is dorsiflexed as it was sprained into
inversion, the posterior talofibular ligament will sustain the most injury.

The swelling will usually be apparent upon visual inspection. With

Grade 2 and 3 sprains, ecchymosis (black and blue bruising) will often
accompany the swelling. This occurs due to the pooled blood in the
tissues that results from broken blood vessels internally. It is important
to realize that pooled blood will usually descend with gravity, so the
bruising will often show lower than the actual site of injury. If the
swelling is not severe, it can be easily missed. So, for minor sprains,
check for swelling by comparing the contour of the lateral malleolus on
the injured side to the non-injured side; the visual clarity of the bony
contour on the injured side is often diminished due to the swelling
around the bone. Soft tissue swelling can also be detected by manual
palpation assessment.

Palpation is also important for determining the location of pain to

assess which ligament(s) is/are injured, as well as to have a sense of
how severely damaged each ligament is. The sooner after the injury the
palpation can be done, the better, because once the swelling forms, it
can block the ability to palpate the underlying structures.

Passive ROM can also be done. Because inversion ankle sprains result in
the tearing of laterally placed ligaments, the client’s/patient’s inversion
passive ROM will usually be increased (the normal healthy foot should
invert approximately 20 degrees from anatomic position). Assuming the
client/patient has not sprained the other ankle, inversion ROM will
likely be greater on the side of injury, so comparing left and rights can
be helpful. It should be kept in mind that the presence of swelling can
decrease the client’s/patient’s ROM, so an accurate evaluation of ankle
ROM might have to wait until the swelling has subsided. Further, due to

© Learnmuscles.com Page 7
the tenderness of the region, if passive ROM is attempted, it should be
done very gently.

It is also important to assess the eversion musculature because it might

be overstretched and torn along with the ligament tissue. In other
words, the client/patient might have experienced an ankle joint
muscular strain along with the ligamentous sprain. Because the tissues
on the medial side of the ankle joint are approximated during inversion,
it is worthwhile to also assess the medial ankle joint region as well for
compression injury.

It is not necessary to take X-Rays to assess/diagnose a ligamentous

sprain. However, if the client/patient has experienced a moderate or
severe sprain it is wise to have films to rule out an osseous fracture. A
powerful sprain into inversion can possibly result in one of the lateral
ligaments remaining intact and instead causing an avulsion fracture at
its bony attachment, usually the lateral malleolus. It is also possible for
the approximation of bones on the medial side to result in a crush
fracture there as well.

Differential assessment of ankle sprain

Whenever a client/patient has sustained a powerful inversion ankle
sprain, the force that sprains the ligamentous tissue can easily damage
other tissue. Therefore, it is important to also assess for other
conditions. Chief amongst these is a strain of the eversion musculature
and/or avulsion fracture on the lateral side of the ankle or possibly a
crush fracture on the medial side. If the force is powerful enough, it is
also possible to dislocate the ankle joint, subtalar joint, or even the
transverse tarsal joint (located between the talus and calcaneus
proximally and the navicular and cuboid distally; technically composed
of the talonavicular joint and the calcaneocuboid joint).

© Learnmuscles.com Page 8
Manual therapy treatment for an inversion ankle sprain

EFFLEURAGE STROKE OVER THE ANTERIOR LEG MUSCULATURE FROM DISTAL TO PROXIMAL.
PERMISSION: JOSEPH E. MUSCOLINO.

Manual therapy treatment for an acute inversion ankle sprain is

primarily palliative in nature and aimed at decreasing swelling and
inflammation and relieving associated muscle spasm that might be
occurring to splint/stabilize the joint. Effleurage strokes and ice
(cryotherapy) are used to decrease swelling/inflammation. Effleurage
strokes should be gentle and directed from distal to proximal. Ice
should be left on until the area is numb; then removed. Muscle
splinting is likely in the eversion musculature, but is also likely
throughout the entire lower extremity and even the contralateral lower
extremity and low back because of the antalgic gait from the ankle

© Learnmuscles.com Page 9
sprain. Therefore, it is important to work these associated areas
proactively to prevent other conditions from developing.

For a chronic inversion ankle sprain, the major goal is for the
client/patient to strengthen the eversion musculature to compensate
for the loss of lateral ligament integrity. The role of manual therapy is
to work any muscular spasming and myofascial trigger points that
might have developed as a result of the sprain. This can be done with
any and all techniques with which you are comfortable. Even though
the ankle joint will likely be hypermobile into inversion, it is important
to assess (via motion palpation) the joints of the lower extremity for
non-axial joint play motion (motion palpation) and perform joint
mobilization (arthrofascial stretching) if compensatory hypomobilities
are found.

SUMMARY OF MANUAL THERAPY TREATMENT PROTOCOL OF INVERSION

ANKLE SPRAIN

ACUTE SPRAIN:

1. GENTLE EFFLEURAGE OF THE FOOT/ANKLE/LEG FROM DISTAL TO

PROXIMAL
2. ICE
3. SOFT TISSUE MANIPULATION TO THE EVERSION MUSCULATURE
4. WORK THE ENTIRE AFFECTED LOWER EXTREMITY, CONTRALATERAL
LOWER EXTREMITY, AND LOW BACK

CHRONIC SPRAIN:

1. WORK ASSOCIATED MUSCULATURE FOR TIGHTNESS AND TRIGGER

POINTS (SOFT TISSUE MANIPULATION, MOIST HEAT, STRETCHING)
2. MOBILIZE (ARTHROFASCIALLY STRETCH) COMPENSATORY JOINT
HYPOMOBILITIES, IF PRESENT
3. STRENGTHEN THE EVERSION MUSCULATURE

© Learnmuscles.com Page 10
Precautions/contraindications when treating a client with inversion ankle
sprain
Because an inversion ankle sprain results in tearing of ligamentous
tissue, no stretches that would cause the injured ligaments to lengthen
should be done until the ligament tissue has fully healed. Therefore
stretching into inversion and likely plantarflexion are contraindicated,
especially during the acute stage. During the acute stage, nothing
should be done that would increase swelling and inflammation;
therefore, any soft tissue manipulation should be gentle in force.

Self-care for the client/patient with ankle sprain

Self-care for the acute ankle inversion sprain is RICE: rest, ice,
compression, and elevation. The client/patient should be
recommended to ice the ankle as long as swelling is present, whether
that is three days, three weeks, three months, or longer. Instruct the
client/patient to keep the ice on the ankle/foot until the area is numb
and then remove it; this should be repeated as often as possible.

THERA TUBING (THERA-CISER™ BY FOOT LEVELERS) RESISTANCE EXERCISE FOR THE EVERTORS OF THE
FOOT. PERMISSION: JOSEPH E. MUSCOLINO.

© Learnmuscles.com Page 11
Self-care for the chronic ankle sprain involves strengthening the
associated musculature, both generally because the client/patient is
deconditioned/weaker from not having been active for some time, and
specifically to strengthen eversion musculature to compensate for the
lost integrity of overstretched lateral ligaments. An easy and
inexpensive way to strengthen the evertor musculature is to use elastic
thera tubing or thera bands. The client/patient should be made aware
that no matter how much the eversion musculature is strengthened,
strong musculature can only compensate for lax ligaments when the
muscles are directed to contract. Therefore, during an unguarded
moment, such as unexpectedly stepping on uneven ground that turns
the foot into inversion, the musculature might not be able to contract
quickly enough to protect the client/patient from another inversion
sprain. For this reason, the client/patient who has experienced a
moderate/marked inversion sprain must be careful into the future. Any
manual or movement therapy that is directed toward increasing the
client’s/patient’s proprioception would be valuable toward improving
the reaction time of evertor musculature to protect the ankle joint into
the future.

Medical approach to ankle sprain

The medical approach to treatment of an ankle sprain (inversion sprain)
depends on the severity of the injury. For a mild to moderate sprain, it
is RICE (rest, ice, compression, elevation), and possibly the use of a
brace/boot. Anti-inflammatory medication might be prescribed, or an
injection of cortisone to decrease swelling is possible. Injection of
platelet rich plasma (PRP) can also be done to help stimulate collagen
growth for fascial ligament tissue regeneration. If the sprain is severe
and/or if the ligament is ruptured, surgery can be done to sew the
ligament back to its attachment.

© Learnmuscles.com Page 12
Manual therapy case study for a client with ankle sprain
Joe is an 18-year-old who runs cross-country for his high school team.
During a race two weeks ago, he stepped on a tree root and sprained
his right ankle joint into inversion. Because he was moving forward as
the sprain occurred, the sprain was also into plantarflexion. The degree
of the sprain was moderate and he was not able to complete the race.
He experienced immediate pain, which was worst when weight
bearing; his ankle began to swell within a few hours. Joe went to his
chiropractic physician who ordered X-Rays, which were negative for
fracture. Joe’s father is a regular client/patient of a clinical orthopedic
massage therapist, so he brought Joe to the therapist to see if manual
therapy would be of any help.

Upon visual examination, the therapist noted moderate swelling

immediately distal to, and also distal and anterior to, the lateral
malleolus; no ecchymosis was observed. Palpatory examination
revealed exquisite tenderness over the anterior talofibular ligament, as
well as mild/moderate tenderness over the calcaneofibular ligament.
No pain was experienced with palpation of the posterior talofibular
ligament. Palpation also revealed tightness and myofascial trigger
points in the fibularis longus and brevis muscles, as well as in
the gluteus medius and quadratus lumborum on the opposite (left)
side. All passive ranges of motion of his right ankle joint were
restricted, likely due to the swelling; Joe felt immediate pain with
inversion.

Joe experienced a grade 2 inversion ankle sprain of the right ankle joint.
The therapist recommended one to two half hour massages per week
for four weeks. With the client/patient supine, the therapist performed
approximately 5-10 minutes of gentle effleurage strokes to Joe’s right
foot, ankle, and leg, distal to proximal in direction. While this was being
done, moist heat was applied to his left gluteus medius. A flexible ice
pack was then placed on the lateral side of Joe’s right ankle for 5-10
© Learnmuscles.com Page 13
minutes while the therapist worked into the bellies of Joe’s fibularis
longus and brevis musculature with moderate pressure. The therapist
then spent the remainder of the time with Joe side-lying on the right
side, working into the left sided gluteus medius and quadratus
lumborum. The therapist reinforced what Joe’s chiropractic physician
had recommended regarding self care with RICE.

At the end of four weeks, Joe’s pain was gone and the swelling was only
mild in degree. With approval from the chiropractor, the therapist
began to introduce gentle joint mobilization to the tarsal bones
and fibula. Joe’s self-care program was also expanded to begin elastic
tubing resistance exercise for the evertors, with icing to be done after
each exercise session. The therapist continued to see Joe once per
week for another four weeks, whereupon Joe was released from active
care.

** Related Video Lessons for DCOMT Members **

If you're not a DCOMT member, click here to subscribe.
Use coupon code: ebook10 to get 10% lifetime discount!

© Learnmuscles.com Page 14