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Ankle Sprains
Principles of Orthopedic Massage and their Application

By Ben Benjamin

Originally published in Massage Bodywork magazine, February/March 2004.
Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.


It is difficult to treat a pain problem effectively if we do not understand the underlying cause of the pain. Injuries to the ankle are common, but understanding the nature of these injuries, as well as the appropriate treatment for them, requires some specialized knowledge. In this article I will discuss several principles that can help therapists understand, evaluate and treat injuries. We will apply these principles specifically to the most common ankle sprains.



Introduction
I learned about ankle sprains in a very personal way. At 15 I sprained one ankle, then at 17 I sprained both ankles at the same time. I don't recommend learning about ankle sprains in this way.

It was not until many years later, after I had already worked as a therapist for 14 years, that I learned key facts about the injury process that would revolutionize not only my understanding of my own pain and healing and the body's capacity for healing, but my ability to help my clients as well. Dr. James Cyriax and Dr. Milne Ongley, pioneers in orthopedic medicine, taught me what I have come to call the Essential Principles -- the underlying principles that govern effective assessment and treatment. These important concepts are based on facts about the normal functioning of the body's tissues and what happens to these tissues when they are injured.


I learned, for example, that muscles are injured frequently but heal easily, while tendons, ligaments and joints often take months or years to heal and often stay injured for a lifetime. I also learned that long-term pain patterns are most often the result of adhesive scar tissue that forms in tendons, ligaments and joints after an injury. Hundreds of discrete injuries to muscles, tendons, ligaments, bursas, nerves and joints can be precisely assessed and successfully treated. Hands-on therapists can effectively treat many of these injuries by using friction therapy, an effective technique that breaks down adhesive scar tissue in muscles, tendons, ligaments and fascia.

Although it took me two decades to grasp these essentials, I now teach these principles of orthopedic massage to therapists all over the country who apply them successfully in their practices. This article will present some of these important concepts that will help you understand the body and its pain in a new way. I will use the ankle joint and its common sprain patterns to illustrate how you can apply these Essential Principles in your own practice.


PRINCIPLE: Specific areas of the body are prone to specific injury patterns
In each part of the body, certain structures are more likely to be injured than others. For instance, the construction of the shoulder includes the rotator cuff, where tendons not only function as tendons but also do the work of ligaments by holding the humerus in the glenoid fossa. This structure allows the shoulder joint great freedom of movement -- but also means there is more likelihood of injury to the tendons in this area when movement is sudden or requires excessive strength. The back of the thigh, in comparison, is a highly muscular area of the body; the most likely casualty of an injury to the mid-posterior thigh will be a tear in the muscles. In contrast to both of these, when an ankle is sprained, the structures that are most commonly injured are the ligaments.


APPLICATION: Ligamentous structure of the ankle joint
The ankle is a hinge joint that primarily permits forward and backward motion. But the ankle is also capable of subtle side-to-side movements that help us walk and balance on uneven terrain.

There are three supporting ligaments on the lateral side of the ankle: The anterior talofibular ligament, the calcaneofibular ligament and the talofibular ligament -- sometimes referred to as the posterolateral ligament. These lateral ligaments of the ankle hold the foot to the base of the lateral malleolus, which is in fact the distal end of the fibula. During standing, walking and other activities, these ligaments prevent the ankle from buckling laterally.

The anterior talofibular ligament attaches the anterior portion of the lateral malleolus to the talus. The calcaneofibular ligament attaches the inferior portion of the lateral ankle bone to the calcaneus below. The posterior talofibular ligament attaches the posterior aspect of the lateral ankle bone to the posterior portion of the talus. Together these ligaments create stability for the lateral aspect of the foot and ankle.


PRINCIPLE: Ligaments should be tight
Bones and their joint capsules supply the primary structure of our bodies. Muscle-tendon units enable our bodies to move these bones at the joints. Ligaments supply the stability we need at the joints in order for our movements to be controlled and safe. All these parts of the body must do their individual jobs interdependently to allow us pain-free movement. For ligaments, this means that their fibers must be flexible enough to allow normal movement and yet tight enough to protect the joints and the bones they connect. Ligaments limit movement and provide stability so that we do not fall over when we walk, run or suddenly move to the side.

While it is healthy for us to have muscles that are loose and relaxed, it is not healthy for us to have ligaments that are loose. To appreciate the necessity for tight ligaments, imagine a door where the hinges are loose because the screws are not screwed in tightly. The loose hinges will allow the door to rock around until, eventually, the door or the frame, or both, become damaged or broken. In contrast, hinges that are securely attached to both door and frame allow the door to open and close smoothly, with no undue pressure on any part of the door's structure.

Ligaments function in a similar way. When loose, ligaments allow too much movement at a joint and can lead to injury not only in the ligaments themselves, but also in the relevant joint capsule, tendons and muscles. Appropriately tight ligaments hold the joint stable during movement, thereby limiting the possibility of injury.

Ligaments can become loose in three ways: Through genetics, trauma or by the development of distended scar tissue.

- Genetically, an individual may be born with ligaments that are too long for his body's structure. We all remember kids we would call "double-jointed" because they could get into all sorts of positions that were unimaginable for the rest of us. These individuals did not actually have two joints instead of one; they simply had ligaments that were longer than their joints needed, allowing them to be much more flexible than the norm. Unfortunately, these very flexible individuals are also very vulnerable to injury because they lack joint stability.

- Secondly, trauma from a sudden blow or a severe accident can, in a moment, stretch a ligament permanently.

- The third and very common method that leads to loose ligaments is the development of adhesive scar tissue. Whether the ligamentous scar tissue results from repeated injury or from surgery, it can stretch and distend over time. When it does, this distended scar tissue leaves the person vulnerable to further injury, often of a more serious nature.


APPLICATION: Injuries to the lateral ligaments of the ankle
For the ankle to be stable, its supporting ligaments must be tight. If the ligaments are too loose, there is an excessive amount of joint movement that makes the ankle vulnerable to injury.

After low back and cervical pain, lateral ankle sprains are probably the third most common injury a massage therapist sees. "Sprain" refers to tears in the ligamentous fibers. The seriousness of a sprain can vary from minor sprains in which only a small number of ligament fibers swell or tear, to a more serious sprain in which one or more ligaments can rupture completely.

It is common for the ligaments on the lateral aspect of the ankle to be looser than the medial ligaments. Often just stepping on a small stone or off a curb unexpectedly will cause the ankle to buckle outwards. The majority of all ankle sprains occur to these lateral collateral ligaments of the ankle.

An outer-ankle sprain often involves the fibers of all three of the lateral ankle ligaments named above and shown on pages 68 and 69 (the anterior talofibular ligament (A), the calcaneofibular ligament (B) or the posterolateral ligament (C)). In almost all cases the anterior talofibular ligament is affected, and in many lateral ankle sprains all three ligaments are partially torn.

There are three grades of sprains that we can think of as mild, moderate and severe. The extent of the sprain can be judged by the severity of the pain and the degree of swelling. However, there is an exception to this. With extreme sprains one ligament (the anterior talofibular) can rupture and in these cases the pain often completely disappears. When an ankle ligament rupture occurs, although the pain usually subsides quickly, the ankle feels very weak and unstable. An important ligament is now gone. When dealing with any sprained ankle, especially when there is swelling and pain, the massage therapist should have the client visit a physician to get an X-ray before seeing the client. The ankle could be broken. Even with moderate sprains, the swelling can be severe enough that seeing the ankle bones and making an assessment can be difficult.

Many activities or conditions can lead to sprained ankles. Poor alignment of the bones of the feet, where the arches pronate and drop toward the ground, makes a person very prone to ankle sprains. High arches also make the ankle less steady and prone to injury. Instability from excessive flexibility at the ankle joint, which may come from stretched or inherited loose ligaments, increases the likelihood of a sprain as well. If a person has very weak or chronically tense calf and shin muscles, they are less able to adapt to changes in the ground surface, increasing their vulnerability to injury. Other causes are muscular imbalance in the lower leg and wearing high-heeled or platform shoes. Of course, a person could be doing everything just right yet slip on the ice or accidentally trip and end up with a badly sprained lateral ankle.

The lateral ankle is frequently sprained during athletic activity and commonly involves a severe, sudden trauma. This injury can easily occur during an off-balance shot in basketball, while landing incorrectly from a jump during dancing, crashing into somebody playing soccer, sliding into third base, or tripping on some uneven ground while running or walking. There is often severe pain, and sometimes a loud "snap" is heard. It usually takes an hour or so for the swelling to occur and the pain to intensify. Within a few hours, the swelling and pain are usually quite severe. After swelling has progressed, it becomes difficult to walk.

In other cases, the sprain is not immediately apparent. In the heat and excitement of activity, a slight falling over on the ankle is barely noticed; the person recovers his balance automatically without missing a step. An hour or so later, a nagging pain begins to appear and may or may not be accompanied by swelling. It may remain just a slight irritation, that gets worse over the next few days as the ankle is used or it may become increasingly painful after several hours.

If the sprain causes adhesive scar tissue, the ongoing pain pattern is often irregular, causing pain at the beginning of activity and/or after the activity has stopped. This pattern emerges when an ankle sprain does not heal properly. When a sprained ankle becomes chronic and will not fully heal, it is generally caused by scar tissue that is malformed during the healing process. The ligament fibers heal in the wrong direction and/or improperly attach to the bone they should glide over, and a sense of instability as well as pain results. Strenuous activity re-tears this weak and unwanted scar tissue, resulting in a seemingly endless cycle of pain, no pain, pain and no pain. It is an enduring problem that can continue for many years if not properly treated.


PRINCIPLE: Injured ligaments often result in a capsular pattern
British orthopedic physician Dr. James Cyriax coined the term "capsular pattern" to refer to "a pattern of limitation of movement of a specific joint." The principle of the capsular pattern is based on one of the emergency systems the brain puts into effect to protect us when we become injured. When a joint or its supporting ligaments become damaged, the brain tells the synovial membrane that forms the lining of the joint to begin secreting excess fluid. This swelling is telling us to rest and limit the use of the joint until it is healed. The body speaks loudly saying something like, "Stop moving this joint until I heal, or I will hurt you more."

When a joint swells in association with an injury, the result is called a traumatic arthritis, which means an inflammation of the joint as the result of trauma. This joint inflammation and swelling usually disappears when the triggering injury is resolved. People who have a traumatic arthritis in a particular joint experience the same pattern of limitation, or capsular pattern.

The principle of the capsular pattern is an important concept because it helps us differentiate different types of injuries from other conditions in the joint. For instance, in the knee the capsular pattern is always the same; it is more difficult to bend the knee than it is to straighten the knee. Similarly, the capsular pattern for traumatic arthritis of the elbow shows up as more difficulty bending the elbow and less difficulty straightening the elbow. If that pattern is reversed and the person can easily bend the elbow but has a great difficulty straightening it, a different condition is present.


APPLICATION: Capsular pattern in the ankle
The capsular pattern in the ankle means more limitation in plantar flexion than in dorsiflexion. When you see a client who has this pattern of limited movement, it means the person either has a sprained ankle that has not been resolved or some other irritation to the joint that is causing swelling and therefore pain and limitation of movement.


PRINCIPLE: Passive testing tells you when passive structures are injured
One of the most important skills a therapist can develop is the ability to assess which structures are involved when a client presents with an injury. A therapist can learn many assessment tests to help evaluate the client's condition. These assessment tests are specifically designed to pinpoint exact structures that may be damaged. In order to determine whether ligaments, joints and bursas have been injured, one essential principle predominates: Passive testing tells you when passive structures are injured.

Ligaments, joints and bursas are referred to as passive structures because, unlike muscles, they do not initiate movement. Ligaments support the joints of the body, and joint capsules hold the bones together. Bursas cushion the gliding surfaces of muscles, tendons, ligaments and so forth.

During a "passive test," the client remains relaxed and allows the practitioner to initiate and complete a movement with no help from the client. If there is pain and/or limitation of normal movement on a passive test, it means there is damage to whatever passive structure is being tested. For instance if we stretch a ligament passively and it hurts, this tells us the ligament is injured. If, on passive testing, a joint is limited in its capacity to move, this usually indicates the joint is swollen and inflamed.

Therapists can learn how to perform numerous passive tests in order to determine, very specifically, which passive structures have been injured.


APPLICATION: Passive tests for lateral ankle sprains
If the X-ray is negative, we test for a sprained ankle by having the client lie supine while trying to reproduce the type of movement that originally caused the sprain. There are separate tests for the anterior talofibular ligament, the calcaneofibular ligament and the presence of a capsular pattern indicating a traumatic arthritis in the joint. The posterolateral ligament is difficult to test, but if you palpate the ligament and compare the level of discomfort between the injured ankle and the good one, you can assess with a great degree of certainty if it is sprained as well.
With recent sprains, very little pressure is needed to induce pain. Ask the person to let you know immediately if they feel discomfort; there is no need to give excessive pressure causing the person pain. If any of these movements caused even mild discomfort, it means the structure you are testing is injured.

If the sprain is very mild or if it is an old chronic sprain, you will need to give the foot an extra push after you have it in the stretched position. This should reproduce the pain of an old or mild sprain. As a general rule, remember to go gently at first and harder only if necessary.



Capsular Pattern
If there is pain and/or limitation of movement on passive dorsiflexion or passive plantar flexion (see the next two photographs), this indicates the ankle is swollen. There is usually greater limitation in plantar flexion than in dorsiflexion. This indicates there is a capsular pattern.


Passive dorsiflexion- Sit on a stool at the client's feet and place one hand under the heel for support. Now place the heel of your other hand on the ball of the client's foot and press the foot into full dorsiflexion. If there is no pain at the end of the range, give the foot an additional push further into dorsiflexion. When there is swelling, it soon becomes apparent this movement is difficult for the person to tolerate.



Passive plantar flexion
- With the hand still under the heel for support, bring the foot into full plantar flexion, giving a slight additional push if there is no pain. If there is swelling the movement is quite limited and painful under gentle pressure.

Passive supination and passive inversion of the heel help you determine if the anterior talofibular ligament or the calcaneofibular ligament, or both ligaments, are injured. Palpate the posterolateral ligament on both ankles in order to determine if this important ligament is also involved.



Passive supination
- Place one hand under the back of the client's heel for support, then with your other hand firmly grip the top of the foot with your elbow raised and the curve of your thumb facing you. Now gently supinate the foot. (Supination is a combination of plantar flexion, medial rotation and inversion -- all done simultaneously.) Pull the foot medially and down toward the floor as you inwardly rotate it. If the ankle is sprained, this should cause pain at the lateral ankle slightly to the front of the ankle bone. This test assesses the sprain of the anterior talofibular ligament.



Passive inversion of the heel in dorsiflexion
- Hold the foot in dorsiflexion with the medial hand and grip the lateral ankle with the heel and palm of the lateral hand. Now, forcefully stretch the lateral ankle by rotating the heel medially into what is called a varus stretch. This test assesses the calcaneofibular ligament.

Peroneus brevis or longus tendinitis is sometimes mistaken for a mild ankle sprain because this pair of tendons passes around the back of the ankle very close to the ligaments. Confusion often results from the fact that the pain is similar in both of these injuries.

In cases of severe ankle sprain, one or both of the peroneal tendons are often stretched and strained along with the ligaments of the ankle. What happens to many people is that the ligaments heal, but the pain remains. This pain often results from strained tendons that have not been paid attention to or treated. If five or six weeks pass and an ankle you have been treating still hurts behind or just below the outer ankle, check the peroneal tendons by having the person push their forefoot out laterally against resistance.


PRINCIPLE: External adhesions must be eliminated for healing to occurInjured soft tissues react to trauma by forming internal or external scar tissue. Internal adhesive scar tissue forms within a structure (for example within a tendon or a ligament). When an external adhesion forms it is between two different structures (for example between a ligament and the bone the ligament is supposed to glide over). In certain conditions, the formation of adhesions can often be a random, uncontrolled process. If, for example, the range of movement is significantly restricted, the newly forming scar tissue may adhere to whatever it touches. If the person is immobilized, more scar tissue generally forms in odd places. However, if healing occurs in the presence of full movement, the formation of external adhesive scar tissue is minimized.

Scar tissue begins to form within minutes of an injury. Therefore, prophylactic treatment of adherent scar tissue formation can theoretically begin the same day the injury occurs. Friction therapy is not recommended in the first two or three days, unless the therapist is very experienced and knowledgeable in treating such injuries. In the first few days, all that is needed to prevent adhesions is two or three well placed friction strokes along with frequent movement. If treatment is done too harshly or for too long at this stage, friction might interfere with the normal healing process.

To eliminate firmly entrenched external adhesive scar tissue takes a considerable force. Deep sustained friction therapy, manipulation or injection are three techniques that are usually effective in the appropriate circumstances.


APPLICATION: Eliminating external scar tissue adhesions in the ankle
When the ankle is sprained, strenuous activity should cease immediately; the leg should be elevated and the ankle iced. As soon as possible, a doctor should check for broken bones or complete rupture of the ligaments. If the ankle isn't broken, rest. The use of ice and elevation of the leg should begin at once.

As soon as the person can move the ankle, the foot should be flexed, pointed and moved circularly in both directions many times throughout the day. It is recommended that the leg be elevated while exercising in this way. This will prevent much of the adhesive scar tissue from forming. Walking on the injured foot should begin only when mild discomfort remains. With proper treatment, this should not take more than three to five days at the most. Care should be taken not to rush into any exercise or athletic activities, for a re-sprained ankle is often worse than the original injury.

In mild and sometimes in even more serious cases of sprained ankle, the self-care treatment described above can promote successful healing without treatment. This usually takes three to six weeks, depending upon the severity of the injury. This does not apply when the sprain is an extremely severe one. If it is severe, the person should be under the care of a physician and/or therapist. Ankle sprains do not heal well without some treatment. Instead, they improve and then recur regularly. If massage therapy is initiated within two to six weeks of a sprain, proper healing is greatly facilitated.


Deep Massage and Friction Therapy
When performed by a skilled therapist, therapeutic massage is effective in mild to moderate cases. Massage, applied directly to the foot, ankle and leg, can reduce the swelling and help speed in fresh blood for healing. Gentle effleurage may begin right after the injury. When massage is combined with friction therapy of the damaged structures, treatment is much more effective. In recent sprains, friction therapy stimulates healing of the ligament while preventing unwanted adhesive scar tissue from forming.

In chronic sprains where there is external scar tissue, sustained friction followed by manipulation done by a chiropractor or osteopath is often required to tear the malformed adhesive scar tissue. The anterior talofibular ligament will often adhere to the surface of the talus, the bone that it is supposed to glide over. If this occurs the person will suffer from, mild, but chronic, ankle swelling and pain.

Location and friction of the anterior talofibular ligament
With the client lying supine, supinate the foot with one hand and feel the lower edge of the outer ankle bone with the thumb of the other hand. Go to the base of the ankle bone and then work your way around toward the front of the bone. The anterior talofibular ligament is slightly to the front of the distal part of the lateral malleolus. Keeping the ligament stretched by holding the foot supinated, friction in either direction with your thumb or forefinger. When the ankle is sprained, it is not that difficult to locate the ligament because it is very tender. The anterior talofibular ligament is key to most ankle sprains.

Location and friction of the calcaneofibular ligament
The calcaneofibular ligament is located distal to the lateral malleolus, the outer ankle bone, and goes vertically down and slightly back to the calcaneus. The tear is usually just below the ankle bone and friction is applied by pressing the ligament up under the inferior edge of the malleolus. If both ligaments are torn, alternate two or three minutes in each place and come back to it a few times. It is most effective to treat ankle sprains two or three times a week for three to four weeks initially. Slowly scale down the frequency of the visits as progress is made. If you are successfully treating the ligament, swelling should be quickly reduced for it is only a secondary reaction to the ligament damage. Other signs of improvement are less pain while walking and exercising the foot, more normal range of motion, less pain during treatment and less pain when re-testing the ankle.


Conclusion
In this article I have introduced several of what I consider to be the Essential Principles of the field of orthopedic massage, and have applied these principles to the specific case of ankle sprains. These principles can guide a therapist to more exact and effective assessment, verification and treatment of clients who present with injuries.

Ben Benjamin holds a doctorate in education and sports medicine. He is the founder and president of the Muscular Therapy Institute in Cambridge, Mass., and the author of Listen to Your Pain, Are You Tense? and Exercise Without Injury. He can be contacted at bb@mtti.com or benbenjamin.net for further information and training in these principles.





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