Ankle Sprains or Inversion Sprains
An ankle sprain refers to the tearing of the ligaments of the ankle and account for approximately 40% of all athletic injuries. 85% of ankle sprains occur on the outside (lateral side) of the ankle and are known as an inversion sprain. This is the type of injury that most runners experience when they sprain their ankles. Medial ankle sprains (along the inside of the ankle) occur less frequently and are usually caused by fractures or other traumatic events.
So, why is an inversion sprain so common? You can put it down to our lopsided anatomy! The bone on the lower outside of the ankle (the lateral malleolus – distal fibula) extends further down than the bone on the inside of the ankle (medial malleolus – fibula). This difference gives the inside of the ankle (medial side) more stability than the outside of the ankle (lateral side).
At a symptomatic level, most ankle sprains appear to resolve completely without rehabilitation. In reality, ankle sprains that have not been rehabilitated correctly are usually susceptible to further injury.
Anatomy of an Ankle Sprain
The outside (lateral side) of the ankle achieves its stability from a three-ligament complex. These three ligaments are the:
- Anterior Talofibular ligament (ATFL)
- Calcaneofibular ligament (CFL)
- Posterior Talofibular ligament (PTFL)
In an inversion sprain, the Anterior Talofibular ligament (ATFL) is the most commonly injured. Ligaments in the ankle are named according to the bones to which they connect. In this case, the Anterior Talofibular ligament connects to the talus bone of the ankle as well as to a long bone of the lower leg – the fibula. The function of the ATFL is to prevent forward (anterior) displacement of the ankle (the talus).
In a severe ankle sprain another ligament called the calcaneofibular ligament (CFL) may also be damaged. This ligament connects your heel bone (calcaneous) with the fibula. This is a stronger ligament than the ATFL, and is not damaged as easily.
Both the ATFL and the CFL are usually damaged in motions where the foot is both pointed down (plantar flexed) and rolled out (inverted). Considerable instability in the ankle can occur when both these ligaments are injured.
The posterior talofibular ligament (PTFL) is not injured very often, except when there is a complete dislocation of the ankle (talus). The PTFL is the strongest ligament in the lateral complex.
Another sprain injury that is becoming more prevalent is called a “High Ankle Sprain” (syndesmotic ligament complex). In this injury, the ligament and connective tissue between your shin bones (tibia and fibula) are torn. This is a serious injury that may require surgery to resolve.
Not Just Ligaments
An ankle sprain may also result in damage to other structures. You may also experience damage to connective tissue, tendons, muscles further up the ankle, and even to the bones (possible fractures). This is why, with a severe ankle sprain, it is important to see a medical professional who can determine exactly which structures have been injured, and then provide treatment recommendations.
Ankle sprains are graded in increasing severity from grade 1 to 3. The following grading system should give you an indication of the severity of your ankle sprain.
Grade 1: Sprain
- The injured person can still walk, although with some degree of difficulty.
- There may be some swelling, stiffness, and pain.
- There is only minor tearing of the ligaments. A common analogy is comparing a ligament to a piece of tissue paper. In a Grade 1 injury there are only minor tears in the tissue.
- The ankle joint remains quite stable. This stability will be evident with stress testing (Anterior Drawer Test, and Anterior Tilt Test).
Grade 2: Sprain
- The injured person may experience considerable difficulty when walking and could be in severe pain. There may be swelling and some degree of bruising.
- There is a moderate amount of tearing of the ligaments. To use the tissue analogy, there will be a significant amount of tears in the tissue.
- The ankle will become somewhat unstable. This instability is evident on stress testing (with increased anterior motion showing on the Anterior Drawer Test and indicating an ATFL tear).
Grade 3: Sprain
A Grade 3 Sprain is a complete tearing of the ligament. To use the tissue analogy, the tissue is now torn into two pieces. This type of sprain may require surgical intervention to reattach the ligament. In most cases a conservative period of therapy will be tried for about six weeks before surgery is considered.
- The ankle is completely unstable, and the patient cannot walk or place weight on the ankle. (Increased motion on the Anterior Drawer and Talar Tilt Tests indicates a complete tear of the ATFL and at least a partial tear of CFL).
- There will be severe pain at the initial event, followed by a compete lack of pain, as long as there is no weight placed on the joint.
Treatment of Ankle Sprains
There are a number of things you can do to treat ankle injuries.
Just After the Injury
Immediately after spraining your ankle, it is important to do everything you can to reduce the swelling in the ankle. The faster you can implement treatment, the faster you will recover. An ankle sprain injury that is addressed quickly will often resolve in short period of time. If the injury is ignored, the ankle sprain could be prolonged for extensive periods of time.
So, immediately after the injury, while still in the acute stage – use RICE – rest, ice, compress, and elevate!
R = Rest: During this stage, it may be necessary to take all weight off of the injured ankle. In such cases, crutches are commonly used. In my opinion, it is important to quickly return to weight-bearing as soon as possible to improve healing. I have found that reintroduction of weight-bearing stresses tends to decrease recovery time. When should you do this? As soon as possible, but not too soon! Rest is also essential.
I = ICE : See our page about Cold Therapy and Icing. Ice for at least 20 to 30, minutes 4 to 5 times per day to reduce swelling.
C = Compression: Compression (with an ACE wrap) reduces both swelling and bleeding. With a Grade 3 sprain, wear a brace at all times until you are able to bear weight on your ankle.
E = Elevation: Elevating the injured area acts to reduce swelling and bleeding.
Once you have used “RICE”, it is very important to introduce motion into the ankle as soon as possible. Depending on the degree of injury, the patient could be asked to perform gentle ankle circles, or if able to do so, write the alphabet with their feet. Light calf stretching and using a stationary bicycle may also be beneficial.
If you are going to use medication (NSAID’s) to reduce inflammation, be sure not to use them for more than seven days. Using anti-inflammatory medications for long periods of time inhibits tissue remodeling. See our Blog about Recommendations to Reduce Inflammation without Medication.
So, why is scar tissue formation such an issue when resolving ankle sprains? When ligament fibers are torn, the body lays down collagen in an attempt to support, reconnect, and reinforce the damaged tissue. This collagen is what we commonly refer to as scar tissue. Scar tissue is much weaker, less flexible, and easier to tear than normal ligaments. Scar tissue is weak and inflexible because it is laid down in a random pattern and does not follow the same fiber orientation as the normal ligaments. These areas of scar tissue formation have a different consistency and strength than the normal ligaments. This alteration in ligament consistency then creates instability in the ankle, resulting in abnormal motion patterns, which then can result in further injuries. A considerable amount of scar tissue can form with repeated ankle sprains (which are common). Although the initial intention of the body was to stabilize the ankle with scar tissue, it can have the effect of destabilizing it instead, due to the random patterns of fiber orientation.
Therefore, it is essential to remove this scar tissue, thereby helping in the restoration of normal motion patterns, and increasing flexibility and strength.
Manual therapy can make a huge difference in the recovery and prevention of an ankle sprain. By manual therapy, I am referring to techniques such as Active Release, Graston Technique, Massage Therapy, Fascial Manipulation, Manual Manipulation, and other manual procedures. In my opinion, these procedures are essential in the rehabilitation of an ankle sprain since they all act to break down and prevent scar tissue formation.
Manual therapy also speeds healing by increasing blood supply, oxygen, essential nutrients, and displace waste products that accumulate after an injury. This is especially important in treating ligaments because they generally have a very poor blood supply to begin with.
It is Important to Treat All Structures
Earlier, I mentioned that there might be damage to several types of structures after an ankle sprain, especially the connective tissue, tendons, muscles, and nerves. The following is list of structures that are often injured in a lateral ankle sprain (inversion sprain).
- Anterior talofibular ligament (ATFL) – Most common injured structure.
- Calcaneofibular ligament (CFL) – Second most commonly injured structure.
- Posterior talofibular ligament (PTFL)
- Peroneal tendon
With an inversion sprain, it is common for the tendons of the peroneal muscles to be injured. It also common for the peroneal tendon to move out of its normal position (subluxate) during the recovery stage of an ankle sprain.
- Peroneus brevis muscle – Longitudinal tears of the peroneus brevis are commonly associated with lateral ankle sprains.
- Peroneus longus muscle – These muscles often show a different activation pattern when there is ankle instability. This is often due to restrictions that have formed in the muscle. These restrictions, if not removed, could make a person more susceptible to future injuries.
Both muscles, evert the foot at the tarsal joint, and plantarflex the foot at the ankle.
- Peroneal retinaculum
During a lateral ankle sprain, the foot rolls inwards with considerable force. This forceful action can tear the peroneal retinaculum. This retinaculum is a band of connective tissue that keeps the peroneal tendons in place. When a tear in the retinaculum occurs, patients will notice a snapping sensation in the lateral ankle. Conservative treatment is 4 to 6 weeks in a short leg cast. However, a severe tear of the retinaculum is not a candidate for standard manual therapy and may require corrective surgery.
- Superficial peroneal nerve – This nerve is at risk for traction injury during a lateral ankle sprain (inversion sprain).
Fascia was once thought to be nothing more than packaging material covering muscles and organs. Back in school, when we worked in the dissection lab, we went out of our way to remove this material in order to expose those structures that were considered to be more important (an experience that I have heard repeated by many individuals in the medical field). Unfortunately, this lead to the very misleading perspective that fascia was unimportant.
Now, 20 years later I, and many others, have come to a very different conclusion. Fascia is everywhere, weaving through, and interconnecting every component of our body. Robert Schleip from Ulm University in Germany (of the Fascia Research Project) describes fascia extremely well when he describes fascia as “the dense irregular connective tissue that surrounds and connects every muscle, even the tiniest myofibril, and every single organ of the body forming continuity throughout the body.” In other words, fascia is the physical manifestation of the kinetic web that we have discussed so many times in our blogs and books.
Schleip R. Fascial plasticity—a new neurobiological explanation: part 1. J Bodyw Mov Ther. 2003;7(1):11–19.
Fascial interconnections are not theoretical entities; they are actual physical structures that have been well mapped out. Researchers such as Thomas Meyers (Anatomy Trains) and Luigi, Carla, and Antonio Stecco (Fascial Manipulation) have spent decades researching these interconnections. During the last International Fascia Research Congress at the University of Amsterdam, I had the privilege of listening to medical experts from around the world confirm this and related fascial research.
Fascia as an Anchor for Force Generation
When one considers the prevalence of fascia throughout the body, it is not surprising to discover that it actually plays a critical role in all bodily actions, and that it is much more than the “bubble wrap” that many considered it to be.
In conventional medical theories, muscles have both an origin and insertion at the bone(s). In this view, when a muscle contracts, it pulls the origin toward the point of insertion to create motion. In reality, muscle fibers actually originate from, and insert into, fascial fibers. These fascial fibers, in turn, insert into multiple regions of the bone, and even into adjacent muscles. These additional points of contact and control provide the muscle with the ability to generate force in multiple directions.
In reality, when a muscle contracts to perform an action, only certain sections of the muscle contract. Force is not generated from just the origin and insertion points, but also through the numerous fascial connections. Anatomists at the University Maastricht in the Netherlands have done some incredible research that confirms this understanding.
Van Mameren H. Reaction forces in a model of the human elbow joint. Anat Anz. 1983;152:327–328.
Fascia as a Neurological Feedback Loop
Muscles work together as functional units that coordinate their actions across multiple joints. Depending on the degree of motion required, and amount of force that is needed, each muscle will contract only specific areas of the muscle, rather than the entire muscle. As incredible as it may sound, these very specific motions are largely coordinated by the neurological receptors embedded in the fascia, and not by the brain. This is a form of non-localized intelligence, a concept that has long been postulated, but is only now being acknowledged as occurring in all life forms.
Fascia is full of two types neurological receptors – mechanoreceptors and proprioceptors. A mechanoreceptor is a sensory receptor that responds to mechanical pressure or distortion. A proprioceptor is a sensor that provides the brain with information about joint angle, muscle length, and tension.
Motion is coordinated by the feedback of the neurological receptors in the fascia when tension is transferred from one area to the next. (Previously these receptors were only thought to be located within just the muscles).
When we evaluate an inversion sprain of the ankle, we must also take into consideration all the fascial connections to the structures that are involved in performing and coordinating ankle motion. It is important to look at the big picture, and take into consideration that multiple muscles, working across multiple joints (all of which are interconnected by fascia) are all required to coordinate these motions.
In the case of an inversion sprain, the fascial connections we should consider is in the Lateral Line (see Anatomy Trains by Thomas Meyers). The following is a short synopsis of the lateral line. I have also included a link to the Anatomy Trains dissection video about the Lateral Line – Thomas Meyers Lateral line Video.
Beginning at the foot with the peroneal muscles, fascial interconnections travel up the outer leg to just below the knee (fibular head). This fascia then connects directly into the lower IT band into the deltoid complex (gluteus maximus, gluteus medius, and tensor fascia latae).
The fascia then connects to the pelvis (iliac crest), which connects into the abdominal muscles (internal and external obliques), and then into the quadratus lumborum which connects into the ribs and the spine.
The fascia then travels up between the ribs (intercostals muscles) and continues up the body to connect into the fascia of the neck (SCM, splenicus cervicis, and scalenes).
Once you see these videos, you will find it very hard to dispute the importance of these fascial connections.
You can try treating inversion sprains with all the right techniques (ART, Graston, Massage etc.) and find that you still have not resolved a chronic inversion sprain if you did not consider, and treat, the fascial interconnections.
In addition to the soft-tissue treatment component, you must also address the osseous (bone/joint) component. Joint manipulation helps to restore active range of motion in the ankle and speed recovery. It is very common for several of the joints of the feet to become stiff and rigid, due to either the initial injury or due to soft-tissue compensations over a period of time.
The exact area that requires joint manipulation varies depending on the severity of the sprain, number of reoccurrences, and the length of time that has passed since the injury occurred. The longer you wait, the more compensations your body must make, and the longer it will take to treat and recover from the injury.
When prescribing ankle exercises, we must take into consideration the multiple structures that are involved in performing and coordinating ankle motion. To attain a full resolution from an inversion sprain, we must be sure to consider multiple muscles and complex fascial layers, all of which work together across numerous joints.
To do this, we must be sure to address three essential components: strength, flexibility, and proprioception.
Strengthening the Ankle
Strengthening exercises are essential! Manual therapy, by itself, will not fully prevent an injury from returning without the addition of strengthening exercises. This is because the type and quality of tissue remodeling that occurs after an injury is dependent on the type of forces that are applied to that tissue. When appropriate strengthening exercises are applied, the collagen remodels to withstand the stresses that are placed upon it. The possibility of re-injury is very high without appropriate strength training.
Strengthening exercises for an inversion sprain can be subdivided into several categories depending on the stage of the injury. The following subcategories describe stages from non-weight-bearing to full-weight-bearing.
Restoring Flexibility to the Ankle
It is extremely important to stretch after experiencing an ankle injury of any kind. During the recovery phase, your body forms and lays down collagen to repair the injured area from two days, and up to 6 weeks after, the injury occurs.
If you suffer from an inversion sprain, and perform the correct stretching exercises, then you can ensure that the majority of the collagen that is being laid down, is being laid in the same direction as the tissue which is being repaired. This makes the repaired tissue stronger and more capable of performing its function in the future. However, if you do not stretch the injured area, the new collagen will be laid down in more random patterns, leading to the development of weaker tissue (scar tissue) that is easily re-injured.
Here are some of the areas for which we recommend stretching exercises when our patients are recovering from an ankle injury:
- Calf muscle (gastrocnemius and soleus) – Stretch the calf muscle as it often becomes very tight after an ankle sprain, as these structures try to protect the injured joint.
- Peroneal muscles – Stretch the peroneals (along the sides of your calf) as these muscles are often injured along with the ligaments in the ankles
- Iliotibial Band – Yes, these tissues are in your upper leg, but there are direct fascial connections from the peroneal muscles into the IT band. A injury to the peroneal muscle may cause compensation injuries up into the IT Band. So be sure to perform stretches to release the IT Band.
- Gluteal muscles – Since the IT band is formed from the deltoid complex (gluteus maximus, gluteus medius, and tensor fascia latae, problems in the IT band will affect hip function. So it is important to release the muscles of the gluteals with stretches and foam rollers.
Whenever an inversion sprain occurs, the injury is usually not restricted to just the ligaments, tendons, muscle fibers, and fascial fibers. Often, the embedded neurological structures within these soft-tissue structures are also damaged. These neurological structures (golgi tendon organs, muscle spindles, and joint receptors) perform an essential role in positional control. Any damage to these structures can have the effect of decreasing stability, which can lead to chronic ankle problems.
Fortunately this damage can be repaired with exercise protocols that involve balance and proprioception. Some of the proprioceptive exercises we use with our patients at the clinic are:
This is a good initial exercise to try, with a slow progression into partial single leg squats. Do all of this exercise within a pain free range-of-motion.
Wobble board training
Slowly increase the difficulty of wobble board exercises from the two-legged balance exercises, into a single-leg exercise that combines full-body motions. Once you are ready, you can even try the single-legged version with your eyes closed. Note: The eyes-closed version should only be attempted after you are fully recovered and you are ready to work on increasing athletic performance.