Treating Ankle Sprains with Massage Therapy and Balance exercises.

What is a sprain?

A sprain happens when the one or more ligaments attaching bones together are forcibly or excessively stretched, twisted past their normal limits or avulsed (by temporary dislocation or wrenching violence to the joint). Sprains may be graded as a 1, 2, or 3.

Grading your Sprain.

All injuries are different and dependant on many factors, like health and age. As a rule of thumb, these are the very basic guidelines for the different grades.

Grade 1: This is nothing more than a slight stretch of the ligaments, with the possibility of some minor inflammation and disability. Recovery is usually 6-14 days, with little or no increase in joint laxity.

Grade 2: A definite stretch and possible tearing of the ligaments, and possible partial avulsion at bony attachment points. This is the most common type of sprain, but also the hardest to fully diagnose and treat. Pain, inflammation and disability occur with this degree of damage. Recovery is about 4-8 weeks, but can take longer, dependant on amount of damage, mechanism of injury and previous injuries to area.

Grade 3: This is usually a complete rupture of ligament(s) or avulsion of bony attachments. Joint instability and inflammation are associated with this, although pain is sometimes not due to the complete rupture of the ligaments. Surgical intervention is needed to repair this and healing can take 4-6 months, although it can take upwards of a full 18-24 months to regain strength and proprioception and even this is rarely a full 100%.

Typical Signs and Symptoms:

- immediate pain

- swelling of involved and surrounding structures

- inflammation of involved tissue

- tenderness with palpation

- functional disability

The structures involved.

As mentioned, bones and ligaments are the tissues affected by sprains. With the ankle, the most commonly sprained ligament is the anterior talofibular ligament. This ligament is one of three that make up what is known as the ‘Lateral Collateral Ligament’. The other two ligaments are the posterior talofibular ligament and the calcaneofibular ligament.

The Lateral Collateral Ligament of the ankle holds the foot to the base of the lateral malleolus (the distal end of the fibula). When standing, walking or participating in other activities, these ligaments prevent the ankle from collapsing laterally.

Ligaments are designed to be taut, not loose. Loose ligaments can lead to excessive joint movement or play that makes the joint unstable. Instability can lead to more serious injuries and disability.

Upon Injury:

Immediately apply the “PRICED” principle.

Protect, Rest, Ice, Compression, Elevation, Doctor (if required).

Treatment Goals.

- decrease pain

- decrease inflammation

- decrease/prevent adhesions

- decrease muscle spasms

- decrease secondary compensations and atrophy of surrounding muscles

- prevent further injury

- increase functional ability (strength and proprioception)

Massage Therapy:

The benefits of massage therapy:

In the acute stage, massage can help by increasing lymph flow to reduce swelling. Ligaments heal very slowly. Adhesions form between the sprained ligament and nearby tissues which cause pain and limited movement. Massage therapy can significantly reduce the limiting adhesions, especially if early attention is received.

The Acute Stage:

Initial treatment with PRICED. Light effleurage and/or MLD can be done proximal to the injury to assist with edema drainage. Lightly applied cross-fiber frictions may be incorporated to the injured ligament(s) to help stimulate healing in the ligament and decrease scar tissue formation. At this point during the injury all active activities should be restricted as to minimize the chance of re-injury. Gentle ankle pumping movements with the ankle elevated can help decrease swelling and reduce the severity of decreased range of motion.

The Subacute Stage:

At this time cryotherapy can be implemented. The use of ice cube massage or ice packs over the injured area will help to reduce or decrease local tissue, thereby causing a decrease in secondary hypoxic injury. Light non-weight bearing exercises for maintaining range of motion (ROM) may progress to full weight bearing as pain permits. Deeper massage to the surrounding tissues and maintaining the light cross fiber frictions are continued. Joint mobilizations techniques can be included to help decrease pain, increase overall ROM and increase nutrition to the articular structures.

The Chronic Stage:

Full “Active Range of Motion” (AROM) with weight bearing, progressing to “Resisted Range of Motion” (RROM). At this point there may still be some chronic edema and muscle weakness due to recent immobilization. Massage to the surrounding tissues continues as well as frictions to the ligament(s). Joint mobilizations are continued. Assessment via “Passive Range of Motion” (PROM) and palpation for any possible adhesions causing movement restriction.

Range of motion exercises:

As healing gets underway, it is important to begin series of movement exercises to increase movement in your ankle. At first, you'll work on bringing your toes up towards your nose and bending them toward the floor (ankle pumping). Later, circles and diagonals can be used. If you feel pain doing these movements, stop the exercise immediately.

Strength progression:

Once pain-free ROM can be achieved, then very gentle weight bearing exercises may be started. Stability for the ankle is of utmost importance, therefore the muscles need to be worked are all that cross over the ankle joint. This means training the ankle flexors, extensors, invertors and evertors. During the initial strengthening phase, Isometrics may be chosen. These are strengthening exercises in which the muscles are working but there is no change in muscle length. They allow you to exercise with the ankle at different angles, helping you stay away from painful positions of the ankle. These exercises provide the benefit of reducing overall pain and swelling. They also help the muscles remember what they're supposed to be doing.

Early resisted exercises:

Walking in water is helpful in reducing the effects of gravity, allowing you to begin strengthening without causing pain. Light tubing exercises may also be recommended at this time.

Program progression:

Throughout your rehabilitation treatment program, all exercises should be gradually increased in level of difficulty by increasing the difficulty of exercise or amount of resistance or number of sets and reps. Common examples may include partial/full squats, step ups/downs, single leg balance, and lunges, because these exercises relate to many of the activities of daily living.

Balance exercises:

These exercises are especially important following a ligament injury. Healthy ligaments protect the joint(s) from excess movement. Once a ligament has been injured, some of these receptors may be unable to receive and send the needed information to the brain. This increases the possibility of injury in the future. As well, restoration of proper muscle function surrounding a joint will improve the proprioceptive function in those muscles and tendons. Balance exercises can help to restore this kinesthetic awareness (sense of body position in space) by heightening the sensitivity in the remaining intact receptors and retraining the healing ligaments and/or muscles. This can start with a very simple one-legged stance and progressing to more advanced exercises involving unstable or uneven surfaces that are more functionally or sport appropriate.

Hydrotherapy:

When a ligament injury first happens (acute stage), apply cold or ice to the injured site immediately. This will help to reduce inflammation, swelling and pain. Chronic stage sprains benefit from alternating contrast applications of hot and cold. Place one towel in hot water (36-38C) and another in cold water (16-18C). These temperatures can be modified depending on tolerance, but initially started at the recommended temperatures. Alternatively, these can also be done as foot baths using 2 basins that allow for a depth that comes up to the middle of the calf muscle. Start with the warm first for 3 minutes, then the cold for 30 seconds. Repeat this 3 times in succession for a total time of 10.5 minutes. This will help flush out the edema and increase circulation.