High ankle sprains, evaluation and management

By James Lehman

While practicing as a chiropractic orthopedist in New Mexico, I cared for many athletes suffering with pain from spinal and extremity injuries. It was my experience that with acute ankle sprains, patients responded well to chiropractic care, including cryotherapy, high-volt galvanic, taping and bracing, exercise, and joint manipulation. Yet, I found it essential to differentiate the lateral ankle sprains from the high ankle sprains with the latter being more difficult to manage.

Many medical providers understand that chiropractic care focuses on the maintenance of spinal biomechanical function, but it is frequently necessary to evaluate and manage recurrent ankle sprains with spinal, pelvic, and lower extremity manipulation or mobilization.

Injuries to the ankle frequently present to primary care providers and emergency rooms, but they also seek care from chiropractors willing to provide treatment for athletic injuries. Despite appropriate evaluation and management, ankle sprains are subject to recurrent injury.

Ankle injuries are among the most common injuries presenting to primary care providers and emergency departments and may cause considerable time lost to injury and long-term disability. Inversion injuries about the ankle involve about 25 percent of all injuries of the musculoskeletal system and 50 percent of all sports-related injuries. Medial-sided ankle sprains occur less frequently than those on the lateral side. High ankle sprains occur less frequently in the general population, but do occur commonly in collision sports. Providers should apply the Ottawa ankle rules when radiography is indicated and refer fractures and more severe injuries to orthopedic surgery as needed.

Historically, emergency room providers immediately ordered radiographic studies when patients presented with ankle injuries. It is suggested that chiropractors perform a physical examination including history, observation, and palpation prior performing provocative procedures and use of specific ankle guidelines prior to ordering radiographic studies. Identify the injured tissues, observe the areas of discoloration due to bleeding and edema, and determine if the patient was able to walk immediately after the injury. Perform the “crossed leg test” by asking the patient to cross the leg of the injured lower extremity for pain might indicate a high ankle sprain. It is recommended that more provocative, orthopedic testing not be performed during the initial 72 hours post-trauma.

Today, there are reasonable guidelines to follow that reduce exposure to ionizing radiation and costs while improving quality of care, the Ottawa Ankle Rules. If the rules indicate that radiographic study is indicated and a fracture is ruled-in, it is best to co-manage the patient with an orthopedic surgeon. If a fracture is ruled-out, orthopedic, provocative testing may take place once the initial bleeding stops (24-72 hour period). If a fracture is suspected as a result of specific findings, a radiographic study should be ordered.

The Ottawa ankle rules are used to rule out a fracture, and radiographs are indicated if there is pain within the malleolar zone that is accompanied by any of the following findings: (1) tenderness along the tip of the posterior edge of the lateral malleolus, (2) tenderness over the medial malleolus, and/or (3) the inability of the patient to bear weight for a minimum four steps.9 Radiographs are also indicated, according to the Ottawa ankle rules, if there is pain in the mid-foot area accompanied by any of the following findings: (1) tenderness with palpation at the base of the fifth metatarsal, (2) tenderness over the navicular bone, and/or (3) an inability to bear weight for a minimum four steps.

If the Ottawa Ankle Rules did not indicate a fracture, or the radiographic study was negative for fracture, physical examination should include orthopedic testing after 24-72 hours. Provocative testing with the anterior drawer and inversion stress tests should be performed to determine if the ankle is stable. Palpation and range of motion testing should reveal the injured ligaments.

Always grade the severity of a sprain or strain as mild, moderate, or severe. The mild sprain (Grade 1) indicates that the ligamentous tissue has been overstretched with not more than 5 percent tearing. The moderate sprain (Grade 2) indicates up to 50 percent tear of the ligaments. The severe sprain (Grade 3) indicates a complete rupture of the damaged ligaments.

A lower ankle sprain reacts well to cryotherapy for the initial three to seven days. Placing the injured ankle in ice water with high voltage galvanic will reduce pain and improve recovery time. Although many providers use lace-up ankle supports, I prefer the air stirrup brace with an elastic compression wrap to reduce edema and pain, enhance recovery, protect the injured tissues, and permit some mobility. Allopathic providers do prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) and mild opioids, but it has been my experience that conservative care without the opioids is preferred.

The acute care should be followed with neuromusculoskeletal training and mobilization of the injured joints. Chiropractic evaluation and management of spinal posture and function should promote improved function for spine, pelvis, and the lower extremity.

A high ankle sprain warrants a more cautious management program than the lower ankle sprain because of the potential for severe rupture of the interosseous membrane, the anterior tibiofibular ligament, the posterior superficial, the deep tibiofibular ligaments, and/or fracture of the tibia and fibula. It is common for athletes participating in baseball, American football, and soccer to incur a high-ankle sprain with inversion, dorsiflexion, and rotational components.

The clinician may rule-in the diagnosis of high ankle sprain with the squeeze test, also known as Pott’s compression. A positive clinical diagnosis of high ankle sprain warrants the use of radiographic examination including a standing posteroanterior view to demonstrate presence or absence of splaying of the tibiofibular joint.

A mild, high ankle sprain may be managed similar to a lower ankle sprain except the patient must be more cautious with activities in order to prevent additional injury to the osmotic membrane. I suggest that co-management with an orthopedic specialist be considered with a moderate or severe high ankle sprain. There are both medical doctor and chiropractic docotr orthopedic specialists that could co-manage this condition.

References

Czajka CM, et al. Ankle sprains and instability. Med Clin North Am. 2014 Mar;98(2):313-29. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/24559877.

Gillman SF. The impact of chiropractic manipulative therapy on chronic recurrent lateral ankle sprain syndrome in two young athletes. J Chiropr Med. 2004 Autumn; 3(4):153-9. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/19674638.

Mauntel TC, et al. The Epidemiology of High Ankle Sprains in National Collegiate Athletic Association Sports. Am J Sports Med. 2017 Jul;45(9):2156-2163. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/28423285.

Ottawa Ankle Rules. Retrieved from: http://ohri.ca/emerg/cdr/docs/cdr_ankle_card.pdf.

McGovern RP & Martin RR. Managing ankle ligament sprains and tears: current opinion. J Sports Med (2016). Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/27042147. 

Tiemstra JD. Update on Acute Ankle Sprains. Am Fam Physician. 2012 Jun 15;85(12):1170-1176. Retrieved from: https://www.aafp.org/afp/2012/0615/p1170.html.