During my time as a collegiate strength and conditioning coach, I have seen many common ankle sprains (inversion ankle sprain). Depending upon the grade of the ankle sprain the athlete was held out of training was almost always given a form of immobilization along with crutches. I would have to admit throughout my athletic career this made sense. Team doctors and ATCs taught me R.I.C.E (Rest, Ice, Compression, Elevation). This was the protocol for ankle sprains and its what we have always done so that’s what we did.
It was not until I got to the University of Texas under Todd Wright, Logan Schwartz, and Eric Fry that I saw a new path. That performance TEAM worked togeather and got amazing results with rehabilitation. Unfortunately, most other treatments I have witnessed are not so progressive. You see it every day on college campuses and your local grocery store. The athlete in the walking boot and the person buying groceries from an electric scooter. Is there a better way?
Let’s first understand the inversion ankle sprain and then dive into the research. When an inversion ankle sprain occurs the body’s first reaction is to protect the injured area. The body naturally protects the joint by taking away (pain response) available motions. More specifically in the inversion ankle sprain (pain in inversion) the body will limit ankle dorsiflexion and eversion. The body’s natural healing process takes over and the area starts to swell (inflammation).
Wait…Is inflammation bad?
No inflammation is just the first step of the body’s immune/ reparative system. This process stimulates connective tissue remodeling through reabsorption of excessive fibrosis and regeneration. Once the injury occurs it increases the number of fibroblasts in the affected area. Fibroblasts maintain the structural integrity of the connective tissue and play an essential role in healing by laying down new collagen fibers.
The most important role we have is to communicate with the fibroblasts to teach them where to lay down this new connective tissue. The way we communicate with our cells is thru force or movement.
“Only early movement permits the correct formation of collagen fibers along the functional lines of force.” Dr.Stecco
Research from Loghmania and Warden (2009) treated (MCL) ligaments and found that movement thru cross-friction massage improved collagen fibre bundle formation and orientation within the scar region when compared with nontreated ligaments. If we do not use force to communicate with our cells the fibroblast will not lay down the collagen fibre effectively. This, in turn, will cause an increased recovery time and can create movement restriction.
When any ankle injury occurs the retinaculum is damaged. Think of the retinaculum as the facial sock that supports the ankle joint. The retinaculum also has the greatest amount of mechanoreceptors which provide information to the brain on mechanical stimuli. We find specific mechanoreceptors like Pacinian corpuscles which provide information on pressure and vibration. Meissner’s corpuscles and Merkel cells sense compression and touch along with providing information on the position. Also, Ruffinian endings respond to sustained pressure and joint angle changes. These mechanoreceptors are paramount to the rehabilitation process and success back into optional function. If we immobilize a joint over an extended period of time we are providing inaccurate information to the mechanoreceptors. If we start with authentic functional environments we provide a clearer picture to the brain about what is expected of this joint.
“Damage to the retinacula and their embedded proprioceptors result in inaccurate proprioceptive afferentation. This may result in poorly coordinated joint movement and eventual inflammation and activation of nociceptors. A treatment focused on restoring normal fascial tension may improve the outcome of ankle sprain.” Stecco et al (2011)
In my humble opinion, it is not effective to utilize immobilization over an extended period of time. Our goal should be to restore successful movement to the injured tissue within individual tolerance. Success for each injury will be different and based on individual thresholds. Treatment could look like isometrics hours after the injury or standing nose reaches. Movements that include force thru gravity, ground reaction forces and momentum should be prescribed as soon as possible. This creates an authentic environment for collagen disposition and mechanoreception. Specifically for the inversion ankle sprain, we could drive successful motions of dorsiflexion and eversion. That way when we return to global function we do not find movement restrictions in those motions. We should also assist the inflammation process with increased blood circulation. Blood circulation provides heat as well as nutrients and waste removal. This can be done in many forms such as compression, heat/ice contrast, or massage.
Before we can complete the rehabilitation process we need to understand that we must increase the load bearing capacity of that tissue. In the example of the inversion ankle sprain rehabilitation must continue loading past the range of motion of the injured joint motion. If we never train the injured joint motion to a new capacity then we never get injury prevention.
“Anyone who conducts an argument by appealing to authority is not using his intelligence; he is just using his memory.” -Leonardo da Vinci
Dr. Andreo Spina
Myers, T.W., 1997. The ‘anatomy trains’. Journal of Bodywork and Movement Therapies 1, 91e101.
Ital J Anat Embryol. 2011;116(3):127-38. The fascia: the forgotten structure. Stecco C(1), Macchi V, Porzionato A, Duparc F, De Caro
Stecco C, Stern R, Porzionato A, et al. Hyaluronan within fascia in the etiology of myofascial pain. Surg Radiol Anat. 2011;33:891–896.
Stecco Carla1, Macchi Veronica1, Porzionato Andrea1, Duparc Fabrice2, De Caro Raffaele1. 2011 IJAE Vol. 116 The fascia: the forgotten structure