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Ankle Sprain

by Tyler Cymet, DO, FACOFP

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    00:00 New topic area. We’re going to talk about ankle sprains because osteopathic medicine researches change what we think about ankle sprains.

    00:09 Generally, when somebody comes to the emergency room with an ankle sprain, we want to make sure there’s nothing broken.

    00:14 We want to see what the future is going to be, how bad it is, and how long it’s going to take him to feel better? Up until about ten years ago we put them on a rest and we didn’t touch it very much.

    00:25 We didn’t move it very much. That thinking is changing, where even in the emergency room we’ll do a full range of motion even though it’s uncomfortable. The discomfort is due to swelling.

    00:35 The swelling is over the first one to two hours after the sprain occurs.

    00:40 This is the most common injury to the ankle.

    00:44 It’s the deltoid ligament that generally has one piece of the three parts of it that has been interrupted, has been pulled or stretched, or separated from the bone.

    00:54 It’s most commonly caused when you invert and supinate at the same time because that’s when you lose some of the stability of the ankle and you’re more susceptible to a loss of balance and an over pressure to a piece of the ankle that will lead to a tear or a stretch of the ligament.

    01:16 The most commonly injured ligament is the anterior talofibular ligament which is the anterior portion of the deltoid ligament.

    01:24 When you see a person with an ankle sprain, it’s generally going to be localized.

    01:29 It’s going to affect one area. The ankle is going to be tender much more so in the area that has had the tear. Whether it’s anterior talofib or one of the other pieces of the ligament, you’ll be able to tell from touching it.

    01:43 The bruising, the color will tell you how long ago it happened and how much pulling and how much old blood you have by what color it is.

    01:50 You can also tell by how concentrated and how much display you have of the hematoma.

    01:57 You’ll also know the decreased range of motion because of the swelling in the joint.

    02:01 It will also be warm because you have the fluid there.

    02:04 You may or may not be able to make out the ankle architecture.

    02:09 So one thing I always notice, how bad is the swelling.

    02:12 Has it gone past the lateral malleolus? Can you still see where the lateral malleolus starts and finishes? When you press in the lateral malleolus, do you get pitting? All of those are important things to note.

    02:23 In the emergency room, for me the question is do we X-ray the ankle.

    02:27 We use the Ottawa ankle rules to determine if there’s a good chance of the X-ray being positive or not because yes, you can have the ankle mortise break.

    02:38 Yes, you can have lateral or medial malleolus break.

    02:42 Yes, you can have a talar bone fracture or you can have a fibular bone fracture.

    02:49 Generally, it’s just a sprain. If you’re able to palpate 6 centimeters up the fibula and not note any tenderness, the risk of it being broken is small.

    03:02 If the patient can take four steps and weight-bear right away, generally, there’s not going to be anything broken.

    03:10 A lot of people will take one step and hobble.

    03:13 But if they can bear weight, I'm not worried about the ankle, I may still be worried about the foot.

    03:18 With the foot the Ottawa ankle rules, look at where the pain is.

    03:22 The talus and the navicular region are the two areas I make sure to touch because if there’s tenderness there if they jump I’m more concerned, I'm more likely to get an X-ray to look at those bones.

    03:32 The base of the fifth metatarsal is another area where it’s common to have a break and not just a sprain.

    03:39 Those are areas you look at and areas you touch to decide whether or not you’re going to need an x-ray.

    03:45 Ankle sprain treatment is mostly symptomatic and mostly geared at developing comfort and giving the patient an assessment of what to expect.

    03:54 So we protect the ankle because at the point of an ankle sprain, the ankle is unsteady.

    04:00 The patient is more likely to fall again, more likely to hit it and have trouble walking up or down stairs.

    04:06 Resting the ankle even with some range of motion, making sure you move the fluids around, help for healing is going to be good. Ice is helpful, 20 minutes on, 40 minutes off. That decreases the swelling from occurring.

    04:21 Compression which may help restore some of the fluids to circulation and elevation just using gravity to help the fluids clear.

    04:31 More common now is to use an air or gel-filled cast in order to help limit the patient's motion.

    04:37 OMM, general range of motion is also going to be helpful.

    04:42 Acupuncture may have some role as well.

    04:46 Also when I treat ankle sprains, I’m going to make sure the patient has exercises to maintain a full range of motion, and also help with lymphatic drainage and lymphatic return.

    04:53 I’ll make sure that we get to start in a functional rehabilitation, walking on uneven surfaces, walking up and down stairs and making sure there’s no foot drop, foot flopping, or difficulty in maintaining balance.

    05:05 NSAIDS are helpful at limiting inflammation.

    05:09 If I don’t get the patient getting better, I consider referral to a surgeon for further evaluation or repair.

    05:17 When you’re treating an ankle sprain from an osteopathic perspective, make sure you look at the biomechanical considerations.

    05:23 Make sure you get ankle dorsiflexion, ankle plantarflexion and make sure you're prepared to prevent further sprains because the person most likely to sprain their ankle is someone who sprained it before.

    05:35 Once they get some weakness, some laxity, you can spread that sprain and strain and tear more and more of the ligament.

    05:43 I also want to think about the cardiorespiratory model and the motion needed to help with return of fluid and make sure that they are able to function and have their ankle heal.

    05:56 I also want to check the tibiofibular interosseous membrane.

    06:01 I want to look for other strains as well.

    06:04 We don’t understand the interosseous membranes well.

    06:07 We do know we can move it. We can pivot it.

    06:09 We can move it on its axis and they maintain connection.

    06:13 In bad strains, they get separated. But it’s important to pay attention to it and learn more about how the connection between the bones matters, what it does and when we’re going to have to intervene to help with instability in that area.

    06:30 Also from an osteopathic perspective when you have an ankle sprain or strain, the fibular head can move. It can move posteriorly or anteriorly.

    06:38 You want to at least touch the distal fibular head, see where it is, see if it’s tender.

    06:44 If it needs to be manipulated back into place, manipulate it back into place.

    06:48 We used to say the fibula was mostly muscle attachments and help with motion.

    06:55 But we’re finding that it has more in weight-bearing and also in orientation of motion.

    07:01 So you do pay more attention to the fibular head.

    07:04 Here’s a picture of the interosseous membrane just to think about it.

    07:08 Because while it does connect the tibia and the fibula, and we are able to move it by moving the fibula and it does appear to be more involved in times of sprains or strains, we don’t have a good sense of what the interosseous membranes are there for, what they’re doing and how it affects proper functioning.

    07:28 When do we do a myofascial release of the interosseous membranes? When you have restricted fascial rotation.

    07:35 So if you’re moving the tibia and the fibula and not having good motion, you want to consider a myofascial release.

    07:43 I will tell you I’m not sure if it’s the actual interosseous membrane or the fascia that is being manipulated but you are helping restore motion.

    07:51 Relative contraindications are fear of fracture.

    07:55 If you have pain or tenderness in the navicular region or the talar region, you may want to consider doing an X-ray before you do further treatment or get other imaging that will give you a good sense of what’s going on.

    08:07 We also have to bring up the issue of deep venous thrombosis since a lot of ankle sprains are trauma.

    08:13 If indicated, you should evaluate further.

    08:16 The interosseous membrane holds the proximal tibia at the tibial tuberosity and the fibular head together.

    08:24 When you want to move it, you may want to hold them with one hand.

    08:27 Make sure you know where the fibular head is and just generally rock it.

    08:33 Move it back and forth. Feel how much motion you can get.

    08:36 While you may not get much of the fibular head, you can see what kind of freedom you have.

    08:41 I generally rotate it in opposite directions and then reverse it to see what kind of torsion you may have, and whether or not you can twist it up over or if it’s just a single motion.

    08:52 I find that people have their own normals and it’s good to know that.

    08:56 But it’s going to be hard because it’s going to come at a time of injury.

    09:00 But having a baseline is important.

    09:02 In general when I treat interosseous membrane or myofascial release, it’s going to be indirect. I find the way it wants to go, not the way it won’t go.

    09:13 I generally stretch it out a little bit and rotate it further to make sure we get more motion, help free people up and try and make them more comfortable.

    09:21 Then at the end, you retest the rotational torsion to see if there’s any change or an enhancement to functioning.

    09:28 Balanced ligamentous tension and balanced membraneous tension are also different ways of treating the fibula and an anterior or posterior fibular head.

    09:38 This is a little bit more involved because you are going to be holding the area, measuring the motion a little bit more exactly and assessing how your treatment is going to be affecting motion in the foot.

    09:51 You’re going to adjust the fibular head and the membrane by having the patient lying down in a supine position and you’re going to be holding the calf and the tibia and the fibula at the base and seeing what kind of motion you get.

    10:10 You balance it until you find a good area of ease and a good motion.

    10:15 Then I usually put some pressure with my thumb to try and move it and see what kind of motion I could get.

    10:22 Then you just glide the fibular head with your thumb back into place.

    10:29 So I’ll glide it anterior to balance it and see if we can get it more comfortable.

    10:35 Sometimes it takes fine tuning and multiple times to push on the fibula.

    10:40 It is generally mobile in one direction.

    10:43 Sometimes you can twist it as well to get full motion.

    10:46 Concentrate on the tenderness.

    10:48 Make sure you’re not making the patient uncomfortable.

    10:51 And see when you have a release and enhanced motion.


    About the Lecture

    The lecture Ankle Sprain by Tyler Cymet, DO, FACOFP is from the course Osteopathic Treatment and Clinical Application by Region. It contains the following chapters:

    • Ankle Sprain
    • Treatment of Ankle Sprains
    • Interosseous Membrane

    Included Quiz Questions

    1. Bone tenderness along from the tip of the lateral malleolus to the distal 6cm of the posterior fibula
    2. Bone tenderness along the tip of the medial malleolus to the distal 6cm of the posterior/medial tibia
    3. Inability to bear weight immediately and unable to take four steps
    4. Absent posterior tibial pulses of the affected lower extremity
    5. Reduced sensation in the ankle
    1. Tenderness in the midfoot and at the base of the fifth metatarsal
    2. Pain in the midfoot and at the navicular bone
    3. Inability to bear weight for four steps
    4. Absent distal dorsalis pedal pulse
    5. Reduced sensation in the foot
    1. Acute sprain
    2. Acute fracture
    3. Compartment syndrome
    4. Deep venous thrombosis
    5. Pregnancy
    1. Direct passive technique
    2. Indirect passive technique
    3. Direct active technique
    4. Indirect active technique

    Author of lecture Ankle Sprain

     Tyler Cymet, DO, FACOFP

    Tyler Cymet, DO, FACOFP


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