New topic area. We’re going to
talk about ankle sprains
because osteopathic medicine researches change
what we think about ankle sprains.
Generally, when somebody comes to the
emergency room with an ankle sprain,
we want to make sure
there’s nothing broken.
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.
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.
The swelling is over the first one to two
hours after the sprain occurs.
This is the most common
injury to the ankle.
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.
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.
The most commonly injured ligament is the
anterior talofibular ligament
which is the anterior portion
of the deltoid ligament.
When you see a person with an ankle sprain,
it’s generally going to be localized.
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.
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.
You can also tell by how concentrated and
how much display you have of the hematoma.
You’ll also know the decreased range of motion
because of the swelling in the joint.
It will also be warm because you
have the fluid there.
You may or may not be able to
make out the ankle architecture.
So one thing I always notice,
how bad is the swelling.
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.
In the emergency room, for me the question
is do we X-ray the ankle.
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.
Yes, you can have lateral or
medial malleolus break.
Yes, you can have a talar bone fracture
or you can have a fibular bone fracture.
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.
If the patient can take four steps
and weight-bear right away,
generally, there’s not going
to be anything broken.
A lot of people will take
one step and hobble.
But if they can bear weight,
I'm not worried about the ankle,
I may still be worried
about the foot.
With the foot the Ottawa ankle rules,
look at where the pain is.
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.
The base of the fifth metatarsal
is another area
where it’s common to have a
break and not just a sprain.
Those are areas you look at
and areas you touch
to decide whether or not you’re
going to need an x-ray.
Ankle sprain treatment is mostly
symptomatic and mostly geared at
developing comfort and giving the patient
an assessment of what to expect.
So we protect the ankle because at the point
of an ankle sprain, the ankle is unsteady.
The patient is more likely to
fall again, more likely to hit it
and have trouble walking
up or down stairs.
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.
Compression which may help restore
some of the fluids to circulation
and elevation just using gravity
to help the fluids clear.
More common now is to use
an air or gel-filled cast
in order to help limit
the patient's motion.
OMM, general range of motion
is also going to be helpful.
Acupuncture may have
some role as well.
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.
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
NSAIDS are helpful at
If I don’t get the patient getting
better, I consider
referral to a surgeon for
further evaluation or repair.
When you’re treating an ankle sprain
from an osteopathic perspective,
make sure you look at the
Make sure you get ankle dorsiflexion,
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.
Once they get some weakness, some laxity,
you can spread that sprain
and strain and tear more and
more of the ligament.
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.
I also want to check the tibiofibular
I want to look for other
strains as well.
We don’t understand the
interosseous membranes well.
We do know we can move it.
We can pivot it.
We can move it on its axis
and they maintain connection.
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.
Also from an osteopathic perspective when
you have an ankle sprain or strain,
the fibular head can move. It can
move posteriorly or anteriorly.
You want to at least touch the distal fibular head,
see where it is, see if it’s tender.
If it needs to be manipulated back into place, manipulate it back into place.
We used to say the fibula was mostly muscle
attachments and help with motion.
But we’re finding that it has more in weight-bearing
and also in orientation of motion.
So you do pay more attention
to the fibular head.
Here’s a picture of the interosseous
membrane just to think about it.
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.
When do we do a myofascial release
of the interosseous membranes?
When you have restricted
So if you’re moving the
tibia and the fibula
and not having good motion, you want to
consider a myofascial release.
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.
are fear of fracture.
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.
We also have to bring up the issue of
deep venous thrombosis
since a lot of ankle
sprains are trauma.
If indicated, you should
The interosseous membrane
holds the proximal tibia
at the tibial tuberosity and
the fibular head together.
When you want to move it, you may want to
hold them with one hand.
Make sure you know where the fibular head
is and just generally rock it.
Move it back and forth. Feel how
much motion you can get.
While you may not get
much of the fibular head,
you can see what kind
of freedom you have.
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.
I find that people have their own
normals and it’s good to know that.
But it’s going to be hard because it’s
going to come at a time of injury.
But having a baseline
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.
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.
Then at the end, you retest
the rotational torsion
to see if there’s any change or
an enhancement to functioning.
Balanced ligamentous tension and
balanced membraneous tension
are also different ways of treating the fibula
and an anterior or posterior fibular head.
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.
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.
You balance it until you find a good area
of ease and a good motion.
Then I usually put some pressure
with my thumb to try and move it
and see what kind of
motion I could get.
Then you just glide the fibular head
with your thumb back into place.
So I’ll glide it anterior to balance it and
see if we can get it more comfortable.
Sometimes it takes fine tuning and
multiple times to push on the fibula.
It is generally mobile
in one direction.
Sometimes you can twist it as
well to get full motion.
Make sure you’re not making
the patient uncomfortable.
And see when you have a release
and enhanced motion.