Treatment for Ankle Sprains

Here's a great article regarding the causes and treatments of ankle sprains.

Chronic Ankle Pain (Unresolved Ankle Sprain)
By James Brantingham, DC, CCF , Randy Snyder, DC, CCFC, John Wong, DPM, D.C., Charles Brantingham, DPM and Bruce Haggart, DC

Introduction
Unresolved, chronic ankle pain secondary to ankle inversion sprain is a commonly seen condition. Many mechanisms have been suggested as the reason for chronic ankle pain: lack of appropriate and early immobilization in severe cases; lack of appropriately prescribed mobility and strengthening exercises; development of scar tissue; development of late hypermobility; secondary, continuing aggravation due to unrecognized or untreated hyperpronation; too much immobilization.

Common, acute inversion ankle sprain and its management is first covered followed by diagnosis and treatment of chronic ankle pain. Representative case studies will be presented in Part II of this article (see Feb. 12, 1993 issue).

Common, Acute Inversion Ankle Sprains

Inversion sprain is the most common injury affecting the ankle joint. Injury frequently occurs to the anterior talofibular ligament. The calcaneofibular ligament may also become involved if inversion occurs while the ankle is at a right angle. However, the sprain usually occurs with inversion stress when the foot is also slightly plantar flexed. Occasionally, the posterior talofibular ligament may also become injured.

When the foot plantar flexes, the posterior portion of the talar trochlea advances in the ankle mortise. This creates an added space between the posterior portion of the talus and the malleolus inducing lateral instability. The lateral collateral ligaments are shorter and weaker than the medial collateral ligaments. Additionally, the anterior ankle joint is capsular and the posterior ligaments are thin.1 The calcaneofibular ligament is the only component of the lateral collateral ligaments that is extracapsular and is stronger than the anterior talofibular ligament.

Ankle sprain is commonly seen in the presence of uncompensated rearfoot varus, forefoot valgus, rigid plantar flexed first ray, and the cavovarus foot.2

The intensity of force governs the type of injury produced. Most inversion sprains involve an element of internal rotation and plantar flexion of the foot. Young people tend to tear ligaments and injure epiphysis while older people tend to fracture the lateral malleolus.2 Ligament tears rarely occur in the middle, usually sustaining a tear at either the proximal or distal point of attachment.1 A small bone fragment may be avulsed with the ligament rather than the ligament actually tearing. Therefore, inversion type ankle injuries can tear lateral ankle ligaments, fracture the lateral or medial malleolus, cause separation at the distal tibiofibular syndesmosis, and occasionally fracture the posterior lip of the tibia.2 Ankle stability occurs with rupture and anterior displacement of the talus in the ankle mortise.

Treatment

Initially, control of swelling must be considered. Effusion favors the formation of adhesions which can delay healing. Swelling should be controlled by application of a firm bandage, cold, rest, and elevation of the leg. Oral anti-inflammatories may also be used to help minimize inflammation.1

Plain film radiographs should be taken immediately to rule out fractures. Stress views are helpful in determining ankle instability due to ligamentous rupture.1

If a strain is diagnosed then daily bandage changes with continuation of ice therapy is helpful. After about four days the cold pack modality can be replaced by immersing the involved area in hot water to the patients tolerance for 10 to 15 minutes daily.

Active nonweightbearing exercises should be started within the first few days, and the patient should put the involved foot and ankle through all the normal ranges of motion. Dispersal of edema, maintenance of muscle tone, and the prevention of adhesions will result if done frequently.1

Chiropractic physiotherapy modalities and treatments, such as ultrasound, whirlpool baths, and iontophoresis, help recovery but are not superior to the ice, heat, and active exercises already mentioned. Please take notice of our additional discussion in this paper on the use of manipulation and mobilization.

Providing there are no ligamentous tears, and that swelling has subsided, the ankle should be taped and weightbearing usage resumed. Taping will help to give stability and prevent further stretching of the ligaments while the healing process continues. Depending on the appearance, function, and pain of the ankle, sports activities should be avoided for one to three weeks.1 Proprioceptive sense can be retrained by coordination and balancing exercises. Additionally, specific strengthening exercises may be used to isolate and improve certain muscle functions.

Treatment of avulsion or tear of the lateral collateral ligament generally involves casting. The cast is generally kept on for 10 weeks and may have a walking heel applied. Occasionally, surgical intervention may be necessary.

It is not our intention to cover in depth this well-known and accepted material on acute sprain and its management. We wish to deal with chronic, recurring or continuing ankle pain secondary to an inversion sprain. (Note: Chronic ankle pain in this paper will mean pain secondary to ankle sprain of more than six months duration and has been resistant to previous orthopedic or podiatric treatment.)

Unresolved, Chronic Ankle Sprain

One common cause of unresolved, chronic ankle sprain is unrecognized and untreated excessive pronation.2 Chiropractic authors have also written about the need to recognize and treat excessive pronation as a cause of chronic ankle sprain.3,4 It also appears to be the consensus within podiatry that unrecognized, excessive pronation is a common cause of chronic ankle pain.5,6,7 The prescription of orthotics has been reported as useful in relieving chronic, unresolved ankle sprains,2,3 and we are in agreement with this consensus although it should be noted that no controlled study, as of this writing, has absolutely proven that orthotics, which correct pronation, will resolve chronic, unresolved ankle sprains.

There are still hyperpronated patients who, despite orthotic therapy, or patients who are not pronated, that have suffered inversion ankle sprain (and do not need orthotics to correct excess pronation) that continue to have chronic ankle pain. These patients have chronic ankle pain due to unrecognized and untreated joint dysfunction.

The primary purpose of this paper is to document effective treatment of unresolved, chronic ankle pain by appropriate diagnosis and manipulative treatment of feet and ankle joint dysfunction.

Michaud published case studies in which marked weightbearing rearfoot inversion, in compensation to a marked secondary forefoot valgus, produced an ankle predisposed to easy inversion sprain -- in essence a hypersupinated foot which could easily "tilt over the edge" into an inversion sprain.2 Michaud outlined the prescription of orthotics that pronate the hypersupinated foot and suggested appropriate manipulative and physiotherapeutic diagnosis and treatment.3 This subject was adequately covered by Michaud and need not be discussed here.

James Brantingham, D.C.
Randy Snyder, D.C.
John Wong, DPM, D.C.
Charles Brantingham, DPM
Bruce Haggart, D.C.
Tarzana, California

Athletic Performance Not Found To Be Enhanced By Popular Supplement Quercetin

The antioxidant quercetin is increasingly being marketed as a supplement that boosts athletic performance, but a new University of Georgia study finds that it is no better than a placebo. Professor Kirk Cureton, head of the department of kinesiology in the UGA College of Education, and his colleagues tested quercetin in a double-blind, placebo-controlled study that assessed a variety of measures, including the ability of muscles to synthesize energy, cycling performance, perceived exertion and strength loss following exercise. The researchers, whose results appear in the early online edition of the Journal of Applied Physiology, found that quercetin did not improve athletic performance in any of the measures they examined. "We did not see any performance enhancing effect of quercetin," Cureton said. "To a certain extent that was disappointing because our hypothesis, based on previous studies in mice, was that we would see positive effects. But our findings are important because they suggest that results from the animal studies shouldn't be generalized to humans." Quercetin is a naturally occurring antioxidant found in the skins of fruits, leafy vegetables, and berries, as well as in black tea, red wine and various fruit juices. It is sold as a supplement in nutrition stores and is an ingredient in sports drinks such as FRS Energy, which is promoted by cyclist Lance Armstrong. In mice, quercetin has been shown to stimulate the production of mitochondria, which are the energy producing components of muscle cells and other tissue. One study found that mice supplemented with quercetin increased their running endurance by up to 37 percent. In humans, however, the results have been mixed. An early and widely-cited study reported improvements in performance during a cycling time trial, but Cureton notes that data from the experimental group was not compared to the control group, making the statistical significance of the finding unclear. Published studies on competitive runners and cyclists have found no improvement in performance. A recent published study by the same researchers who reported mitochondrial and endurance increases in mice, however, found that volunteers who consumed a drink containing quercetin saw a 13 percent improvement in endurance. Cureton said the reason for the conflicting results is unknown, but added that several other studies currently in review for publication also have found no performance-enhancing effect. Cureton and his colleagues hypothesized that the athletes used in the previous studies might not have benefitted from quercetin because they had already maximized their mitochondrial density through aerobic training. To address that possibility, the researchers recruited 30 men who were healthy but not endurance trained and randomly assigned them to either an experimental group or a placebo group. The experimental group consumed a sports drink containing 250 milligrams of quercetin four times a day for up to 16 days, a dose and duration similar to previous human studies and comparable to studies in mice. The placebo group received the same sports drink without quercetin. Because the mechanisms of quercetin's action are unclear, the researchers examined a number of variables in what is the most comprehensive study to date on its effect on athletic performance.

The variables included:

The rate at which muscles synthesize energy after strenuous exercise;

Peak oxygen consumption;

The rate of perceived exertion during cycling;

Metabolic changes, such as the percentage of energy derived from fats and carbohydrates (more conditioned individuals tend to use more fat for energy);

Performance on a cycling test;

and Strength loss following prolonged cycling. Cureton notes that had there been a performance-enhancing effect of quercetin, a sample size of 30 would have been sufficient to detect it. Plant-based compounds related to quercetin, such as resveratrol, have been similarly touted for their health benefits based primarily on animal studies, but Cureton said his findings should serve as a reminder that the gold-standard of science is randomized, double-blinded studies in humans. "The take home message here is that promising results in mice don't necessarily translate to humans," Cureton said.

The research was funded by the Coca-Cola Company.

Source: Sam Fahmy University of Georgia