Ankle Sprains or Inversion Sprains – Part 3

Scar Tissue

So, why is scar tissue formation such an issue when resolving ankle sprains? When ligament fibers are torn, the body lays down collagen in an attempt to support, reconnect, and reinforce the damaged tissue. This collagen is what we commonly refer to as scar tissue. Scar tissue is much weaker, less flexible, and easier to tear than normal ligaments. Scar tissue is weak and inflexible because it is laid down in a random pattern and does not follow the same fiber orientation as the normal ligaments. These areas of scar tissue formation have a different consistency and strength than the normal ligaments. (Image Body Worlds - permission granted).

This alteration in ligament consistency then creates instability in the ankle, resulting in abnormal motion patterns, which then can result in further injuries. A considerable amount of scar tissue can form with repeated ankle sprains (which are common). Although the initial intention of the body was to stabilize the ankle with scar tissue, it can have the effect of de-stabilizing it instead, due to the random patterns of fiber orientation.

Therefore, it is essential to remove this scar tissue, thereby helping in the restoration of normal motion patterns, and increasing flexibility and strength.

Manual Therapy for an Ankle Sprain

Manual therapy can make a huge difference in the recovery and prevention of an ankle sprain. By manual therapy, I am referring to techniques such as Active Release, Graston Technique, Massage Therapy, Fascial Manipulation, Manual Manipulation, and other manual procedures. In my opinion, these procedures are essential in the rehabilitation of an ankle sprain since they all act to break down and prevent scar tissue formation.

Manual therapy also speeds healing by increasing blood supply, oxygen, essential nutrients, and displace waste products that accumulate after an injury. This is especially important in treating ligaments because they generally have a very poor blood supply to begin with.

It is Important to Treat More Than Just the Ligaments

Earlier, I mentioned that there might be damage to several types of structures after an ankle sprain, especially the connective tissue, tendons, muscles, and nerves. The following is list of structures that are often injured in a lateral ankle sprain (inversion sprain).

Ligaments

• Anterior talofibular ligament (ATFL) – Most common injured structure.

• Calcaneofibular ligament (CFL) – Second most commonly injured structure.

• Posterior talofibular ligament (PTFL)

Tendons

• Peroneal tendon

o With an inversion sprain, it is common for the tendons of the peroneal muscles to be injured. It also common for the peroneal tendon to move out of its normal position (subluxate) during the recovery stage of an ankle sprain.

Muscles

• Peroneus brevis muscle – Longitudinal tears of the peroneus brevis are commonly associated with lateral ankle sprains.

• Peroneus longus muscle – These muscles often show a different activation pattern when there is ankle instability. This is often due to restrictions that have formed in the muscle. These restrictions, if not removed, could make a person more susceptible to future injuries.

Both muscles, evert the foot at the tarsal joint, and plantarflex the foot at the ankle.

Retinaculum

• Peroneal retinaculum -

o During a lateral ankle sprain, the foot rolls inwards with considerable force. This forceful action can tear the peroneal retinaculum. This retinaculum is a band of connective tissue that keeps the peroneal tendons in place. When a tear in the retinaculum occurs, patients will notice a snapping sensation in the lateral ankle. Conservative treatment is 4 to 6 weeks in a short leg cast. However, a severe tear of the retinaculum is not a candidate for standard manual therapy and may require corrective surgery.

Nerves

• Superficial peroneal nerve - This nerve is at risk for traction injury during a lateral ankle sprain (inversion sprain).

In Part Four of Ankle Sprains we will cover Fascia and Inversion Sprains as well as the Benefits of Joint Manipulation in the treatment of ankle sprains.

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