Key Points 

• Ankle sprains typically occur in one of three areas—lateral, medial, or syndesmosis.

• Massage therapy is a core component for treating ankle sprains and is used with other treatments used by other providers, such as laser therapy, ultrasound, microcurrent, and electrical stimulation.

Ankle sprains are among the most common injuries encountered in both athletic and general populations, affecting millions globally every year. This pervasive injury can significantly impact an individual’s daily activities, athletic performance, and quality of life. The nature of an ankle sprain, often resulting from a sudden twist or misstep, can lead to varying degrees of ligament damage, pain, and functional impairment.

The ankle is a complex structure, stabilized by an intricate network of ligaments, tendons, and muscles, all working together to facilitate movement and bear the body’s weight. Massage therapists can play an important role in treating this condition and helping clients return to activity. Let’s explore the key aspects of anatomy, biomechanics, assessment, and treatment for these common soft-tissue disorders.  

Anatomy

The ankle region is a complex structure, incorporating bones, joints, and soft tissues that work together to allow locomotion. They provide strength, stability, and flexibility essential for daily activities and dynamic movements. Let’s delve deeper into ankle sprains, starting with the bones.

The ankle comprises multiple joints, with four main bones playing key roles in ankle function: the tibia, fibula, talus, and calcaneus (Image 1). The tibia bears the brunt of the body’s weight, while the fibula is a support and attachment point for muscles. Together, they rest upon the talus, which in turn transfers force to the calcaneus below. This arrangement creates a stable yet adaptable foundation for efficient movement and shock absorption.

Three main joints form the ankle complex: the talocrural, subtalar, and distal tibiofibular joints (Image 1). The talocrural joint is where the tibia and fibula meet the talus. The subtalar joint lies between the talus and calcaneus, and the distal tibiofibular joint connects the lower ends of the tibia and fibula.

Ligaments play a crucial role in ankle stability, spanning these joints. The ankle ligaments are grouped into three categories: lateral, medial, and syndesmotic. The lateral ligaments, consisting of the anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL), and calcaneofibular ligament (CFL), work synergistically to prevent foot inversion and offer lateral stability (Image 2). On the medial side, four ligaments make up the deltoid ligament complex
(Image 3) and are referred to as the deltoid ligament; they resist eversion. The syndesmotic ligaments, running between the distal ends of the tibia and fibula, provide stability and protection against forces attempting to separate these bones (Image 3).

Numerous muscles and tendons play vital roles in the ankle’s structure and function, contributing to movement and stability. The Achilles tendon, the largest in the body, connects the calf muscles to the calcaneus, enabling the powerful plantar flexion needed for propulsion. The fibularis (peroneal) tendons, crucial for eversion and stabilization, run along the ankle’s outer side, helping us navigate uneven terrains. Internally, the tibialis anterior, tibialis posterior, and flexor hallucis longus tendons assist in various movements, support the arch, and contribute to overall stability.

The ankle’s structure is designed for stability and flexibility and is crucial for bearing weight and executing various movements. A thorough understanding of this anatomy is paramount for practitioners to accurately assess and treat ankle sprains. 

Biomechanics

Anatomy helps us understand structure, but it is also imperative that we understand the mechanical function of these ligaments and joints. The primary movements of the ankle are dorsiflexion and plantar flexion, both occurring at the talocrural joint. Typically, the ankle can move about 20 degrees in dorsiflexion and up to 50 degrees in plantar flexion.

The ankle complex also enables inversion and eversion movements, predominantly occurring at the subtalar joint. Inversion involves raising the foot’s medial edge and turning the sole inward, while eversion entails lifting the lateral edge and turning the sole outward. These movements are essential for navigating uneven surfaces and maintaining stability during dynamic activities.

The ankle distributes forces in specific patterns during various activities. For instance, walking begins with a heel strike, transitioning forces through the ankle as the foot flattens and the body’s weight moves forward. The forces peak during push-off, demanding substantial plantar flexion strength and stability. Running intensifies these forces, requiring enhanced shock absorption upon landing and more powerful propulsion during push-off. Ligaments and tendons in the ankle play pivotal roles in joint stabilization, while muscles manage the force production.

Ankle sprains can lead to pain and instability, significantly impacting smooth and efficient movement. Therefore, understanding ankle biomechanics will direct your treatment and rehabilitation.  

Ankle Sprains Defined

A sprain refers to the tensile (pulling) stress injury of a ligament, thus, it’s an overstretching or tear in one or more of the ligaments connecting the ankle joints. Sprains are usually graded in one of three levels: first-degree (mild), second-degree (moderate), or third-degree (severe).

Ankle sprains typically occur in one of three areas—lateral, medial, or syndesmosis, all of which have ligaments we previously identified. Grasping the intricacies of each type will help you deliver effective treatment and aid optimal recovery.

Lateral Ankle Sprains

These are the most frequently occurring ankle sprains, generally caused by excessive inversion or a combination of inversion and plantar flexion. Such movements can put undue stress on the lateral ligaments, potentially leading to injury. The involved ligaments here are the ATFL, PTFL, and CFL.

The ATFL, being the most vulnerable, is usually the first to get injured due to its relative weakness and its susceptibility to stress during inversion and plantar flexion. The CFL comes next in vulnerability, as it provides stability in both neutral and dorsiflexed positions. The PTFL, being the most robust of the three, is infrequently injured. Symptoms of a lateral ankle sprain may range from pain, swelling, and bruising to instability, with severity depending on the sprain’s grade.

Medial Ankle Sprains

These sprains are rarer and typically involve the deltoid ligament complex, often resulting from an outward turning of the foot or a traumatic force to the outer part of the ankle. Given the deltoid ligament’s strength, a considerable force is usually required to cause a medial ankle sprain.

The deltoid ligament group provides extensive support to the ankle’s medial side, and injuries here may occur alongside fractures or other more severe injuries. Symptoms can include pain, swelling, and tenderness along the inner ankle, dependent on the extent of ligament damage.

Syndesmosis Sprains

Also referred to as high ankle sprains, these affect the syndesmosis joint above the commonly injured lateral and medial ligament groups. While less common, they tend to be more severe and require longer recovery.

High ankle sprains usually stem from rotational forces or a forceful widening of the ankle, such as from a planted foot and a twisting body, or an impact that forces the ankle into dorsiflexion and eversion. These incidents can disrupt the syndesmosis joint, potentially resulting in instability between the tibia and fibula.

Symptoms may include pain during dorsiflexion or when compressing the sides of the lower leg, as well as tenderness along the syndesmosis. Given the potential for long-term instability resulting from these injuries, thorough evaluation and careful management are imperative.

Assessing Ankle Sprains

Conducting a detailed soft-tissue assessment will help you clarify the specifics of the sprain and develop an effective treatment plan. It’s important not to underestimate the role of assessment in injury evaluation. Even with a diagnosis, your treatment will be far more efficient and direct if you know what tissues are involved and how. The process does not need to be time intensive; just a few quick evaluation methods can pinpoint where and how you need to apply your care.

Using various assessment techniques not only aids in identifying the affected ligaments, but it also sheds light on the ankle’s overall health so you can customize the intervention. 

The evaluation process begins with history-taking and involves collecting detailed information about the injury’s occurrence, the pain’s characteristics, and any prior injuries to the area. In particular, you will want to explore the injury mechanics—was there a twisting motion, a direct blow, or an awkward landing? These details offer insights into which ligaments may be compromised.

Visual examination can reveal signs of swelling, bruising, and skin color changes, while palpation aids in identifying areas of tenderness and evaluating ligament integrity. The subsequent physical examination, including range of motion and resistance testing, should help narrow down the affected ligaments and their contribution to the pain. For example, during both active and passive movements, any motion that further stretches the ligament is likely painful. This assessment will also help you differentiate ankle sprains from other soft-tissue injuries.

In addition to these techniques, special orthopedic tests can provide further insights. Tests such as the anterior drawer test, targeting the ATFL, and the talar tilt test, focusing on the CFL, can be instrumental in confirming the presence and gauging the severity of ligament injuries.

Treatment Strategies

Crafting an effective treatment plan for an ankle sprain should evolve directly from the information gathered during the assessment process. A multifaceted approach is most effective in treating ankle sprains and combines immediate care strategies, manual therapy, rehabilitative exercises, and advanced treatment options when necessary. Massage therapy is a core component for treating sprains. It can be used with other treatments used by other providers, such as laser therapy, ultrasound, microcurrent, and electrical stimulation. 

RICE Protocol

The rest, ice, compression, and elevation (RICE) protocol is the widely accepted initial protocol for the acute phase of ankle sprains. The acute injury stage covers the first 48–72 hours after injury. In the early stages, immediately after the injury, ice has analgesic effects and reduces initial swelling. However, research indicates that prolonged use of ice can interfere with, and slow, healing. Rest, compression, and elevation are necessary to start the healing process. Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used at this stage. Practitioners should avoid treating the region if it is still in an acute inflammatory phase.

Manual and Massage Therapy

Massage or soft-tissue treatments are core, indispensable components of any ankle sprain treatment regimen, offering a range of benefits. These begin after the acute phase.

Post-strain discomfort is often a result of excess fluid in the area that presses on nerve endings and fills the interstitial spaces. Light massage will reduce this swelling. Gentle stroking in a proximal direction aids lymphatic drainage in the area, which reduces excess tissue fluid and decreases pain.

Swelling can persist for several weeks post-injury. Do not wait until the visible swelling is gone or you will miss the ideal window of opportunity for injury rehabilitation. Massage techniques can be delivered in moderation, even if chronic swelling persists. Just use caution and work within your client’s tolerance.

As the swelling begins to subside, deep transverse friction at the injury site will aid in repairing ligament tissue damage, in part by stimulating fibroblast activity. In addition, deep transverse friction plays a role in mobilizing the ligament and preventing it from adhering to adjacent tissues. This friction is typically performed in a direction that is perpendicular to the direction of the ligament’s fibers (Image 4).

In addition to the foot, the lower leg muscles are treated, especially if they are in a protective spasm following the injury. For example, after an inversion sprain, there is usually tightness in the peroneal muscles—the muscles are likely to become hypertonic. Not everyone experiences the same rate of injury healing. Someone with scar tissue from an older injury could take longer to regain proper functional movement than someone with a recent sprain.

It is essential to achieve early mobilization in the area for the most beneficial healing. But because passive movement runs the risk of overstretching the damaged tissue, active movement is preferable, especially in the early stages. The client is unlikely to perform movements that hurt too much, so active movement is self-limiting and not likely to cause further damage. It is helpful to stretch muscles that might also be in protective spasm. Leave stretching for the later recovery stage to develop healthy and functional movement.

Finally, rehabilitative exercise is a cornerstone of ligament sprain recovery. A pivotal aspect of preventing further sprains and ensuring safe ligament healing involves enhancing proprioceptive awareness and strengthening the surrounding muscles. This is typically conducted in physical therapy sessions, using tools like a wobble board.  

Conclusion

Ankle sprains are among the more frequently seen injuries in the massage clinic. Massage has a core role in their treatment. We can significantly contribute to our client’s recovery by making our care as informed and efficient as possible. Not only will the client return to function quicker, but they will also endure less pain.