Case Study: Treating an Ankle Sprain with Integrative Manual Therapy Techniques: The Role of Bone Bruise and Disruption of Membrane Techniques

Author: Sarah Ryterband, M.D.

Abstract: Approximately 25,000 ankle inversion injuries occur each day in the United States. Yet, aside from surgery, there is little mention of structural rehabilitation in the literature.(1) After an extensive review of the literature, orthopedists Lynch and Renstrom found "that early functional treatment provided the fastest recovery of ankle mobility and earliest return to work and was complication free, whereas surgery had serious, though infrequent, complications."(2) Although functional treatment has been shown to be effective, what the literature does not show, as yet, is how the application of various manual therapy techniques might effect the course of recovery. As increasing numbers of individuals are learning these various skills, practitioners can apply them to persons with this prevalent injury or to those 20% with ankle instablity following injury, many of whom now go on to surgery.(3)

Case Study

History

A 50 year-old male professor presented with an acute inversion injury of the right ankle, incurred while playing volleyball. He had landed on another player’s foot after jumping to return the ball. He complained of pain at the tibiotalar junction and inferior to the medial malleolus. He was unwilling to bear weight on the right foot. He had no previous history of significant ankle injury, despite having danced professionally. His goal was to resume walking and playing sports as soon as possible.

Evaluation

On initial exam there was considerable ecchymosis and swelling of the right foot and ankle corresponding to the areas of pain. The patient complained of pain on palpation of the tibiotalar junction, the anterior talofibular(ATFL) and calcaniofibular(CFL) ligaments, and the distal fibula. ROM was limited in dorsiflexion, plantar flexion, inversion and eversion. Stability testing was not performed and he was not sent for xrays, although he met 2 out of 3 of the Ottawa criteria.(4)

Treatment and Results

I limited initial treatment to Chikly’s Lymph Drainage Therapy5 and to the 3-planar Fascial Fulcrum Release(FFR).6 The patient was encouraged to continue to ice and elevate the extremity. He self-medicated with a NSAID and for his comfort used an Ace wrap and crutches and then a cane.

I saw the patient a week following injury and did Myofascial Mapping of his ankle. He had positive mapping, which "indicates neuromusculoskeletal dysfunction which indicates the need for Manual Therapy",7 along the tibiotalar junction and mid-lateral malleolus. I repeated soft tissue and articular FFR and then, based on the mapping and the method of injury, proceeded to look for and treat bone bruises8 of the talus and lateral malleollus, "disruptions"9 of the ATFL and CFL, as well as a Type II tibiotalar joint dysfunction.10 I also performed the "[t]echnique to correct an anterior subluxation of talus."11 After this session the patient had the following ranges of motion: plantar flexion 30 0, dorsiflexion 0 0, inversion 3 0, and eversion 3 0, and he ambulated without complaints of pain.

However, several months later, the patient had not resumed his athletic pursuits, due to a sense that his ankle would give way, although this had not actually occurred. He experienced this sensation as he descended a staircase. He denied any pain. A horizontal linear positive mapping was found on the medial malleolus which was eliminated with Bone Bruise Technique. He was then able to resume all activities.

Discussion

It appears that bone bruises may not be evident immediately, but may contribute to chronicity. I am surprised to find that a bone bruise would be perceived as instability in the ankle and hypothesize a protective advantage: had the patient felt secure to resume normal activities, further damage may have been incurred. The bone bruise may also have been an incidental finding in the setting and its treatment may have caused a secondary effect which allowed the patient to experience full stability of his ankle.

A review of the literature on bone bruises following traumatic inversion injury of the ankle shows an incidence of 7-40%12-15 and a strong association with ligament rupture. Lynch and Renstrom cite evidence of AFTL rupture in 65% of patients with acute ankle sprains and an additional 20% have rupture of the CTL as well. Utilizing the technique for disruption of membranes, a practitioner can actively assist the healing of the ligaments of the ankle.

Like Labovitz and Schweitzer, I discovered bone bruises of the talus and the medial and lateral malleoli.14 Although Alanen’s group showed no prospective difference in functional outcome in the presence of bone bruises, their patients had no treatment directed at the bone bruises. Until bone bruises are identified and treated, to suggest that they are benign or have no clinical importance is shortsighted. I believe that with techniques to correct bone bruises and ligament disruptions, the time to return to work, limitations of walking or physical activity, or clinical outcome scores at 3 months, as defined by their study, may well be effected.15 Prospective studies utilizing these techniques are indicated.

Summary

Ankle sprains are commonplace. Magnetic resonance imaging has provided visible evidence of the high incidence of concomitant bone bruises and ligament disruptions. As this case demonstrates, manual therapy techniques can be directly applied to address these injuries. Prospective studies are required to document changes in time for patients to return to their premorbid status.

References

1 Childs S. Acute ankle injury. Lippincott’s Primary Care Practice. 1999; 3(4): 428-44.

2 Lynch SA, Renstrom PA. Treatment of acute lateral ankle ligament rupture in the athlete conservative versus surgical treatment. Sports Med. 1999; 27(1): 61-71.

3 Colville M. Surgical treatment of the unstable ankle. J Amer Acad of Orthop Surg. 1998; 6(6): 368-77.

4 Stiell I, Greenburg G, McKnight R, et al. A study to Develop Clinical Decision Rules for the Use of Radiography in Acute Ankle Injuries. Ann Emerg Med. 1992; 21(4): 384-90.

5 Chikly B. Lymph Drainage Therapysm Study Guide Level I. Palm Beach Gardens, Fl: UI Publishing; 1996.

6 Weiselfish-Giammatteo S. Integrative Manual Therapy for the Upper and Lower Extremities. Berkeley, Ca: North Atlantic Books; 1998: 101-110.

7 Weiselfish S. Manual for Myofascial Release for the Orthopedic and the Neurologic Patient. Hartford, Ct: Dialogues in Contemporary Rehabilitation, no year available: 13-14.

8 Weiselfish-Giammatteo S. Manual for Cranial Therapy Series Course Three. Hartford, Ct: Dialogues in Contemporary Rehabilitation; 1998: 15-16.

9 Weiselfish-Giammatteo S. Manual for Visceral Mobilization with Muscle Energy and ‘Beyond’ Technique: The Gastrointestinal Tract. Hartford, Ct: Dialogues in Contemporary Rehabilitation; 1998: 97(phase 3).

10 Weiselfish-Giammatteo S. Integrative Manual Therapy for the Upper and Lower Extremities. Berkeley, Ca: North Atlantic Books; 1998: 25-27.

11 Weiselfish-Giammatteo S, Weiselfish A, Burnham K, Giammatteo T. Compression syndrome for the tibiotalar joint and a protocol to increase ankle dorsiflexion. dcr-Dialogues in Contemporary Rehabilitation. 1998; 1(2): 5

12 Nishimura G, Yamato M, Togawa M. Trabecular trauma of the talus and medial malleolus concurrent with lateral collateral ligamentous injuries of the ankle: evaluation with MR imaging. Skeletal Radiol. 1996; 25(1): 49-54.

13 Pinar H, Akseki D, Kovanlikaya I, et al. Bone bruises detected by magnetic resonance imaging following lateral ankle sprains. Knee Surg Sports Traumatol Arthrosc. 1997; 5(2): 113-7.

14 Labovitz J, Schweitzer M. Occult osseus injuries after ankle sprains: incidence, location, pattern, and age. Foot Ankle Int. 1998; 19(10): 661-7.

15 Alanen V, Taimela S, Kinnunen J, et al. Incidence and clinical significance of bone bruises after supination injury of the ankle. A double-blind, prospective study. J Bone Joint Surg Br. 1998; 80(3): 513-5.

Submitted: September 1, 2000