I'm Brett DeGoyer. I'm a primary care sports medicine specialist and neuromusculoskeletal medicine specialist practicing for Samaritan HealthCare in Moses Lake, Washington. In this case, we're dealing with a high ankle sprain, usually a high energy type injury. Most of the pain is going to be associated with the anterior tibiofibular ligament, which gets damaged, but also possibly the syndesmosis. But this particular case, the patient that was injured is specific to the ATIFL. There are two considerations that we'll think about here. Sideline management with osteopathic manipulative treatment, and then recovery or long term. On the sideline, the evaluation in conjunction with the athletic trainer and physical therapist who is there with you at the event, we find that there's a lot of tenderness, restriction in motion, but not quite a lot of swelling or bruising just yet. To help mitigate that, we want to gently mobilize the area because we don't want to aggravate or make worse the injury that's already there. But we want to make sure that the tissues are supple. So a lot of the vascular and lymphatic drainage is being unrestricted. That will include resting the foot on the knee, making sure they're in a comfortable position, and then adding in effluage, which is a type of soft tissue treatment to make sure that you're milking the tissues to promote appropriate drainage. The other is to do a counter strain treatment, which essentially is to put the foot in a over-exaggerated position to approximate the fibers, which are running in an oblique connection, so that it reduces the amount of pain sensation and nociception at that area of injury. Think of it as finding the place that is most painful, adding a tiny bit of monitoring pressure with a finger, and then wrapping around that point and holding for a period of 90 seconds to let that nervous system input settle down. Now, once the athlete has gone through a recovery phase, and it's important to note that on the sideline, the treatment that was just demonstrated can be repeated throughout the recovery process. But once the recovery process is near completion, and the athlete is out of immobilization, now we can do more aggressive treatment. Finding the areas of pain along where the fibers are running on the ATIFL, we can repeat that counter strain, just to make sure that the tissues and the nociceptive input has been settled down, and then progress on to an articulatory treatment of the tibiotalar joint. And one way to do that is to cup at the calcaneus underneath, and then cup over the top on the talus. And then you add a little bit of traction and start to do some gentle range of motion in circular fashion. Once you feel like there is good motion there, then you start to alternate your motion from your calcaneal hand to your talus hand. So it's a ringing motion. So you progress from just a circular motion to a ringing, almost a figure of eight motion, to help mobilize that joint, always maintaining just a little bit of traction, because that will help to also mobilize at that talotibial joint. Progressing from the articulatory treatment, now we can go to a muscle energy treatment. And for the ankle in recovery, they've often been locked down in immobilization, so we need to get their motion back and their strength back. So in conjunction with what they're doing through physical therapy and in the training room with the athletic trainers, in our office, we have them do similar things, where we're going to induce dorsiflexion and have them push in plantarflexion, just gently. Once they have contracted for about two to three seconds, we have them relax, and then we carry into further dorsiflexion. From there, we can go into plantarflexion and do the same thing in the opposite way. Once we've completed that action, we can put the ankle into inversion and have them twist their ankle against. So as I put her foot into inversion, I'm going to hold steady, and she's going to push out laterally into abduction. Again, contraction two to three seconds. Longer if you feel it is necessary, up to five or 10. And continue to, after relaxation, carry it into further inversion. After inversion, do the opposite into eversion. That helps to stretch out the ankle joint and the surrounding tissues to help reduce that amount of stiffness, and then allow them to progress through their home exercises that they should be doing as instructed by physical therapy and athletic training.

3rd Edition, Case 02

3rd Edition

Ankle

high ankle sprain

anterior tibiofibular ligament

osteopathic manipulative treatment

muscle energy treatments

rehabilitation