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ESSENTIAL SKILLS When dealing with any sprained ankle, especially when swelling and pain are present, be sure to have the client get an X-ray before you begin treatment. HOW IT HAPPENS Lateral ankle sprains commonly occur during athletic activity. They are often caused by a sudden, severe trauma such as landing incorrectly from a jump in basketball, crashing into somebody in soccer, sliding into third base, or tripping on some uneven ground while running. In some cases, the person immediately feels severe pain. They may also hear a disconcerting snap. After an hour or so, swelling occurs, the pain gets worse, and it becomes very difficult to walk. In other cases, the sprain is not immediately apparent. In the heat and excitement of activity, a slight falling over on the ankle is barely noticed; the person recovers balance without missing a step. A little while later, a nagging discomfort begins to develop. It may be just a slight ache or irritation that slowly worsens over the next few days as the ankle is used, or it may become very painful. There may or may not be swelling. Ankle sprains can also occur during everyday activities like taking a walk on uneven ground, stepping off a curb, or horsing around with the kids. A variety of factors can increase vulnerability to ankle sprains. These include high arches, which make the ankle less stable; poor alignment of the bones of the feet, where the arches pronate and drop toward the ground; and extremely hypertonic calf and shin muscles, which reduce a person's ability to adapt to changes in the ground surface. Excessive flexibility at the ankle joint due to stretched or congenitally loose ligaments also increases the likelihood of a sprain. Other causes include muscular imbalance in the lower leg and wearing very high-heeled shoes or platform shoes. Of course, a person may be doing everything just right and yet slip on a patch of ice or trip and fall and end up with a severely sprained ankle. When an ankle sprain does not heal properly, it can become a chronic problem. The ligament may have been stretched or may have developed poorly formed (and therefore weak) adhesive scar tissue, causing instability at the joint. Strenuous activities continually re-tear the scar tissue, resulting in a seemingly endless cycle of pain that comes and goes, with intermittent swelling. This can continue for many years if the injury is not properly treated. INJURY VERIFICATION Within about an hour after an ankle is sprained, the swelling and pain are usually quite severe. In fact, the ankle can swell to the size of a grapefruit. This can make it difficult to perform a precise assessment at that time. It may take a few days before the swelling goes down and an accurate assessment is possible. There are three grades of sprains: Grade 1 (slight damage, not affecting ankle stability); Grade 2 (more serious damage, with no significant instability but pain on walking); and Grade 3 (a complete tear of one or more ligaments, causing instability and typically making walking difficult). Usually the more severe the damage, the greater the pain and swelling. When a ligament totally ruptures—although the ankle feels extremely unstable, the pain often subsides quickly. The most commonly ruptured lateral ligament is the anterior talofibular ligament. When dealing with any sprained ankle, especially when swelling and pain are present, be sure to have the client get an X-ray before you begin treatment. The ankle could be broken, requiring medical attention before any hands-on treatment is appropriate. If the X-ray is negative, proceed with the following tests, which attempt to reproduce the type of movement that originally caused the sprain. TEST 1. PASSIVE SUPINATION (ANTERIOR TALOFIBULAR LIGAMENT) With the client lying supine, place your left hand under the back of the client's left heel for support, then firmly grip the top of the foot with your right hand. (Reverse these directions if you're testing the right ankle.) Now gently supinate the foot (supination is a combination of plantar flexion, medial rotation, and inversion, all done simultaneously). Pull the foot medially into plantar flexion as you internally rotate it. If the ankle is sprained, this should cause pain at the anterior lateral ankle. 112 massage & bodywork january/february 2008