[:en]ABSTRACT This article describes a less commonly recognized form of ankle sprain/strain, known as a high ankle sprain. The substantial consequences of this type of strain for the whole body, including for the progress of a series of structural integrations (SI) sessions, are described. Mechanisms of injury, assessment methods, and treatment methods for high ankle sprains are detailed.

Author’s Note: I learned this from Mark Thomas, DC of Cottage Grove, Oregon. He described learning it from an instructor in a chiropractic continuing education workshop on an entirely different topic, when a high ankle strain was discovered as an incidental finding.

Classic Sprained or Strained Ankles

Sprained ankles are common. Most adults have had at least a mild one. More than 23,000 ankle sprains are estimated to occur per day in the US. Stated another way, each day one in 10,000 people sprains an ankle. Given an average US life expectancy of seventy- nine years, or 28,835 days, an average person may experience three ankle sprains in a lifetime. These numbers may be an underestimate, as many mild ankle sprains are self-treated rather than seen in medical settings.

Residual problems after healing from ankle sprains persist for more than half the people who have this type of injury. Residual effects commonly include pain, stiffness, and instability. Ankle sprains usually involve the lateral complex of ligaments at the ankle, which includes the anterior talo-fibular ligament (ATFL), the calcaneo-fibular ligament (CFL), and the posterior talo-fibular ligament (TFL). Similar injury to the medial aspect of the ankle is uncommon, due to both strength of the medial ligaments and to differences in bony architecture. (For a fuller description of ankle sprains see the Physiopedia web link in the resource list at the end of the article.)

Sprained ankles are usually caused by forced inversion of the foot. Concurrent plantarflexion of the ankle may exacerbate the injury. Ankle sprain usually occurs in a misstep where the person misjudges the contour of the surface s/he is walking or running on. Choice of shoes, or patterns of shoe wear, may contribute to the injury.

Long-term effects of ankle sprains include positional and tensional compensation all the way up the kinetic chain. If a person’s right ankle does not support him/her well and/or is uncomfortable, the person will shift weight to the left foot in standing and modify gait to preferentially load the left leg. This will include overuse of the left tensor fascia lata and gluteus medius muslces. This leads to a cascade of compensation all the way to the head and upper limbs. Symptoms may be felt in any part of   the body. As usual, in this situation the location of pain or dysfunction in the body is a very incomplete guide to where in the body to work to resolve the symptoms and structural problems.

High Ankle Sprains/Strains – An Overview

There is a second type of ankle sprain, the ‘high ankle sprain’, which can occur concurrently with, or often independently of, the lateral ankle sprain. This is a sprain of the lower junction between the tibia and fibula, the distal tibiofibular syndesmosis.

Anatomy

The lower leg has two bones, the larger tibia and the smaller fibula. These two long bones are jointed to each other at their ends and bow slightly away from each other for most of their length, though connected along their whole length by the interosseous membrane. The nature of the joints at the two ends is different. The superior or proximal tibiofibular joint, inferolateral to the knee, is a synovial gliding joint with a strong capsule and a synovial-fluid-filled center. The inferior or distal tibiofibular joint is a syndesmosis. A  syndesmosis  is an all-ligament joint with no synovial fluid space. The trade-off between these two types of joints is that synovial joints provide greater range of motion and syndesmoses provide greater stability.

The proximal tibiofibular joint is actually a hybrid with a much thicker than usual joint capsule with a very short span, so while it has more range of motion than a pure syndesmosis the range of motion is less than typical synovial joints. Similarly, the stability of the proximal tibiofibular joint is higher than a typical synovial joint.

Together the distal ends of the tibia and the fibula form the superior (or proximal) element of the ankle joint, meeting the inferior (or distal element), the dome of the talus. Thus, there are three bones forming the ankle joint, tibia, fibula, and talus. However, the superior two bones, the tibia and fibula, are tightly knit together with very little movement between them, forming a stable common articular surface known as the mortise.

The lower leg is known by the Latin name crura. The ankle joint is between the dome of the talus and the mortise formed by the distal ends of the tibia and fibula. This joint is known as the talocrural joint. The major movement in the talocrural joint is dorsiflexion and plantarflexion. The talocrural joint also has low, single-digit-millimeter anteroposterior glide. The talocrural joint has no significant lateral glide. There is no rotation around an  anterior-posterior  (A-P)  axis.   There is only subtle rotation around a vertical axis, provided by the slight movement in the distal tibiofibular syndesmosis. This last motion, though small, is valuable for accommodating to uneven ground and in making turns in walking.

We can make a circular motion seeming to circumduct the ankle, however the lateral movement components of this apparent circumduction motion are entirely distal to the talocrural joint, prominently in the line shared by the talonavicular joint, and the calcaneocuboid joint, with some contribution of the talocalcaneal joint. The available movement at the talocrural joint is only dorsiflexion and plantarflexion.

Dysfunction of the Distal Tibiofibular Syndesmosis

The ligaments making up the distal tibiofibular syndesmosis can be too tight, which reduces the slight accommodation useful in rotation around a vertical axis, such as when we turn our bodies while a foot is planted. This excess tension may also reduce the ankle joint space lateral to the talus as it faces the distal projections of the tibia and fibula, which may increase effort required to plantarflex and dorsiflex the ankle.

The distal tibiofibular syndesmosis can be sprained, creating laxity. Laxity in the distal tibiofibular syndesmosis may be called a distal tibiofibular syndesmosis sprain, more commonly called a high ankle sprain. A good description of high ankle sprains can be read at at https://www.physio-pedia. com/index.php?title=Lateral_Ligament_ Injury_of_the_Ankle&oldid=219990.

The degree of laxity in a high ankle sprain varies in severity from slight to severe. In the most severe condition, the distal tibia and fibula are disconnected, the ligaments between them largely or completely severed. In that condition a person cannot stand, much less walk. In this most severe condition, a surgical solution is to screw the distal tibia and fibula together, which restores the ability to walk while sacrificing the adaptive capacity of the slight vertical- axis rotary movement in this joint.

Moderate high ankle sprains are painful and offer poor support in the limb, motivating sufferers to seek medical attention where this problem is often recognized. With appropriate medically directed and supervised immobilization, accompanied by a hiatus from weight-bearing, moderate high ankle strains can heal in a satisfactory fashion.

Mild high ankle sprains often go unrecognized because symptoms are higher up in the body at the knee, hip, and/or low back due to lack of support from below and unconscious guarding in an attempt to achieve stability. With mild high ankle strains symptoms felt at the ankle itself are often very mild to absent. Left untreated, mild high ankle sprains can persist for the rest of a lifetime with important negative consequences for the biomechanics of the whole person. It is the assessment and treatment of these prevalent chronic milder high ankle strains that is the central subject of this article.

Mechanism of Injury

High ankle strains are caused either by forced dorsiflexion of the ankle or forced external rotation of the foot at the ankle, or a combination of the two. Forced dorsiflexion commonly occurs during a misstep where there is an unexpected object under the forefoot. (Stepping on another players foot in basketball is a common scenario.) Forced external rotation can occur when the body is suddenly rotated over the person’s planted foot. An example is a running soccer player who has just planted his right foot and then collides with another player in the left front side of the torso spinning him to the left.

Consequences

With a mild high ankle strain the person often has no awareness or only slight awareness of ankle discomfort. However, stiffness and discomfort at the knee, hip, and low back are common. Practitioners not alert to the mild high ankle strain situation are likely to look elsewhere for the sources of the more superior leg and low- back pain. Since such searches are unlikely to find the whole problem, frustration results for client and practitioner.

Whether the practitioner is working with a nervous-system model or connective- tissue model of treatment, if the instability at the ankle is not addressed, attempts to treat resulting issues higher in the body will not be fully successful, and may be profoundly unsuccessful.

Mild high ankle sprains often go unrecognized because symptoms are higher up in the body at the knee, hip, and/or low back due to lack of support from below and unconscious guarding in an attempt to achieve stability. . .

Left untreated, mild high ankle sprains can persist for the rest of a lifetime with important negative consequences for the biomechanics of the whole person.

Prevalence

The prevalence of mild high ankle strains in the general population has not been well studied, likely due to the fact that they are often not recognized. Over the decades in my practice, about one client in twenty has this condition.

Assessment of High Ankle Sprain

With moderate to severe high ankle strains, a standing, weight-bearing A-P x-ray of the ankle will show excessive space between the distal tibia and fibula. This radiologic finding is definitive for this condition. With milder strains the space between the distal tibia and fibula may appear normal or equivocal. In this situation mobility testing reveals the true story.

First Test

To assess for high ankle strain, have the client lie supine on a treatment table with the heels just off the end of the table. Explain to the client what you are testing for and how you will perform the test. Stand facing the client’s feet. For the right ankle, firmly grasp the lateral malleolus with the thumb and finger tips of the left hand. Similarly grasp the medial malleolus with your right fingers and thumb. Securely control both bones as you test. Do not slide soft tissue over the bones. With this secure hold, concurrently move the lateral malleolus straight posterior and the medial malleolus straight anterior, at a moderate pace, to a comfortable anatomic limit. Reverse directions, to now move the lateral malleolus anterior while concurrently moving the medial malleolus posterior. Go back and forth, not more than twice. Excessive repetition of this test may further mobilize an already hypermobile joint. Test once. Believe your hands.

As you do this test there will be a tendency for your A-P counter-loads on the malleoli to rotate the leg sequentially internally and externally. To achieve the motion you wish to produce, which is a straight A-P shear between the two bones, bias the loads you apply with slight counter- rotary vectors as a dynamic stabilization to prevent rotation around a more or less vertical axis through the leg.

Do this test routinely on all clients. One benefit of testing all clients is for you to feel a range of tissue responses in people so you can recognize normal tissue span, laxity, and stiffness. The other benefit is you will find a significant number of high ankle strains.

Second Test

A second test should also be done,  which has two additional benefits: it supports the result of the first test, and if there is laxity in the distal tibiofibular syndesmosis the second test will make a vivid demonstration to the client. For this second test, the client continues supine on the table. Move to the client’s side facing the lower leg. For the right leg stand on the side of the table facing the client’s right lower leg. With your left hand, contact the distal femur and use this hand to roll the leg sequentially medially and laterally to comfortable anatomic limits. Note both the range of motion of hip rotation and the ease of movement within this range of rotation. Let the leg rest to neutral. Now use your right hand to grasp the right ankle either on the malleoli or at the narrowest part of the ankle just superior to the malleoli. Firmly compress the tibia and fibula toward each other in a frontal plane. This provides external stability to the ankle substituting for the lax tibiofibular syndesmosis. While maintaining this strong stabilizing compression, use the left hand on the femoral condyles to again sequentially rotate the leg internally and externally. If there is a high ankle strain, both the range and ease of the rotational movement will be markedly improved. With the external stabilization of the distal tibiofibular syndesmosis, the person’s nervous system will immediately drop guarding that it had been doing at least as high as the hip joint.

Treatment of High Ankle Sprain

Full healing and remodeling of injured tissue may take two years (see the chart of phases of wound healing at https:// en.wikipedia.org/wiki/Wound_healing). However, the healing process begins fast and then incrementally slows down. Often after six to eight weeks the healing tissue is strong enough to handle moderate loads of daily living. As an example, casts are usually removed from broken bones after about that much time. It is not good to return to playing contact sports at that time, but gentle walking and many activities of daily living will now be productive in promoting healing.

The situation with healing high ankle strains is that during sleep each night when there is no load on the distal tibiofibular ligaments, a little healing occurs. Then the first steps the next morning wreck the night’s work. Repeat cycle. In this way the lax ligaments can continue lax for the rest of a person’s life. Eventually the body will stop trying to heal the ligaments, establishing their lax condition.

The solution is to provide external stability to the distal tibiofibular ligaments during moderate waking use. After about two months of this there is usually enough structural integrity to the ligaments that healing processes (fibroblast  activity) can continue to build structural strength without external support. Vigorous activity including many sports should not be resumed for at least a further two months.

External stabilization for the distal tibiofibular syndesmosis is best provided by a comfortably tight band of inelastic material around  the  ankle.  Canvas  is  a good choice of material due to its inelasticity. Ace brand or similar elastic wrappings are ineffective as they are  too stretchy. Similarly, kinesiotape has too much elasticity for this purpose. The canvas band must be worn 24/7 except when bathing. After the first month the band can be taken off at night, however it must be applied before weighting the foot if one gets up at night. A good solution is to loosen the band at night while leaving it in place. It can then be tightened before putting weight on the foot.

It is wise to also advise clients to limit load on the leg. Avoid lifting or carrying heavy objects. It is important to walk – this helps stimulate healing and avoids muscle atrophy – however moderate the pace and length of walking. In the early phases, walking in waist-deep water may be beneficial. The buoyancy of water reduces the gravitational load on the legs, while at the same time providing resistance to moving forward through the water. For more serious high ankle strains a cane may be helpful and can reduce load at the ankle by one-third.

When I first began using these methods I had people shop for their own brace. They usually bought something that they paid too much for that was also ineffective. Ankle braces designed for sprained ankles do not work for this purpose.  Thus for a long time I have stocked in  my office Velcro-closure canvas bands, intended for ‘tennis-elbow’ condition support, manufactured by AZMEC. The manufacturer’s contact information is provided in the resource section at the end of the article. Azmec band #647 is well sized for most adults. For children and for the smallest adults, Azmec bands #649 and #649A, intended for carpal- tunnel-syndrome support, are well sized. I stock all three sizes in my office.

I make a trial fitting of the Velcro closure band with the client on the table. Ask the client to dorsiflex the ankle to a 90˚ position, and then cinch the strap tight. When the foot is returned to a neutral position the strap will be looser, usually at about the right tension. I then ask the client to walk around the room to assess the comfort of the band. The band should be as tight as possible within comfort. I impress on the client that this is not an opportunity to demonstrate stoicism – the band must be truly comfortable. Reducing circulation to the foot or excessively compressing tissue is potentially harmful. The band may be worn either inside or outside of socks. I provide each client with two bands, as in the course of sixty days they will want to launder the bands.

At each subsequent client visit, repeat the mobility test of the distal tibiofibular syndesmosis as  described  above. Usually there is noticeable reduction in the A-P glide between the distal tibia and fibula from visit to visit, and by eight to nine weeks the mobility of the syndesmosis is returned to normal. If the stability is progressing but not yet quite normal at two months, the procedure may be somewhat extended. In any event, after the mobility in the distal tibiofibular syndesmosis tests normal, have the client continue to wear the band for a further two weeks as insurance.

In about 10% of cases there is little or no progress  toward  syndesmosis   stability. It appears that in these cases the tissue healing process had already ceased. In this situation I refer the client to a physician for evaluation for possible treatment with prolotherapy. The prolotherapy injection is an artful new injury to the ligament, which vigorously restarts the healing process. (For an introduction to prolotherapy see http://prolotherapycollege.org/what- is-prolotherapy/.) During healing from prolotherapy, it may be beneficial for the client to wear the ankle band. This is a topic for discussion between client and physician.

The assessment and treatment methods for high ankle strains described here are an application of one of Jeffrey Maitland’s Principles of Intervention – the principle of support:

Movement has to be supported from below by structural integration. Ease of movement is in proportion to the integration of the support system, gravity. Functional ease is found only when each piece of the body receives sufficient support to cope with the constant pressure of gravity.

Support at the ankle is foundational to the rest of the body.

Jeffrey Burch was born in Eugene, Oregon in 1949. He grew up there except for part of his teen years lived in Munich, Germany. Jeffrey received bachelor’s degrees in biology and psychology, and a master’s degree in counseling from the University of Oregon. He was certified as a Rolfer in 1977, and completed his advanced Rolfing SI certification in 1990. Jeffrey studied cranial manipulation in three different schools, including with French etiopath Alain Gehin. Starting in 1998 he began studying visceral manipulation with Jean-Pierre Barral and his associates, completing the apprenticeship to teach visceral manipulation. Although no longer associated with the Barral Institute, Jeffrey has   Jean-Pierre   Barral’s    permission to teach visceral manipulation. Having learned assessment and treatment methods in several osteopathically derived schools, he then developed several new assessment and treatment methods that he now teaches, along with established methods. In recent years he has developed original methods for assessing and releasing fibrosities in joint capsules, bursas, and tendon sheathes, which he  is also beginning to teach. Jeffery is the founding editor of the IASI Yearbook; he contributes regularly to this Journal and elsewhere. He is a former member  of  the Rolf Institute® Ethics Committee and Board of Directors. For more information visit www.jeffreyburch.com.

Resources/Bibliography

The American Osteopathic  Association  of Prolotherapy Regenerative Medicine 2019. “What Is Prolotherapy?” Available at http://prolotherapycollege.org/what-is- prolotherapy/ (retrieved 10/28/2019).

Azmec: See product info at www. azmecinc.com. Contact: info@azmecinc. com; phone 951 582 0153; fax 951 582 0135 Physiopedia        contributors        2019.

“Lateral Ligament Injury of the Ankle” from the website Physiopedia, latest revision 8/23/2019. Available at https:// www .physio-pedia.com/index. php?title=Lateral_Ligament_Injury_ of_the_Ankle&oldid=219990 (retrieved 10/24/2019).

Wikipedia 2019. “Wound healing.” Latest revision 10/23/2019. Available at https:// en.wikipedia.org/wiki/Wound_healing (retrieved 10/28/2019).

Maitland, J., M. Salveson, J. Sultan “The Principles of Rolfing” (class handout). Boulder, Colorado: Rolf Institute®.

Assessment and Treatment of High Ankle Sprain in SI[:]