Any athletic activity requiring footwork allows for the potential of ankle injury. Even walking doesn’t remove one from the chance of twisting an ankle. For those that injure an ankle, treatment should be administered as soon as possible. Improper treatment, or lack thereof, can cause poor healing and leave the ankle more susceptible to repeated injury.
First, let’s analyze the lower leg and foot. The muscles that move the ankle are located in the lower leg. These muscles are called extrinsic muscles of the foot, since they control the foot from outside of the foot itself. The gastrocnemius, soleus, tibialis anterior/posterior, peroneus group, etc. are incredibly powerful muscles and help one to walk, jump, and run. These large muscles in the lower leg are responsible for the gross motor movement of the ankle and foot. The muscles in the foot, or intrinsic muscles, are responsible for finer movements. These intrinsic muscles play a large part in supporting the arches of the feet, providing movement for the toes, and relaying spatial information.
Both the extrinsic and intrinsic muscles relay information to the brain about proprioception, or spatial positioning. This idea is important, because after ankle trauma, such as an inversion ankle sprain, the “sensors” which send proprioceptive signals back to the brain can be injured. During the actual ankle inversion injury, tendons and ligaments can get stretched. The body reacts to these rapidly stretched sinews by strongly contracting musculature supporting the ankle. Why? It’s an inherent protection mechanism from further damage. By tensing the muscles around the ankle, the body tries to avoid possibility of more violent damage. The chance for reoccurence of injury is when these proprioceptive sensors do not return to normal function after trauma.
So, now, the injury is here. The soft tissues around the lateral malleolus are swollen, bruised, and stretched. Some people will apply ice to reduce swelling. Some will apply heat. (We’re not going to go into the ice vs. heat argument here.) But, many will do no more than administer thermal treatment and believe that time and “walking it off” will fix everything. Poor rehabilitation methods can leave the tendons and ligaments damaged and stretched. They can also leave the muscles in spasm, thereby giving the person a feeling of weakness and instability in the ankle.
Since the scope of this article is treatment of musculature for ankle injury, discussion of the mechanics of injury and other forms/areas of treatment will not be found here. But, the reader should note that this article focuses on treatment of the muscles of the lower leg and foot. The ideas found here are extremely important when rehabilitating any type of ankle injury and can be applied to any treatment regimen.
What muscles should be treated in the case of an inversion ankle sprain:
- Peroneus Group – The peroneus muscles of the lower leg are made up of 3 (and sometimes 4) muscles. These muscles are also called Fibularis (longus, brevis, tertius, quartus) and run down the lateral side of the lower leg. They are generally responsible for dorsiflexion and eversion of the foot. Basically, when you “roll your ankle” these muscles try to pull your foot back to a neutral position. Pain from these muscles are located anterior, posterior, and inferior to the lateral malleolus. If you are still having pain in these areas well after your ankle sprain, look to treat these muscles.
- Anterior Tibialis – This muscle is located on the front of the lower leg and is heavily used in foot activity. The job of this muscle is to dorsiflex the foot with some slight inversion. It has a tendency to be tight and easily fatigued from overuse. Pain from tight anterior tibialis can be felt on the anterior portion of the ankle and in the big toe. If there is pain on top of the ankle well after the ankle sprain, look to treat this muscle.
- Extensor Digitorum Longus – The EDL muscle aids in dorsiflexion and eversion of the foot. This muscle assists the peroneus group in their function. It is located underneath and slightly lateral to the tibialis anterior muscle. Due to its deep position in the foot, it is sometimes missed during treatment. Pain in the anterior portion of the foot can be caused by tightness in the extensor digitorum longus.
- Extensor Digitorum Brevis/Extensor Hallucis Brevis – These are two intrinsic muscles of the foot that should be treated after inversion ankle sprain. These muscles are located on the top of the foot, just anterior to the ankle joint. They dorsiflex the toes and you can usually see them contract when doing so.
- Other Supporting Muscles – Soleus, gastrocnemius, flexor digitorum brevis, are other muscles that can also be treated during a rehabilitation phase of ankle sprain.
Why should one treat the muscles in an inversion ankle sprain? As stated earlier, the “sensors” that tell the brain one’s orientation in space can be damaged in an ankle sprain. When these proprioceptive sensors are injured, the brain can get mixed signals as to where the foot is, relative to the body and to the ground. It is important to give these sensors (or stretch receptors in the muscle) the best opportunity to “unstretch” or return to normal function and sensibility. By treating the muscles surrounding the ankle, these proprioceptive signals can reset themselves and bring back the kinesthetic awareness of the feet. Another reason for treating lower leg muscles would be to reduce/prevent inflammation of the tendons as they pass over the and around the ankle joint. The abnormal tension due to tight musculature in the calves can increase the stress on the ankle joint and cause tendonitis.
Treatment of the lower leg and foot musculature along with the damaged ligaments and tendons should be initiated soon after trauma occurs. Alternative and complementary medical care such as acupuncture and massage therapy are beneficial as both can reduce recovery time and assist in the healing process. Alternative treatment modalities can also provide effective, drug-free, natural care, which is easily incorporated into any Western medical recovery program, if necessary.
A sample treatment of ankle sprain that I may use in my clinic would be:
- Acupuncture – LV3, SP10, Peroneus longus/brevis/tertius Motor Points (MP), ST36, Anterior Tibialis MP, Extensor Digitorum Brevis MP, Extensor Hallucis Brevis MP, Soleus MP.
- Massage Therapy – Lower Leg Tui Na and Massage for Posterior and Lateral portion of lower leg.
- External Liniment/Rub – San Huang San poultice during first 2-3 days after injury. After first 72 hours, Sciaticare Penetrating Muscle Rub applied over muscles as well as over swelling and inflammation. Patient would apply Sciaticare PMR daily and massage into area to promote circulation and healing. Application of Sciaticare PMR before any rehabilitation exercises would be recommended as well.
Notes: Attached are a couple of video links showing some simple self-massage and tui na techniques to assist you in the rehabilitation of your inversion ankle sprain.
Disclaimer: If you need to seek outside medical attention, please do so. A second opinion couldn’t hurt.