Ankle Sprain in Collegiate XC Runner: A Case Study

Good morning, everyone! For those of you who I have not had the pleasure of meeting yet, my name is Alex Coleman. I am currently completing my final trimester as a chiropractic student doctor at The FARM seeing patients under the guidance of Drs. Beau and Sloan Beard. I am incredibly excited to continue working alongside The FARMers as I have been through this office both as a patient and an undergraduate intern in my earlier days. 

In light of the upcoming community zoom talk, “Overcoming Ankle Sprains,” that we will be hosting, I thought it would be appropriate to run through one of my ankle sprain case studies that I managed this past trimester at The FARM. 

 History: 

For sake of confidentiality, our patient will assume an unrelated alias and be referred to as Ryan. Ryan is an 18-year-old male competitive cross-country runner and track athlete entering his freshman season at a local university. Interestingly enough, Ryan did not injure his ankle while running on a trail. Rather, he was running down a flight of stairs when his right foot landed awkwardly and he felt a “pop.” This occurred roughly 2 weeks prior to his initial visit. He noted slight swelling around the lateral aspect of his right ankle which had improved since the original onset. Around the same time that this ankle sprain occurred, Ryan contracted COVID which definitively caused him to take one full week to rest. After recovering from illness, Ryan slowly reintroduced running and noted pain in his ankle roughly 2 miles into a 4-mile run.

Exam: 

Initial examination revealed slight swelling over the lateral ankle accompanied by bruising and palpable tenderness. Upon completing a global movement assessment, Ryan passed most tests with flying colors as all tests were functional and non-painful with the exception of diminished single-leg balance on his left leg. Assessment of joint ranges of motion disclosed limited hip internal rotation bilaterally as well as calcaneal eversion bilaterally. Both passive and active right ankle inversion reproduced Ryan’s pain.  Joint restrictions were located in cervicothoracic extension, upper thoracic extension, and sacral nutation. All ankle orthopedic tests and Ottawa Ankle Rules performed were negative eliminating any concern of associated fracture at the foot, ankle, or lower leg.

Intervention:

Using the above-mentioned objective findings as clinical audits, we took Ryan through a series of movements in an attempt to make significant changes to both function and pain. First, we asked Ryan to perform Ankle Controlled Articular Rotations (CARs) in which he was instructed to draw, in the air, the largest imaginary circle he possibly could draw. Ryan noted some pain during part of this circular motion and was instructed to bump right up to the edge of discomfort but not beyond. This exercise aims to begin reintroducing the end range of motion and reducing pain through this range.

Additionally, we performed an isometric single-leg position loading the hip, knee, ankle, and foot. Then, using a spiked ball and a lacrosse ball, Ryan rolled the undersides of his feet stimulating mechanoreceptors and priming the intrinsic foot musculature for our next drill, toe yoga. In this drill, Ryan was asked to independently lift his right big toe while keeping his other toes on the ground. Then, this is repeated with the four lateral toes, and the entire sequence is repeated on the opposite foot. At first, this exercise proved to be difficult, especially on the injured foot. But, with practice and purpose attention, the movement became more competent. Finally, a standing triplanar ankle mobilization was prescribed to mobilize the ankle joint complex in a movement that closely mimics that of the stance phase in running gait.

 After the initial visit, all joint restrictions were adjusted with chiropractic manipulation.

 Retest:

In between each of these previously mentioned interventions, we revisited the functional and painful audits established in the initial exam finding that these exercises improved his ankle range of motion and decreased painful sensations originally elicited with inversion and palpation.

 Diagnosis and Recommendations:

With these objective and subjective findings, we diagnosed Ryan with a grade I-II sprain of his anterior talofibular ligament (ATFL). This ligament is one of the most commonly sprained ligaments when it comes to abrupt ankle inversion moments as Ryan experienced running down the stairs. Oftentimes, runners will undergo rapid, forceful ankle inversion when they step awkwardly onto a rock or root while running along an uneven trail surface. Whether this range of motion is truly limited or the runner is simply not accustomed to navigating this end range of motion, circumstances like these can damage the integrity of the lateral ligaments in the ankle. 

 However, just because these ligaments have been sprained, this does not mean Ryan should discontinue running. For many runners, the benefits of this daily activity are more than just physical. Social interaction is an innate human desire that many runners supply with group runs and/or training partners. Allowing Ryan to continue running while working on his ankle is the best course of action as I was confident we would not be doing further damage by continuing to train. The caveat being he was advised to steer clear of technical trials for the next few weeks and be diligent with the exercises prescribed to reduce pain, increase motor coordination, and reduce joint restrictions that could contribute to future recurrences. 

 Progress:

Over the course of 5 visits in roughly a 3-week period, Ryan slowly progressed his daily runs from 4 miles to around 6 miles with a long run up from 8 to 10 miles. The running surface was also altered to include some flat gravel routes and eventually more technical trails. In terms of rehab exercise progressions, we incorporated single-leg stabilization drills including 4-point touches, ankle pendulums, and triplanar lunges with a slide plate, low oblique sit to improve hip internal rotation and stability, and plyometric drills in the frontal plane to buttress his ankles against future interactions with uneven surfaces.

 If you or anyone you know has dealt with an acute ankle sprain or recurrent chronic ankle instability, give us a call or schedule online at your convenience!