The stretch of trail at the ninth kilometer is flat, packed earth, speckled with dry leaves. A pebble the size of a fingertip lies under the leaves. Your right foot rolls inward, and a sharp pain shoots through the outer ankle bone. You sit down at the edge of the trail, still gripping your trail running pole (a pole for support when running on mountain trails). This is the third time, and the same ankle again. The first time was at a race last year, on a rocky slope. The second was on a sharp bend going downhill. This time the trail had nothing difficult about it.
The whole group stands around you. Someone says take off your shoe and have a look; someone else says stand up and try a few steps, because there are still six kilometers to go to the foot of the hill.
It is the same every time. A few days of swelling, a few weeks of pain, and then you think it has healed. People tend to blame a loose ankle, the shoes, the trail. Injury textbooks and Applied Kinesiology (AK, a way of testing the strength of each muscle by hand to read the state of the body) books look somewhere else. The ligament may have knitted back together, but the proprioceptors (small nerve endings that tell the brain the position and tension of a joint) in the ligament, the joint capsule and the muscles still carry the error from the first time. Sprain it once, and the ankle remembers for a long time. If you want it to roll less, find that error first, and only then train.
When you need an X-ray
The running group’s advice to stand up and try a few steps turns out to be close to a medical rule. The Ottawa ankle rules (Stiell and colleagues, cited in Comfort and Abrahamson; Magee and Manske) help decide whether an X-ray is needed. When the ankle area or the midfoot hurts, just one of the following signs is enough to get an X-ray:
- You cannot walk 4 steps on your own, both right after the sprain and at the time of the examination; limping still counts as walking;
- Tenderness when pressing the back edge or the tip of the outer or inner ankle bone, within the last 6 cm of the bone;
- Tenderness when pressing the base of the 5th metatarsal, the bump halfway along the outer edge of the foot, or the navicular on the inner edge.
The rules do not apply to people under 18, people who are pregnant, people who are drunk, people with several painful injuries at once, head injuries or signs of nerve damage. They were built mainly for acute, first-time injuries (Magee and Manske). For an ankle that has now rolled for the third time, counting steps is only a screening step. Cuthbert, author of an AK textbook on the lower body, classes as a severe sprain needing early examination those cases with a “pop” at the moment of the sprain, bruising that spreads quickly over the outside of the ankle and the heel, or pain in front of the inner ankle bone as well (p. 226).
Do not cover the remaining six kilometers on a painkiller either. Cuthbert is clear: do not use medication to mask the pain and keep moving (p. 228).
The swelling is gone, the balance is not back
People who keep spraining the same ankle are said to have functional ankle instability. The name makes it easy to think the joint is loose. Richie (2001), in a review that Cuthbert cites, argues that most cases are not caused by a loose joint. The deficits lie in proprioception, muscle strength, muscle reaction time and the ability to hold a posture, and in most people the root is that the nervous system has lost some of its control over the muscles. When proprioception is poor, the peroneal muscles react more slowly. Balance can be regained, but it has to be trained through the central nervous system (p. 227).
Palomar, an orthopedic surgeon who practices AK, sees the ligaments as a major source of signals telling the brain the position and tension of a joint. A torn ligament, in his view, causes two things at once. The receptors in that ligament itself lose their signal. The receptors in the tissues around the joint fire more, because the joint is less stable (Neurogait II, ICAK 2008–2009, p. 167, 174).
On a trail, these are exactly the signals that have to work hardest. Mechanoreceptors in the foot and ankle control the split-second contractions of the lower-leg muscles that keep the foot steady on uneven ground (Kavounoudias, 2001, cited in Cuthbert, p. 232).
Peroneal muscles that fire half a beat late
The peroneus longus and peroneus brevis lie on the outside of the lower leg, with tendons that curve behind the outer ankle bone. They tilt the foot outward and steady the outer side of the ankle (Walther, Synopsis, p. 333). Garten, a German AK physician, found that this group looks after side-to-side balance and fine control of the foot more than pushing the body forward. The peroneus tertius is a small muscle attached to the base of the 5th metatarsal; it steadies the back of the foot as the heel lifts (Muscle Test Handbook, p. 168, 172).
Rolling the foot inward stretches exactly this group. The peroneus longus and brevis can be injured in the sprain itself, and many repeated sprains happen because they are weak and have not fully recovered (Cuthbert, p. 22). AK calls this the peroneal muscles working below threshold, meaning they test weak. You can still run, and your calf still feels firm. But when your foot lands on the pebble, the command to hold the ankle arrives late.
Tracing three sprains backward
The AK examination waits until the tissue has healed enough for muscle testing, and at that point every muscle that crosses the ankle is tested (Cuthbert, p. 229–230). Usually the swelling in the ankle has gone down and you can walk briskly. You lie on your back with both feet hanging over the end of the table. Normally, the ridge of the shinbone, extended downward, passes through the second toe. When the peroneal group is weak, the foot tilts inward and that line falls outside the second toe (p. 21). You point your foot fully and tilt it outward, and the doctor applies force to the outer edge of the foot in the opposite direction. On the right side, the foot gradually drifts inward.
Peroneal weakness of this kind often starts from a joint out of place in the foot (p. 21). The way to check is a challenge. The doctor applies a light, directed pressure to the talus, the cuboid, and the lower ends of the shinbone and the fibula, retesting the peroneal group after each one. Garten pays special attention to the cuboid: when it is displaced outward, the peroneus tertius often falls short, and a light, directed pressure on the cuboid takes the weakness away (p. 172). The direction that makes the muscle strong again is the direction in which the joint is mobilized.
Then the doctor asks about each sprain in turn. The sprain on the sharp bend, while changing direction, points toward a reactive muscle. A muscle injured earlier, for example a tibialis anterior that tightened up after a stumble, can inhibit the peroneal group through an antagonist reflex (Cuthbert, p. 230). Tested on its own, the peroneal group is still strong. It only weakens right after the other muscle has contracted (Walther, Synopsis, p. 65).
The third time happened on flat ground, for no clear reason. This pattern points toward a ligament stretch reaction: when a ligament is stretched, the muscles of that joint weaken for a moment. AK links this to adrenal stress, and in overtrained athletes with high cortisol (a stress hormone), Cuthbert considers it may be the key to preventing recurrent sprains (p. 230–231). That is why the doctor also asks about your training schedule and your sleep in the weeks before.
The very first sprain, on the rocky slope last year, comes last. Walther notes that the ankle mortise, where the talus sits snugly between the two ankle bones, is one of the two places Schmitt’s Injury Recall Technique (IRT) uses to clear the memory of an old injury (Synopsis, p. 184). At the ankle, the injured spot and the spot that unlocks it lie on the same joint, so the test is very simple. An indicator muscle, meaning a strong muscle used as a gauge, is holding firm. You keep your hand on the ligament on the outside of the ankle, right where you sprained it last year, the doctor pushes the talus snugly into the mortise, and that muscle gives way. With only the touch, or only the push, the muscle stays firm (p. 185). The treatment goes the other way round: with your hand still on the ankle, the doctor makes a very gentle movement at the ankle, without any thrust, to reset the signal.
Any faulty signals left over are treated with Palomar’s P-DTR (Proprioceptive Deep Tendon Reflex, a technique that uses tendon reflexes to correct the sensory signals sent from muscles and joints to the brain). Through muscle testing, the doctor finds which ligaments and which muscles around the ankle are misreporting, then uses tendon reflexes to reload the signal pathway between them (Palomar, p. 13–17). At the end of the session, the peroneal group is retested. You stand on your right leg so the doctor can see whether the ankle still wobbles or sways.
In some cases the muscle still does not respond even when the right spot has been treated. Cuthbert then advises considering an injury to the peroneal nerve after a severe sprain (p. 227, 231). An ankle that stays painful beyond the usual healing time of a ligament may have a fracture of the talus (p. 226). In these cases the doctor orders imaging or refers you to a specialist.
Stand on one leg, then train
In Cuthbert’s book, the order is very clear. AK examination and correction come before proprioceptive training, because exercises work poorly while the joints of the foot and ankle are still out of place (p. 232). From the clinical experience he records, muscles that still test weak on AK testing usually respond poorly to exercise. Strength training starts once the muscles are working normally and you can walk briskly, often only a few days after recovery begins. The foundation of the training is the peroneal group and the muscles that pull the tip of the foot up, because those are what resist the foot rolling inward (p. 231).
The sign that you need proprioceptive training is a very everyday one: you are unsteady standing on one leg (p. 232). Tropp and colleagues (1985) measured stability on one leg in 127 soccer players and then followed them for a season. Those who stood less steadily had far more ankle injuries. Players who had sprained before but stood steadily had no higher risk than those who had never sprained. On this basis Cuthbert says that the English saying “once a sprain, always a sprain” is not necessarily true once function has been restored (p. 229–232).
The clinical practice guideline on ankle sprains published in the American orthopedic and sports physical therapy journal JOSPT (Martin and colleagues, 2021) makes two strong recommendations, in the same order. In the first few days, the ankle needs a brace or tape and ice, and then gradually increasing load through a structured exercise program; severe cases may need to be immobilized for up to 10 days. Later on, for an ankle that has been sprained before, a brace goes together with proprioceptive training to prevent another sprain. Which exercises, how far to progress and what type of brace all need someone to guide you in person. The clinic does not offer manual therapy or massage, so you do the exercises yourself following instructions, or we refer you to the right place.
The bottle of herbal liniment on top of the cupboard
In many homes, a twisted ankle means someone reaches for a bottle of herbal rubbing liquor or a herbal plaster. In the weeks before a drug-tested race, the kinds that contain Ma qian zi (Strychnos nux-vomica seed) are best left on the cupboard.
Traditional medicine books on injuries divide an ankle sprain into two stages. The first stage is blood stasis and qi stagnation (血瘀气滞 / 血瘀氣滯, xuè yū qì zhì), meaning blood pools and the flow of qi is blocked, with swelling, bruising and pain that gets worse with movement. The later stage is the sinews and vessels being undernourished (筋脉失养 / 筋脈失養, jīn mài shī yǎng), meaning the tendons and vessels are not nourished enough, so there is a dull ache and the leg feels weak when walking. In the first stage, the books advise raising the leg and using cold packs, and if a fracture or dislocation is suspected, getting an X-ray, which is the same idea as the Ottawa rules above. Rolling the foot inward is the most common type. Spraining again and again over a long period can lead to post-traumatic arthritis (Ji Qingshan, 纪青山, p. 223–224; Wu Shan, 吴山, p. 182–183; Acupuncture Therapeutics, 针灸治疗学 / 針灸治療學, p. 327).
If you have been examined and a fracture has been ruled out, yet the ankle is still swollen and bruised, with a pricking pain like needles that is worse at night, traditional medicine places it in the blood stasis pattern. The doctor may prescribe a short course of decoction in ready-to-drink 50 ml pouches aimed at invigorating blood and transforming stasis (活血化瘀, huó xuè huà yū; helping the blood circulate and dissolving pooled blood) and easing pain, drawing on Tao Hong Si Wu Tang (桃红四物汤 / 桃紅四物湯, Four Substances Decoction with Peach Kernel and Safflower), which Ji Qingshan uses when there is a lot of swelling (p. 224). The decoction is taken for about 6–12 days, alongside the exercises, and then stopped. This approach rests on the experience of injury practitioners; there are no comparative trials yet in people with sprains. People who are pregnant should not use this approach; people with heavy periods, a bleeding disorder, or who are taking anticoagulants or antiplatelet drugs (medicines that make the blood clot less easily) need to tell the doctor first.
When to see a doctor
If, right after a sprain, you have one of the signs in the first section, see a doctor right away. If a few weeks have passed and the ankle still hurts deep inside, is still swollen, or the foot is numb or drops, you need to be examined again (Cuthbert, p. 21–22). And if the ankle has been sprained two or more times, you still wobble standing on one leg on that side, or it rolls even on flat ground, you should book an appointment.
That day at the ninth kilometer, if you could stand up and walk four steps and pressing around the ankle bones did not hurt, the bone is most likely fine. Three rolls on the same ankle are still worth a careful look. Once the swelling has gone down, book an appointment with Dr. Dinh Ngoc Duc (MD, MSc in Traditional Medicine) and write down the three sprains beforehand: where they happened, whether going uphill or downhill, and how long before you could walk normally again. The doctor will trace back from the most recent one to the one on the rocky slope last year. Book a consultation.
Worth keeping
- After a sprain, try walking 4 steps and press around the ankle bones, the base of the 5th metatarsal and the navicular; if you cannot walk or pressing hurts, get an X-ray;
- In the first days use a brace or tape, cold packs and raise the leg, then let the ankle take gradually increasing load;
- Do not take painkillers to keep running on an ankle you have just sprained;
- Write down each sprain, which side and on what kind of ground, including ones from long ago;
- Each evening, try standing on one leg on the side you sprained, and compare it with the healthy side;
- Do balance training and wear a brace as guided by your instructor, after the muscles around the ankle have been examined;
- If you plan to use a plaster or a rub you bought yourself before a drug-tested race, ask the doctor whether it contains Ma qian zi.
References
Sources in English
- Comfort P, Abrahamson E, editors. 2010. Sports Rehabilitation and Injury Prevention. Chichester: Wiley-Blackwell. p. 192.
- Cuthbert S. 2013. Applied Kinesiology: Clinical Techniques for Lower Body Dysfunctions. Gangasas. p. 21–22, 226–232 (citing Richie 2001; Kavounoudias 2001; Tropp et al. 1985).
- Garten H. 2013. The Muscle Test Handbook: Functional Assessment, Myofascial Trigger Points and Meridian Relationships. Edinburgh: Churchill Livingstone Elsevier. p. 168–170, 172.
- Magee DJ, Manske RC. 2021. Orthopedic Physical Assessment. 7th ed. St. Louis (MO): Elsevier. p. 82, 1353.
- Martin RL, Davenport TE, Fraser JJ, Sawdon-Bea J, Carcia CR, Carroll LA, et al. 2021. Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021. J Orthop Sports Phys Ther. 51(4):CPG1-CPG80. doi:10.2519/jospt.2021.0302. PMID: 33789434.
- Palomar Lever J. 2008–2009. Neurogait II. ICAK-USA Collected Papers 2008–2009. p. 167, 174.
- Palomar Lever J. Proprioceptive-Deep Tendon Reflex (P-DTR) [introductory brochure]. p. 13–17.
- Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. 1992. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 21(4):384-90. doi:10.1016/s0196-0644(05)82656-3. PMID: 1554175 (Cited in Comfort & Abrahamson).
- Stiell IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells GA, et al. 1994. Implementation of the Ottawa ankle rules. JAMA. 271(11):827-32. PMID: 8114236 (Cited in Comfort & Abrahamson).
- Walther DS. 2000. Applied Kinesiology: Synopsis. 2nd ed. Pueblo (CO): Systems DC. p. 65, 184–185, 333.
Sources in Chinese
- 高树中, 杨骏, 主编. 针灸治疗学. 第 327 页.
- 纪青山临证拾金. 第 223–224 页.
- 吴山诊治筋伤学术思想及临证经验. 第 182–183 页.
