Ankle Sprains and Benefits of Dry Needling and Other Manual Therapy Techniques with Physical Therapy for Rehabilitation

By Cody De La Mater, PT, DPT, FAAOMPT, Dip. Osteopractic, Cert. DN/SMT/VCS

As a former athlete and being a sports-based physical therapist I have experienced both as patient and clinician with ankle sprains on many occasions. I remember suffering a very bad left lateral ankle sprain (LAS) as a college linebacker blitzing the outside edge during a scrimmage that I do not believe I have ever fully recovered from. Among physically active people the most common injury to the body is an ankle sprain with a very high likelihood of recurrence.^1-5 If an individual excessively sprains their ankle it can lead to a more serious condition known as chronic ankle instability (CAI) with chronic pain and lingering symptoms.^5-6 Of course this can lead to difficulty returning to sport/recreational activity but also effecting the individual for the rest of their lives.^2,7 With these debilitating injuries it can lead overtime to develop a more sedentary lifestyle for people due to fear avoidance behavior as well as lack of ability to return to more dynamic activities.^8-9 In addition to a lesser quality of life, CAI is a large contributor to the development of posttraumatic ankle osteoarthritis.^10-11 LAS are the most frequent with a gender bias towards females compared to males, with the most prevalent age range to get an ankle sprain being between 18-25 years old for males and females alike.⁸ After receiving an ankle sprain there are two types of ankle dysfunctions that may occur: mechanical and functional instability.^12-14 Mechanical instability refers to joint laxity from a pathological standpoint whereas functional instability has “sensorimotor, or neuromuscular, deficits that accompany ligamentous injury.”¹² 

The most widely used and accepted theory on ankle instability and sensorimotor deficits for many years stems from Freeman and colleagues in the 1960s with their theory of articular deafferentation which during a sprain of ligamentous tissue also damages the mechanoreceptors within that tissue. This in turn alters the feedback loop to the central nervous system (CNS) and causes a lack of response to muscles and allows for a lack of proprioception leading to recurrent ankle sprains and ankle weakness.¹² This theory has faults and should be more evaluated in the future as additional testing by other scientists have failed to consistently recreate the results of lack of proprioception and postural control with anesthetizing lateral ankle ligaments and the entire foot.^15-17 There is clear sensorimotor deficits after an ankle sprain an in the acute stage may just be as a result of ligamentous structural integrity loss, swelling, and pain.¹² In the chronic stage proprioception seems to be effected still even after pain and edema are absent which leads to the development of CAI.¹²

Interventions that have shown promise in the rehabilitation of ankle sprains vary on the type of ankle sprain, comorbidities, as well as stage of healing. Strength training¹⁸ and postural control training^19-22 have shown benefit at various stages of healing from ankle sprains but may not help heal the ankle fully if there is muscle inhibition as a result from spinal level adaptations.”¹² Another intervention for ankle sprain rehabilitation and to help with CAI is dry needling (DN).^23-27 If you are unfamiliar on dry needling, it is the insertion and manipulation of a monofilament needle into “muscles, ligaments, tendons, subcutaneous fascia, scar tissue, peripheral nerves, and neurovascular bundles for the management of a variety of neuromusculoskeletal pain syndromes.”²⁸ DN can be used on multiple tissues as well as myofascial trigger points to alleviate pain and to help reset neuromuscular junctions.²⁹ In the Dry Needling Equilibrium Theory, improvements in the sensorimotor system are elicited through muscular mechanistic changes that the monofilament needles produce in the tissue.³⁰ In a study by Mullins et al 2020, DN to the fibularis (peroneus) longus produced “immediate, short term improvements in postural control in individual with CAI” after a single treatment to latent trigger points.³⁰ Another study by Salom-Moreno et al. found similar findings when performing DN on the same muscle for treating CAI.²⁴ When talking about pain management, DN has been shown to activate pain-inhibitory pathways resulting in overall increase in pain tolerance and perceived pain.²⁷ Rossi et al. in 2017 conducted a randomized controlled trial which demonstrated significant improvements in strength and balance with peripheral DN for individuals suffering from lateral ankle sprains.²⁶  Another benefit for DN, especially in athletes, is that it helps to speed up the recovery process and decrease muscle soreness attributed to strenuous activity.²⁵

The literature suggests high amounts of evidence to propose it for treatment of anyone suffering from ankle sprains as well as other etiologies. The benefits outweigh the risks involved and can help to reduce the overall cost to the healthcare system by effectively treating the problems at hand with the most effective and efficient treatment. As a practicing clinician I am thrilled to be able to put these ideas and treatments into practice for my upcoming athletes and hope to help reduce the risk of reinjury for my ankle sprainers as well as do some self-treatment for my own CAI.

References:

1.      Herzog MM, Kerr ZY, Marshall SW, et al. Epidemiology of Ankle Sprains and Chronic Ankle Instability. Journal of Athletic Training. 2019;54(6):603-610. doi:https://doi.org/10.4085/1062-6050-447-17

2.      Waterman CBR, Owens MBD, Davey CS, et al. The Epidemiology of Ankle Sprains in the United States. The Journal of Bone and Joint Surgery-American Volume. 2010;92(13):2279-2284. doi:https://doi.org/10.2106/jbjs.i.01537

3.      Cumps E, Verhagen E, Meeusen R. Prospective epidemiological study of basketball injuries during one competitive season: ankle sprains and overuse knee injuries. J Sports Sci Med. 2007;6(2):204-211.

4.      Fong DTP, Hong Y, Chan LK, Yung PSH, Chan KM. A Systematic Review on Ankle Injury and Ankle Sprain in Sports. Sports Medicine. 2007;37(1):73-94.

5.      Roos KG, Kerr ZY, Mauntel TC, Djoko A, Dompier TP, Wikstrom EA. The Epidemiology of Lateral Ligament Complex Ankle Sprains in National Collegiate Athletic Association Sports. The American Journal of Sports Medicine. 2016;45(1):201-209. doi:https://doi.org/10.1177/0363546516660980

6.      Attenborough AS, Hiller CE, Smith RM, Stuelcken M, Greene A, Sinclair PJ. Chronic Ankle Instability in Sporting Populations. Sports Medicine. 2014;44(11):1545-1556. doi:https://doi.org/10.1007/s40279-014-0218-2

7.      Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot & Ankle International. 1998;19(10):653-660. doi:https://doi.org/10.1177/107110079801901002

8.      Shah S, Thomas AC, Noone JM, et al. Incidence and Cost of Ankle Sprains in United States Emergency Departments. Sports Health: A Multidisciplinary Approach. 2016;8(6):547-552. doi:https://doi.org/10.1177/1941738116659639

9.      Verhagen RAW, de Keizer G, van Dijk CN. Long-term follow-up of inversion trauma of the ankle. Archives of Orthopaedic and Trauma Surgery. 1995;114(2):92-96. doi:https://doi.org/10.1007/bf00422833

10.   Valderrabano V, Hintermann B, Horisberger M, Fung TS. Ligamentous Posttraumatic Ankle Osteoarthritis. The American Journal of Sports Medicine. 2006;34(4):612-620. doi:https://doi.org/10.1177/0363546505281813

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11.   Hirose K, Murakami G, Minowa T, et al. Lateral ligament injury of the ankle and associated articular cartilage degeneration in the talocrural joint: anatomic study using elderly cadavers. Journal of Orthopaedic Science: Official Journal of the Japanese Orthopaedic Association. 2004;9(1):37-43. doi:https://doi.org/10.1007/s00776-003-0732-9

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12.   Hertel J. Sensorimotor Deficits with Ankle Sprains and Chronic Ankle Instability. Clinics in Sports Medicine. 2008;27(3):353-370. doi:https://doi.org/10.1016/j.csm.2008.03.006

13.   Hertel J. Functional Instability Following Lateral Ankle Sprain. Sports Medicine. 2002;29(5):361-371. doi:https://doi.org/10.2165/00007256-200029050-00005

14.   Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train 2002;37:364

15.   Konradsen L, Ravn J, Sorensen A. Proprioception at the ankle: the effect of anaesthetic blockade of ligament receptors. The Journal of Bone and Joint Surgery British volume. 1993;75-B(3):433-436. doi:https://doi.org/10.1302/0301-620x.75b3.8496215

16.   Hertel JN, Guskiewicz KM, Kahler DM, Perrin DH. Effect of Lateral Ankle Joint Anesthesia on Center of Balance, Postural Sway, and Joint Position Sense. Journal of Sport Rehabilitation. 1996;5(2):111-119. doi:https://doi.org/10.1123/jsr.5.2.111

17.   Feuerbach JW, Grabiner MD, Koh TJ, Weiker GG. Effect of an Ankle Orthosis and Ankle Ligament Anesthesia on Ankle Joint Proprioception. The American Journal of Sports Medicine. 1994;22(2):223-229. doi:https://doi.org/10.1177/036354659402200212

18.   Docherty CL, Moore JH, Arnold BL. Effects of strength training on strength development and joint position sense in functionally unstable ankles. J Athl Train 1998;33(4):310–4.

19.   Holme E, Magnusson SP, Becher K, Bieler T, Aagaard P, Kjaer M. The effect of supervised rehabilitation on strength, postural sway, position sense and re-injury risk after acute ankle ligament sprain. Scandinavian Journal of Medicine & Science in Sports. 2007;9(2):104-109. doi:https://doi.org/10.1111/j.1600-0838.1999.tb00217.x

20.   Wester JU, Jespersen SM, Nielsen KD, Neumann L. Wobble Board Training After Partial Sprains of the Lateral Ligaments of the Ankle: A Prospective Randomized Study. Journal of Orthopaedic & Sports Physical Therapy. 1996;23(5):332-336. doi:https://doi.org/10.2519/jospt.1996.23.5.332

21.   Verhagen E, van der Beek A, Twisk J, Bouter L, Bahr R, van Mechelen W. The Effect of a Proprioceptive Balance Board Training Program for the Prevention of Ankle Sprains. The American Journal of Sports Medicine. 2004;32(6):1385-1393. doi:https://doi.org/10.1177/0363546503262177

22.   McGuine TA, Keene JS. The Effect of a Balance Training Program on the Risk of Ankle Sprains in High School Athletes. The American Journal of Sports Medicine. 2006;34(7):1103-1111. doi:https://doi.org/10.1177/0363546505284191

23.   Mansfield CJ, Vanetten L, Willy R, et al. The Effects of Needling Therapies on Muscle Force Production: A Systematic Review and Meta-analysis. Journal of Orthopaedic & Sports Physical Therapy. 2019;49(3):154-170. doi:https://doi.org/10.2519/jospt.2019.8270

24.   Salom-Moreno J, Ayuso-Casado B, Tamaral-Costa B, et al. Trigger Point Dry Needling and Proprioceptive Exercises for the Management of Chronic Ankle Instability: A Randomized Clinical Trial. Evidence-Based Complementary and Alternative Medicine. 2015;2015:1-9. doi:https://doi.org/10.1155/2015/790209

25.   Tang CT, Song B. Acupuncture and Dry Needling for Sports Performance and Recovery. Current Sports Medicine Reports. 2022;21(6):213-218. doi:https://doi.org/10.1249/jsr.0000000000000968

26.   Rossi A, Blaustein S, Brown J, et al. SPINAL AND PERIPHERAL DRY NEEDLING VERSUS PERIPHERAL DRY NEEDLING ALONE AMONG INDIVIDUALS WITH A HISTORY OF LATERAL ANKLE SPRAIN: A RANDOMIZED CONTROLLED TRIAL. International Journal of Sports Physical Therapy. 2017;12(7):1034-1047. doi:https://doi.org/10.26603/ijspt20171034

27.   Luan L, Zhu M, Adams R, et al. Effects of acupuncture or similar needling therapy on pain, proprioception, balance, and self-reported function in individuals with chronic ankle instability: A systematic review and meta-analysis. Complementary Therapies in Medicine. 2023;77:102983. doi:https://doi.org/10.1016/j.ctim.2023.102983

28.   Dunning J, Butts R, Mourad F, Young I, Flannagan S, Perreault T. Dry needling: a literature review with implications for clinical practice guidelines. Physical Therapy Reviews. 2014;19(4):252-265. doi:https://doi.org/10.1179/108331913x13844245102034

29.   Boyles R, Fowler R, Ramsey D, Burrows E. Effectiveness of trigger point dry needling for multiple body regions: a systematic review. Journal of Manual & Manipulative Therapy. 2015;23(5):276-293. doi:https://doi.org/10.1179/2042618615y.0000000014

30.   Mullins JF, Nitz AJ, Hoch MC. Dry needling equilibration theory: A mechanistic explanation for enhancing sensorimotor function in individuals with chronic ankle instability. Physiotherapy Theory and Practice. Published online July 16, 2019:1-10. doi:https://doi.org/10.1080/09593985.2019.1641870