Chiropractic Management of Chronic Ankle Pain and Limited Mobility in a Pediatric Athlete: A Case Report

Abstract

Objective

The purpose of this case study was to report the chiropractic management of a teenage athlete who had chronic pain after a lateral ankle sprain.

Clinical Features

A 15-year-old male patient presented with persistent ankle pain due to an inversion sprain while playing soccer approximately 8.5 months prior. Emergency department records noted a left lateral ankle sprain, including the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament. The examination revealed ankle tenderness upon palpation, limited active and passive dorsiflexion range of motion, restricted talocrural joint posterior glide, and moderate lateral compartment muscular hypertonicity.

Intervention and Outcome

Chiropractic management included high-velocity, low-amplitude chiropractic ankle manipulation and education on home-based ankle dorsiflexion stretching. After 4 treatments, the athlete returned to unencumbered athletic participation. Follow-up evaluation at 5 months revealed no pain or functional complaints.

Conclusion

This teen athlete's chronic pain from a lateral ankle sprain resolved with a short course of chiropractic manipulation coupled with home-based stretching.

Introduction

Lateral ankle sprain is common in sports involving high-velocity starts, stops, and directional changes, such as soccer, football, and basketball.^{1, 2, 3} Untoward sequelae from lateral ankle sprains may prompt cessation of sports participation, especially the sport of injury, and precipitate long-term lifestyle and health consequences.⁴

Commonly accepted care for acute ankle inversion sprains includes home-based rest, ice, compression, elevation, bracing or splinting, and pain medication. As healing progresses, rehabilitative protocols, including active range of motion routines and strengthening exercises, are often implemented.^5,6 Additionally, manual therapy has been demonstrated as effective in restoring dorsiflexion.^7,8 Despite these efforts, athletes may have persistent post-sprain ankle concerns, including pain, weakness, swelling, and instability.^8,9

There is promising research demonstrating the effects of mobilization for ankle sprains.^{10, 11, 12, 13, 14, 15} However, there is scant literature on chiropractic extremity manipulation for chronic pediatric ankle sprain,^16,17 although several have been described for adults.^5,9,18 The purpose of this case study is to report the chiropractic management of a teenage athlete who had chronic symptoms due to a lateral ankle sprain.

Case Presentation

A 15-year-old male patient had an inversion sprain while playing soccer approximately 8.5 months prior to his presentation at our office. Immediately after his initial injury, his initial assessment and diagnosis were performed at a local hospital emergency room. His medical records described a left lateral ankle sprain of the anterior talofibular ligament (ATFL), calcaneofibular ligament, and posterior talofibular ligament. The radiology report of his 3-view left ankle revealed no fracture or osseous pathology. The treatment included an ankle brace, prescription of hydrocodone-acetaminophen for pain management, instruction on rest, ice, compression, elevation, and use of crutches to assist with ambulation.

The patient's left ankle soreness and limited dorsiflexion range of motion persisted; therefore, he scheduled a chiropractic examination. The patient also reported progressively worsening soreness in his left knee and hip. These complaints impaired his ability to run and to play soccer.

Examination of his left ankle revealed no swelling or bruising. Palpation revealed tenderness on the dorsolateral aspect of his left ankle at the site of the ATFL. Ankle flexion and inversion provocation were positive for pain but negative for limitation of motion. Passive inversion of the subtalar joint was negative for pain and hypermobility. Similarly, talocrural drawer test was negative for joint laxity. Active dorsiflexion range of motion of the left ankle joint was limited to 0°. Passive left ankle dorsiflexion, performed non-weight bearing utilizing a simple goniometer while maintaining toes, foot, and subtalar joint neutral position, was measured to be 0°. Normal, non–weight-bearing dorsiflexion is reported to be approximately 16.5°.¹⁹ Active and passive left ankle plantarflexion, similarly measured by goniometer in neutral position, was approximately 55°, while active and passive subtalar joint inversion and eversion were within normal limits and unremarkable.

Talocrural joint mobility was assessed with palpation of passive foot dorsiflexion and talus posterior glide (Fig 1) and was restricted. No other joint restrictions were noted. Left lateral compartment and deep posterior compartment muscular palpation revealed moderate hypertonicity of the tibialis anterior and marked hypertonicity of the tibialis posterior muscles.

Fig 1.

Talocrural palpation.

The working diagnosis was left talocrural joint dysfunction secondary to chronic ATFL sprain. Treatment included once weekly ankle manipulation for 3 to 4 weeks. The patient was educated to perform daily, self-administered active ankle joint dorsiflexion stretching.

Left talocrural joint chiropractic manipulation was administered with the patient seated on the treatment table and the left hip, knee, and ankle positioned at 90°. Chiropractic high-velocity, low amplitude (HVLA) manual manipulation was implemented using a drop table-assisted mechanism along the sagittal plane of the talocrural joint from anterior to posterior (Fig 2). After the adjustment, the patient reported pain-free, unencumbered left ankle dorsiflexion coupled with normal talus posterior glide, both equal to that of his uninjured, asymptomatic right ankle.

Fig 2.

Talocrural posterior glide manipulation.

Three additional identical treatments were administered at 1 week, 3 weeks, and 9 weeks after his initial assessment. The patient reported increased use/activity and decreased pain with each successive treatment. He resumed running and playing soccer after his first treatment. The patient was released from further care after his fourth treatment, with the expectation that his left ankle joint function required no further intervention. He was asked to return if any symptoms reoccurred.

Approximately 5 months later, this patient returned for assessment and treatment of complaints in other body regions. He noted that he had no issues or limitations with his left ankle following his final (fourth) treatment, described above. Examination of his previously injured and symptomatic left ankle revealed no positive findings of pain, joint restriction, muscle tension, or functional impairment. The patient consented to the publication of this case.

Discussion

This case study reported the findings of a teen athlete with a chronic lateral ankle sprain who had a positive response after a course of chiropractic care.

Residual complaints, such as being unable to vigorously exercise due to persistent ankle pain and limited dorsiflexion, were quantified by a prior study³ that found that 74% of athletes had at least 1 finding, including pain, swelling, weakness or instability, for 1.5 to 4 years post-sprain. As demonstrated in our case, a single administration of chiropractic ankle manipulation reduced this athlete's symptoms, allowing him to resume his athletic endeavors.

Two similar cases of restoring normal ankle function utilizing chiropractic manipulation have been reported.¹⁰ Relatedly, adding HVLA ankle manipulation to standard rehabilitation exercises in adolescent baseball players with chronic ankle instability proved beneficial.¹¹ Additionally, others¹² reported improved outcomes in the treatment of lateral ankle sprain utilizing a chiropractic mortise joint distraction technique. Their described adjustment technique, although similar, did not include the directional vectors of manipulation.

Sprain of the lateral ankle ligaments occurs when the talocrural and subtalar joints move beyond their normal physiological boundaries,^1,5,7 resulting in ligament injury. A common sequela to ankle joint injury is restricted joint mobility.^20,21 Failure to address and correct joint restrictions such as these may result in impaired joint function in the short term, as it did for this young athlete's ankle. Although various techniques of ankle manipulation have been reported as beneficial treatment options in the management of chronic lateral ankle sprains,^{9,14,22, 23, 24} this report indicates that specific chiropractic HVLA manipulation may have improved this patient's return to normal activity.

The risks associated with pediatric ankle manipulation are important to note. Review of the literature reveals no reported incidence of adverse events associated with pediatric chiropractic extremity manipulation. Spinal manipulation in pediatric patients has been described as low risk, inferring that judicious use of extremity manipulation is safe.²⁵

Further study is necessary to investigate the use of specific techniques of chiropractic HVLA manipulation with various types and degrees of ankle sprains, as well as the development of treatment protocols to define frequency and duration of the chiropractic HVLA manipulation component of care.

Limitations

This single subject case report includes the risk of overgeneralizing the outcome to other subject scenarios. Another limitation herein is the inability to establish the cause-effect relationship between treatment and outcome, as in the relationship between treatment and outcome may be coincidence. Lastly, subject or examiner bias may have skewed the reported findings.

Conclusion

Pediatric ankle sprain injuries coupled with prolonged pain and disability can deter young athletes from physical activity. This case indicates that incorporation of chiropractic ankle joint manipulation may have reduced post-sprain symptomatology and facilitated resumption of normal function and activity.