Dry Needling and Chronic Ankle Injuries
Dry Needling for the Management of Chronic Ankle Injuries and Ankle Sprains
Dr. Scott A. Jones
Physical Therapist
Can Dry Needling Improve Ankle Sprains and Prevent Future Injuries?
Ankle sprains seem like they are everywhere. From football to soccer to volleyball — and even golf and ballet dancers in the performing arts — no-one is immune. There is no escape. Even worse, the number one predictor of future injury is previous injury, and this usually leads to ongoing problems for many people. Even months after the initial injury, more than 40% of patients still have moderate to severe symptoms. And for some, as many as 74%, end up with chronic ankle instability (CAI). CAI is when your ankle continues to feel unstable and might even give out on you, even after the sprain has healed. This instability can make it hard to walk or perform other activities, and it can even increase the risk of developing arthritis in the ankle later on.
To understand how to treat CAI better, researchers have been looking at both the physical (foot and ankle structure) and sensory (neurologic and motor control) problems that take root after an ankle injury. They found that besides just the physical damage to the ankle, there are also issues with how the body senses movement (sensorimotor function, also known as proprioception). These problems can stick around long after the injury has healed, leading to ongoing difficulties with stability and movement.
In the 1960s, scientists discovered that injuries significantly change the signals that the brain receives from the joints, affecting how the body knows where the ankle is and how to control movement. This disruption in the communication between the ankle and the brain can lead to problems with balance and coordination. You can think of this like a kink in the internet/information cable that allows only some of the information to get through. This can lead to a host of issues such as decreased balance, decreased strength, and even lingering pain long after the injury has supposedly healed.
There are special sensors in the ankle called muscle spindles that help the body understand where the ankle is and how it’s moving (proprioception). These sensors can get confused after an injury, sending the wrong signals or even a refusal to send signals to the brain. This confusion can lead to even more problems with stability and movement, making your ability to control movement both unpredictable and inconsistent. Look at it this way: would you drive a car if the brakes only worked some of the time and you there was no way to tell when that would be? Me either.
Another issue that can arise after an ankle injury is the development of muscular trigger points (MTrPs). These are areas of tight muscle fibers that can become sensitive and painful. People with CAI often have these trigger points, which can contribute to their ongoing symptoms. These tight muscle fibers, if they stay tight, can become painful overuse injuries due to their inability to let go and relax. And keep in mind that this is a neurologic response to injury. Many times stretching is ineffective.
Dry needling (DN) is a treatment that involves inserting thin needles into these trigger points to help relieve pain and improve muscle function. By targeting these trigger points, DN might not only help reduce pain but also improve how the muscles and joints work together, improving the sequencing and timing of when muscles are active and stabilizing versus when they are more relaxed in a supportive role — which could enhance stability and movement in people with CAI.
Researchers have proposed a theory called Dry Needling Equilibration Theory (DNET) to explain how DN might work to improve position-sense (proprioceptive) function, that is, how well you can sense the position of your ankle, in people with CAI.
According to this theory, Dry Needling helps to reset the signals between the muscles and the brain, much like rebooting your hard drive, thereby improving the body’s ability to sense movement and respond safely during athletic activity.
This improved communication has been shown in the clinic to improve balance, coordination, and overall function in people with CAI.
Understanding Chronic Ankle Instability (CAI) and Sensorimotor Plasticity
So, again, Chronic Ankle Instability (CAI) is a condition where the ankle feels unstable even after a sprain has healed. If that weren’t bad enough, this instability can not only lead to difficulties with movement but also an increased risk of developing arthritis (wear and tear on the joints). Scientists have been studying CAI to understand its causes and find effective treatments.
Neuromechanical Decoupling in CAI:
That’s a mouthful, right? You can think of neuromechanical decoupling as just a “fancy book-learnin’” way of saying the nerve (the information pathway) partially unplugs from the joint (in this case, the ankle) which robs the ankle of strength and function. Kind of like unplugging a dishwasher from its power source. Neuromechanical decoupling happens when the signals between the muscles and the brain stop talking to each other after an injury. This is a protective mechanism, and will likely ensure you avoid more activity in the body’s attempt to help prevent further injury. This can occur in people with CAI, leading to problems with sensing movement accurately. When the nerve can’t get information to the joint, and the brain can’t receive information from the nerve, it can result in issues with motor control, coordination, and balance.
Changes in Motor Control Patterns:
Patterns not parts! As you can see, focusing on the location of the injury is important, but isn’t the whole story and truthfully won’t get us very far. People with CAI often show changes in how their muscles work to control movement. This can manifest as difficulties with balance and posture. Additionally, they may experience decreased sensitivity in the nerves of the foot, which affects their ability to feel sensations like pressure or vibration.
Neuroplasticity in Proprioceptive Systems:
Neuroplasticity is another fancy book-learnin’ word for the adaptability of your nervous system. Specifically, it refers to the brain’s ability to adapt and change in response to experiences or injuries. It’s just like asking Google to re-route you when there is a traffic jam: “do we have other options? Great. Let’s try that.” In people with CAI, changes in the proprioceptive system—the system that helps us sense the position and movement of our body parts—can occur.
There are few treatments that directly target these changes in the nervous system. However, direct current (the DC in AC/DC) neurotherapy is one such treatment and is immediately available to all clients of Peak Health and Performance. If you know what “hot spots” feel like, you know what it feels like to directly target these dysfunctional neurologic patterns and begin the work of eliminating them.
Understanding Trigger Points:
Muscular Trigger Points (MTrPs) are areas of tight muscle fibers that can become sensitive and painful. These trigger points are commonly found in people with CAI and can contribute to their symptoms. The formation of MTrPs may result from muscle damage caused by injury, leading to increased muscle activity and stiffness. Additionally, this stiffening of the muscle will result in stiffening of the associated joints, leading to increased wear and tear and possibly, over time, accelerated joint degeneration.
Physiology of MTrP Genesis:
The exact cause of MTrP formation is still not fully understood, but research suggests it involves damaged motor endplates near the trigger points. These damaged endplates release excessive chemicals that lead to muscle contraction and increased sensitivity to pain. Additionally, recent evidence suggests that increased neurotransmission may play a role in the formation of MTrPs.
Consequences of MTrPs:
MTrPs can lead to chaotic muscle activation patterns, decreased muscle efficiency, and increased muscle activity. These MTrPs may also contribute to muscle fatigue and decreased strength. Additionally, MTrPs can cause stiffness within the muscle, affecting its ability to sense and respond to movement accurately. Did you get that? Think about all the times you’ve heard “we need to activate the muscles.” What if the muscle activity is already so ramped up that the muscle is functionally unable to contribute to movement? What if -downregulation- is what is necessary? That is the power of dry needling.
Effects of Ankle Injuries on Your Nervous System
Ankle injuries, particularly CAI, can have significant effects on the nervous system, causing changes at various levels. CAI leads to alterations in the nervous system, affecting both the input (afferent) and output (efferent) pathways. This failure of the central nervous system (CNS) to regulate muscle tone properly can result in issues like altered movement patterns, recurrent sprains, and even conditions like osteoarthritis, decreasing movement efficiency and increasing the risk of future injury.
Role of Dry Needling in CAI Treatment:
DN is proposed as a way to enhance the ability of muscle spindles to do their job, which is simply to sensing muscle length and respond to protect the joint. By improving the functioning of muscle spindles, DN may lead to better neurological communication pathways, resulting in better function and decreased injury risk. Movement improves, function improves, training improves, resulting in less wear and tear on the joint, and less likelihood of future injury.
Comparison with Other Therapies:
While other therapies like vibration, manipulation, and massage have shown improvements in restoring the brain-body communication pathways, DN stands out because it directly targets and reduces the activity of MTrPs, which affect the ability of the joint to protect itself. This sets dysfunctional/non-painful apart because it targets the “final common input” of the joint protection system—the muscle spindle.
In conclusion, DNET suggests that DN can improve clinical function in individuals with chronic ligament injuries like CAI by enhancing sensation input to the CNS. This improvement is achieved by rebooting the muscle spindle through Dry Needle treatment, which decreases faulty information signals and decreases muscle spasticity. Training under these improved conditions may lead to improved functional movement and athletic changes, thereby improving return to sport performance and decreasing future injury risk.
Hopefully this provides a better understanding of how the brain-body connection responds to an injury in the body’s attempt to protect from further injury. I’ve also tried to create a clearer picture and better understanding of the important role that dry-needling plays in re-establishing important brain-body connections that reduce pain, improve function, and accelerate recovery.
If you’d like more information and you’re possibly wondering if dry needling is right for you, just give us a call at 719-285-7127 or email us at [email protected].
Citations:
Needle AR, Charles B, Buz S, Farquhar WB, Thomas SJ, Rose WC, Kaminski TW 2013a Muscle spindle traffic in functionally unstable ankles during ligamentous stress. Journal of Athletic Training 48: 192–202.
Jennifer F. Mullins, Arthur J. Nitz & Matthew C. Hoch (2019): Dry needling equilibration theory: A mechanistic explanation for enhancing sensorimotor function in individuals with chronic ankle instability, Physiotherapy Theory and Practice
Al-Mahrouqi MM, MacDonald DA, Vicenzino B, Smith MD 2018 Physical impairments in adults with ankle osteoarthritis: A systematic review and meta-analysis. Journal of Orthopaedic and Sports Physical Therapy 48: 449–459.
Anandacoomarasamy A, Barnsley L 2005 Long term outcomes of inversion ankle injuries. British Journal of Sports Medicine 39: e14
Boyles R, Fowler R, Ramsey D, Burrows E 2015 Effectiveness of trigger point dry needling for multiple body regions: A systematic review. Journal of Manual and Manipulative Therapy 23: 276–293.
