Back in January I had a guest post on the AFX – Ankle Foot maXimizer – Part I. This is part II where ankle sprains are discussed. This is a guest post by Timberly George, a Sport Physiotherapist (bio at the end of the article). Here’s Timberly’s post. The photos demonstrate the Ankle Foot maXimizer.
Slippery roots. Rocks. Deep puddles. Steep slopes. Momentary lack of attention to the trail and suddenly – pop! There goes your ankle. Uneven terrain, speed, fatigue, previous ankle injury, poor balance, weak foot and ankle muscles – they can all be to blame for the ankle sprain that plagues many an outdoor adventurer. In a study of 300 adventure racers 73% of them reported an injury over an 18-month period.i Ankle sprains were the most commonly reported injury.
Most of us are aware of the immediate treatment protocol for an ankle sprain, following the old acronym R.I.C.E (Rest, Ice, Compression, Elevation). Do this! It definitely helps in the initial phase of injury management. But, recovering from an ankle sprain doesn’t end there. Just because the swelling has gone down, and the pain has diminished, that doesn’t mean your ankle is ready for the trails again. Research and clinical experience shows us that a person needs to go beyond R.I.C.E. to focus on the instability of the ankle caused by the sprain, in order to prevent another sprain from occurring.ii
So what exactly is an ankle sprain?
In order to understand why you need to go beyond R.I.C.E, you need to understand what exactly happens when an ankle is sprained.
The term “sprain” refers to an injury that involves damaging a ligament. Ligaments are passive structures that connect bones to bones and help stabilize the joints. A ligament sprain can be as simple as a minor stretch or as complex as a complete disruption or tearing of the ligament fibers that give stability to a joint.
There are 3 main types of ankle sprains:iii
Inversion (lateral) ankle sprain – Over 90% of ankle sprains are inversion, making it the most common type of ankle sprain. It occurs when the foot is inverted too much, affecting the lateral side (i.e. outside) of the foot.
Eversion (medial) ankle sprain – far less common due to the strength of the medial ligaments and the mechanics of the joint. Affects the medial side (i.e. inside) of the foot.
High Ankle Sprain – An injury to the large ligaments above the ankle that join together the two long bones of the lower leg, called the tibia and fibula.
Ankle sprains can be classified in to 3 categories: iv
Grade 1: minor damage to a ligament or ligaments without instability of the affected joint. Mild swelling may be apparent but you can usually walk without too much discomfort;
Grade 2: partial tear to one or more ligaments, in which they are stretched to the point of becoming loose. Moderate swelling and some bruising are likely apparent; and,
Grade 3: complete tears of one or more ligaments, causing instability in the affected joint.Moderate to severe swelling and bruising will occur around the ankle and most people will be quite hesitant to immediately bear weight on their foot.
Once ligaments have been damaged, the ankle is left with a loss of range of motion and a mild to severe level of instability. As a result, it is more susceptible to further injury and recurrent ankle sprains are very common. Unfortunately, a ligament does not regain its ability to stabilize the joint and therefore, we are left to rely on the muscles and tendons surrounding the ankle to provide the active stability. A solid rehabilitation program guided by a physiotherapist to regain full mobility, proprioception, and a proper strengthening program is crucial to getting you back on the trails and running again with confidence.
What do you do to recover from and/or prevent an ankle injury?
To begin with, do your own R.I.C.E protocol and get some help from a physiotherapist as soon as possible.v Many people choose to “wait and see” how the ankle repairs itself with time. The trouble with that approach is most Grade 2 and 3 ankle sprains will never regain full mobility and strength on their own without assistance. Even a simple Grade 1 ankle sprain, left untreated, will likely result in another ankle sprain down the road.
Rehabilitation following an ankle sprain cannot be overemphasized. Restoring the normal mechanics and improving the stability of the ankle will allow for a return to safe activity and will decrease the risk for another sprain.ii Your physiotherapist will also be able to determine whether you may have caused other damage, outside of just ligament damage, such as a fracture or cartilage damage which may require further investigations such as x-rays or other imaging.
Once the swelling and range of motion have improved, the next step is strengthening and regaining the control, or proprioception, of the joint. Proprioception refers to our ability to sense where our joints are in space, and to be able to control them without necessarily looking. This is essential when hiking and running in trails when your ankle is constantly adjusting to the terrain of the earth beneath your feet. Proprioception is controlled by nerve receptors in the ligaments around a joint. When the ligaments are damaged in an ankle sprain, so too are the proprioceptive nerve endings. Some simple balance exercises are a good way to start. See the Balance Standing photo at the start of this post.
In order to build the active stability system around the ankle, strengthening the muscles that cross the joint is critical. There are 4 main motions that should be focused on. Your physiotherapist will assess the strength of each muscle group to determine which muscles need the most work, and to ensure balanced strength across the joint.
Strengthening can be done using resistance bands and tubes, or more preferably for many therapists recently, using the AFX-Ankle Foot maXimizer TM foot and ankle strengthening system (www.afx-online.com). The AFX allows for far more controlled and specific strengthening in more variety of planes of movement than the typical bands and tubes, as well as for more balanced strengthening across the ankle joint. The photographs shown here demonstrate the motions.
Plantar Flexion – The motion you do when going up onto your toes, or pointing your foot like a ballerina. Primarily uses your big calf muscles (gastrocnemius and soleus), but also gains assistance from some deeper calf muscles helping to control the position of the foot.
Dorsiflexion – the opposite of plantarflexion. Required for lifting the toes off the ground as you swing your leg through in running and hiking. Necessary for clearing the ground and not tripping on rocks and roots. The muscles involved cross the front of your ankle joint.
Eversion – Movement of the sole of your foot away from the midline of your body. Requires strength of the peroneal muscles running along the lateral or outside border of your calf. Strong peroneii are crucial to help prevent the ankle from rolling over, into inversion, and spraining the ankle.
Inversion – Movement of the sole of your foot towards the midline of your body, similar to the direction you would move into as your sprain your ankle in an inversion sprain. Although one might think this would be counterintuitive to strengthen, it is an important motion as the muscles that cause it to occur are crucial for the strength and stability of the arch of your foot.
A thorough ankle rehabilitation program is essential for protecting ourselves from further injury. An ankle that does not re-gain full range of motion, strength, and proprioception will learn to adapt to its new, less than ideal, way of functioning. This in turn leads to overcompensation of other muscles and an imbalance of strength and flexibility around the joint. This imbalance can not only be the cause of further ankle sprains, but potentially also the cause of overuse injuries in the feet, knees, hips and back. In addition, because we rely on our feet and ankles to take between 7,000 to 10,000 steps a day (and endurance athletes much more!) even minor strength and stability issues can lead to major problems.
But it is not all doom and gloom. The good news is that with a little bit of effort and a good rehab program you can get back on your feet, hiking and running the trails, perhaps even stronger than before.
- Fordham S, Garbutt G, Lopes P. Br J Sports Med. 2004 Jun; 38(3):300-3.
- Barr, K, Harrast, M. Phys Med Rehabil Clin N Am. 2005 (779-799)
- Brukner, P & Khan, K. Clinical Sports Medicine. 3rd edition 2007
- Brotzman, SB, & Manske RC. Clinical Orthopaedic Rehabilitation. 3rd ed 2011
- Levin, S Early mobilization speeds recovery. Physician Sportsmed 1993; 21:70-4
Timberly George’s Bio
Timberly is a Sport Physiotherapist holding a post-graduate Diploma from Sport Physiotherapy Canada and is a clinical instructor at the University of British Columbia. She is very active in the sport physiotherapy community at the regional, national, and international levels. She was Venue Medical Manager for the Richmond Olympic Oval during the Vancouver 2010 Olympic Games and is a therapist for Rugby Canada. Timberly is one of the Vancouver Sun Run’s “Ask an Expert” panel members and provides injury prevention advice to runners through the Vancouver Sun newspaper and at local running clinics throughout Vancouver. In her spare time, Timberly can often be found running the trails or riding one of her bicycles around the mountains of the North Shore and Sea to Sky corridor. Her primary areas of interest are treating sport related injuries, injury prevention and pre and post-surgical rehabilitation. *Timberly has no financial interest in AFX.