Ankle sprains are the most common injury in sports and physical activity, estimating to be about 25% of all injuries across sports. Of all ankle injuries, 85% involve the lateral ankle ligaments. There is strong evidence suggesting you increase risk of re-spraining your ankle two fold within the first year of spraining your ankle. Every year in the US, lateral ankle sprain affects 2.15 of every 1,000 people which results in $2 billion of healthcare costs. (Waterman, Owens, Zacchili, & Belmont, 2010). All these costs are primarily from non-invasive treatment. We know that athletes today benefit from the BEST available rehab techniques and here is a statistic that proves my point: in the NBA there are approximately 100 ankle sprains per season, and in the last 11 years there have only been 4 that require surgical intervention. With high incidence of ankle sprains and the associated economic burden/negative chronic consequences, this calls for Preventative measures.
This article will address a few ways to both Prevent and Rehabilitate the commonly seen ankle sprain by allowing the optimal balance between mobility and stability.
Prehab With Ankle Disc Training
It has been shown that postural control deficits are a huge risk factor for lateral ankle sprain (McGuine et al. 2000). How do we improve this? By improving neuromuscular control/proprioception! PROPRIOCEPTION is a form of kinesthetic awareness whereby you know and understand where your body is placed in 3-dimensional space.
Often times I see people focus excessively on improving mobility in their ankles with thoughts that it will decrease their risk of injury. However, mobility without adequate stability will lead you down a painful road. Ankle disk training will improve your joint’s ability to detect where you are in space and improve reaction time, which will translate into improved postural stability by correcting excessive ankle motion. It is imperative to correct excessive motion because it may lead to excessive reliance on passive structures, such as ligaments, for stability, which could lead to a sprain.
Stabilizing the ankle joint will strengthen your body’s natural intrinsic brace, engaging and utilizing your own muscles. There is some evidence out there that suggests new shoes, bracing, and taping will help prevent ankle injuries. However, Neuromuscular/proprioceptive/balance training has been shown to be MOST effective in preventing ankle injuries.
Here I demonstrate using the ankle disc in order of difficulty:
-First, both feet are on the ankle disc.
-Then I progress to balancing on the disc with one foot at a time.
-Next, I balance with both feet on the disc as I use a medicine ball to challenge my balance
-I then progress to unilateral stability using the medicine ball
-To challenge yourself, even more, you can toss the medicine ball from one side to the other.
The goal of balance training is to develop proprioception/neuromuscular control so that your ankle will improve its muscle reflex activation, leading to more control and protection!
Ankle Sprain Correlates to Poor Balance
Ligaments are passive structures and are meant to keep joints from moving excessively. When a ligament is sprained, proprioception is often impaired, which may result in instability due to damage of the mechanoreceptors within the ligaments. (Solomononow, 2006). Without intervention, the primary re-injury window is over a 1-2 year period post-injury until the individual is back at baseline.
The goals for an acute ankle sprain rehab program should include decreased swelling, pain, and initial inflammatory response while making sure to not be overly aggressive to prevent secondary inflammation. This is why the first 5 days post-sprain are typically focused on the protection of the injured tissue. It is not until days 6-42 when protected stress may be applied (many factors go into this, such as the grade of a sprain). The remainder of this series will show an evidence-based ankle sprain rehabilitation program including ROM, strengthening, and proprioception.
Ankle sprains come in different packages: grade 1 (mild), grade 2 (moderate/partial tear), and grade 3 (severe/complete tear). It is VERY important to see a local skilled physical therapist to make an activity specific rehab program with proper parameters and to know when it’s appropriate to progress/regress exercises based on tissue health. Optimal rehabilitation will DECREASE time to reach baseline and has shown to reduce the recurrence of ankle sprains by approximately 50%.
NOTE: Plantarflexion and inversion is the most common position that individuals fall into when they sprain their ankle. The ATFL (anterior talofibular ligament) is the first ligament that is stressed in this position and is thus the most common ankle ligament to be strained. The ATFL is arguably the most commonly sprained ligament in the body.
Stretching into Dorsiflexion
Prolonged immobilization is a common treatment error with ankle sprains. As mentioned before, while inflammation often interferes with mobility, the balance between mobility and stability is KEY.
Demonstrated here is a passive stretch into dorsiflexion in a non-weight bearing position that can be implemented within 48-72 hours after injury. First I demonstrate this stretch with the knee in extension, which biases the gastrocnemius. Next, the knee is put in a flexed position, which biases the soleus, due to the gastrocnemius being put on slack.
Once weight bearing is tolerable, it is appropriate to progress to a more aggressive stretch like the one shown here. The slant will bias your foot into dorsiflexion. The same idea is applied here as when the foot is on flat ground: with knee extension, you will primarily stretch the gastrocnemius. During knee flexion, you will primarily stretch the soleus.
Parameters here include a pain-free stretch of 15-30 seconds for 10 sets, 3-5 X/day after an ankle sprain. However, if you are an individual simply attempting to gain dorsiflexion range of motion without a history of an acute ankle sprain, you can hold the stretch for 30-60 seconds at 2 sets, 1X/day. Once the range of motion is achieved and swelling/pain are under control, you can begin a strengthening routine, which will be discussed in the next few posts.
Check out this free barefoot running program to improve the core of your foot!
Non-Weightbearing Eversion Strengthening
Adequate ankle strength is necessary for stability, which allows normal movement patterns. Regaining this strength is also thought to be important for preventing future ligamentous injuries.
Some studies have shown eversion- (pushing foot outward, away from midline) to-inversion (bringing your foot inward, towards midline) strength ratios are often different in subjects with ankle instability when compared to subjects without a history of ankle injuries. While there is some contradicting evidence on which side is often impaired post ankle sprain, it seems like the majority of evidence suggests an emphasis on strengthening the ankle-evertor muscles such as the peroneals (which are plantarflexors and evertors of the ankle joint), as weakness here has to lead to a recurrence of ankle sprains.
The peroneals are weak after an ankle sprain because the mechanism of injury into inversion induces overstretching of the passive structures such ligaments as well as the active structures such as muscles (e.g. the peroneals – the muscles on the lateral side of your lower leg). When these muscles get overstretched—just like any other structure—they become weakened.
Both exercises shown here demonstrate non-weight bearing positions to strengthen the peroneals.
The second exercise will bias the peroneals more due to the active plantarflexion component of the ankle during the eversion.
Note: Eversion strength has also been shown to help support/stabilize the ankle.
Note: It has been shown to be more effective when these exercises are performed with clinician assisted manual resistance. This is because some individuals will be able to perform 100 repetitions and still not feel fatigue in the targeted muscle.
Non-Weight Bearing Stability
Alternative to ankle pumps shown here are 2 multi-dimensional non weight bearing exercises for the ankle post-sprain.
First is with the use of a soccer ball, a very unstable surface which requires high demand of proprioception/balance. I go through motions in multiple planes to end ranges, which will additionally work on improving ankle mobility as the swelling is subsiding.
Note: you may use some mobility from your hip joint, however for the intended purposes of this video, focus on controlling the movement at your ankle/foot.
The Second exercise is shown with the very simple platform of a wobble board. Here I work in all three planes sagittal, frontal, and transverse; in which you will shift your weight until the disc’s edge barely touches the floor.
Parameters post ankle sprain typically include 5-10 repetitions for 2-3 X/day
Both of these exercises are great because they work on mobility and proprioception of the ankle in multiple planes.
Note: The data demonstrates that wobble board training can improve discrimination of discrete ankle movements, especially with the ankle moving into inversion which is key to prevent another ankle injury from occurring.
Weight-bearing Eversion Strengthening
Here are some appropriate exercises for when an individual is fully weight bearing free of pain and unrestricted.
Balance is commonly impaired post ankle sprain, (first observed by Freeman et al) with reduced time in single leg stance when compared to the uninjured leg. Authors Glencross and Thornoton found a deficit in ankle position/proprioception to be associated with a history of ankle sprains, which results in a delay of activation of muscles across the ankle joint—especially the evertors. This results in a FAILURE to re-correct excessive ankle position. This decreased sensory input from the joint receptors puts you at great risk to RE-INJURE your ankle. The type of training shown here will improve your joint’s proprioception and reaction time, which will translate into improved postural stability.
For the First exercise, find a good resistance then stand on the foot you desire to train. To progress this exercise, stand on your toes, as this will increase peroneal activation. This increased peroneal activation occurs for 2 reasons. 1) Peroneals are a plantarflexor and evertor of the ankle and going up on your toes requires plantarflexion strength. 2) Going on your toes will decrease your base of support, thus increasing demand of all ankle stabilizers, peroneals included. The second exercise I use a wobble board both bilaterally and unilaterally in multiple planes.
Note: This type of training will target the underlying impairments by re-establishing and strengthening the ankle’s ligamentous and muscular protective reflexes.
Return to Sport Ankle Stabilizing
Athletes must return to pre-injury levels of strength and motor control to reduce future risk of injury. Quick support drills, dynamic landings, and cutting drills are examples of exercises that demand high levels of ankle proprioception, similar to the demands of the sports they want to return back to.
Here are multiple ways in which you can improve proprioception of the ankle:
First I perform a forward lunge onto the center of the blue side of the bosu ball.
Then I begin to step slightly lateral of midline. This will increase demand of my evertors. Be very careful not to deviate too far from midline. The last thing you want to do is give yourself another ankle sprain! -Then I train my ankle in another plane, the frontal plane, which is is done by performing a lateral step onto the bosu ball.
The final exercise here is jumping onto the bosu ball. Notice how I begin very close to the bosu ball. With each repetition I start to increase my jump distance and velocity, which will increase the demand of my ankle stabilizers to stick the landing.
A common mistake is a lack of variability and challenge for the individual. Make sure to vary the speed and intensity of this exercise to keep it challenging.
- “immobilization for acute ankle sprain: a systematic review.” By: Kerkhoffs et al.
- “Optimising ankle sprain prevention: a critical review and practical appraisal of the literature” By: Verhagen.
- “The effect of ankle disk training on muscle reaction time in subject with a history of ankle sprain” by: Osborne et al.
- “epidemiology of lower extremity injuries among U.S high school athletes” By: Fernandez et al.
- Starkey C. Injuries and Illnesses in the National Basketball Association: A 10-Year Perspective. J Athl Train 2000; 35: 161-16
- “Invertor vs. evertor peak torque and power deficiencies associated with lateral ankle ligament injury” by: Wilkerson et al.
- A Prospective study of ankle injury risk factors” by: Baumhaeuer et al.
- “Rehabilitation of ligamentous ankle injuries: a review of recent studies.” Zoch et al.
- “Wobble board (ankle disc) training effects on the discrimination of inversion movement” By: Waddington et al.
- “Chronic lateral instability of the ankle in athletes” By: Karlsson et al.
- “The role of proprioception in chronic ankle instability” By: Lephart et al.