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 PREVENTITIVE measures.
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 as baseline.
The goals for any 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 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 grade of 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). Optimal rehabilitation will DECREASE time to reach baseline and has shown to reduce 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.
This series 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 for 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!
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 acute ankle sprain, you can hold the stretch for 30-60 seconds at 2 sets, 1X/day. Once range of motion is achieved and swelling/pain are under control, you can begin a strengthening routine, which will be discussed in the next post.