Growing up I participated in both Irish Dancing and Soccer. Each requires a good deal of ankle strength and stability, neither of which I possessed. The result was chronic ankle sprains, which eventually landed me in surgery to stabilize them. Unfortunately, when I was younger, the appreciation for rehabilitation of ankle sprains was not like it is today. The incidence rate of ankle sprains is about 1 in 320 in the US, about 850,000 people, or 1 ankle sprain every minute.
Meta-analysis has revealed women and children are more at risk. Irrespective of age or gender, lateral ankle sprains are the most common, and poor rehab can lead to a greater chance of re-injury and instability. This is what happened with me, and surgery to stabilize was the only option followed up with a long course of rehab and preventative exercises I still incorporate today. With such a high rate of these injuries, MDs are focusing more on ankle rehabilitation, as studies show proper rehab can help prevent reoccurrence.
What is a lateral ankle sprain?
First let’s define sprains and strains, as these two are commonly confused. Sprains are an over stretching or tear of a ligament. Ligaments connect bones to bones, whereas tendons connect muscles to bone. It is common to confuse a sprain with a strain, which is an over stretching or tear of a tendon. The ankle has lots of ligaments helping to stabilize it. The ligaments on the outermost part of the ankle are the ones that are commonly sprained when the ankle un-expectantly turned inward, “rolling onto” the ankle. Depending on which ligaments and degree of tear, the ankle sprain is labeled: Grade I, II, III.* Grades I-II typically are not typically treated surgically; however, Grade III sprains may or may not require surgery to stabilize the ankle. The most common sprains are Grades I-II, and once swelling and range is achieved, rehabilitation overall is similar.
Within the first 15-20 minutes of injury, the ideal is to place ice on the involved area: ice for 20 minutes on and 20-40 minutes off for the first few days. Elevating the ankle to minimize swelling is also recommended. Moving the ankle in all directions in a pain free range will help blood circulation, as well as help prevent joint stiffening. Think of making the alphabet with the ankle with the knee straight and knees bent. The use of Kinesio Tape can help resolve swelling. Walking on the injured side may require physical therapy guidance to ensure the walking pattern is ideal and not compensatory, which may lead to muscles strains and re-injury. Gentle isometrics can be implemented in all directions. Those directions include, bringing the foot up, pushing the foot down, pushing the foot out to the side, pushing the foot inward, pulling up and out to the sides, pushing down and out to the sides. As swelling resolves, weight bearing and range of motion increases, a more progressive strengthening and stabilizing routine can be implemented.
The Total Gym is a great adjunct to an ankle program. The following are exercises that can be incorporated, with the exercise rationales and variations provided, so you can incorporate them according to where you are in the rehabilitation or prevention.
Squats: Both legs and One legged
Focus on foot position and arches. Place weight across the ball of the foot and heel and feel the arches lift. To help strengthen the arches, think of sliding the toes back toward the heels without curling the toes. (SEE VIDEO) When performing any weight bearing activities through the entire foot, do your best to maintain this position.
Rationale: Lower incline levels means less weight bearing force and might be used to encourage more range of motion versus strengthening. Placing your feet in varying positions on the squat stand can promote greater mobility at the ankle. Lower levels may also be recommended to help establish foot alignment and position. Higher incline levels will be placing greater force through the ankle.
Variations within the squats:
1. Use a Thera-band around the feet to help increase strengthening of the lateral (outside) ankle muscles.
2. Use a Thera-band in a cross pattern around the legs “monster band” to promote more ideal muscle activation patterns up and down the lower body.
3. Change the surface you are pushing against to allow for varied proprioceptive input. In other words, train your body to learn how accommodate to varying surfaces in safe and controlled environment. You can use a firm pillow, Airex pad or BOSU to name a few surfaces.
4. Plyometric jumps: when you start to incorporate jumping, start at a lower incline level to allow you to promote ideal landing. You want to land lightly though the ball of the foot without the foot or knee turning inward or outward. Start with focusing on landing in one spot then start to land on varying positions on the squat stand to increase agility and prepare the body for higher level sports.
Sprinter Start- Tripod
This can be done on the floor or using the squat stand. Focus here is on pushing through the ball of the foot with the heel lifted.
Rationale: Train the body for push-off through the ball of the foot, which occurs in walking and running activities.
1. Lift the knee to add more of a balance challenge.
2. Jumping allows for increasing stability and power, especially needed for higher-level activities.
Rationale: Greater weight bearing through the leg, as well as, increases balance challenge. Initially use a stable object, like a chair, for support with balance. Start with smaller ranges of motion. Remember if you have the slide distance regulator to control how far the glideboard will move, this may be a good time to use it.
Front Lunges: Face away from the tower. The leg on the floor will be experiencing the greater balance challenges.
Backward Lunges: Face the tower. The leg on the glideboard will be the one experiencing the balance challenges.
Side Lunges: Face sideways to the tower. The foot on the floor will be experiencing the balance challenges.
1. Reach forward to overhead. Reach overhead will increase the balance challenge.
2. Rotate while lunging or hold the lunge and rotate. The rotation of the upper body will challenge with lower body, especially the hip and outside of the ankle by the muscles resisting the knee driving inward or the foot collapsing inward or rolling outward.
Rationale: Stretching the entire lower body is important for the ideal muscle strength, power and agility. Furthermore, the leg pulleys also enhance core strength, as one stabilizes and maintains the spine in neutral (i.e. not lifting off the glideboard) to prevent over stressing the low back.
1. Pulling Straight down with both or one leg focusing on the back of the legs.
2. Leg Circles focuses on the inner thighs.
3. Double Leg Press with feet hip distance and feet flexed (toes toward you) challenges core and coordination.
Remember ankle-strengthening programs are important for returning to your everyday activities and preventing the chance of re-injury. These exercises can be performed as one routine or infused into total body routines. Reps may be 8-12 or for 45-60 seconds with varying tempos between sets or routines. For instance one day you might focus in on slow squats for 45 seconds and then one day you might perform 45 seconds of faster squats. Sets are 1-3. The idea is to prep your ankle for as many different environments as possible so you can nimble and strong.
Grades of Ankle Sprains
* Grade I is anterior talofibular ligament stretched and some fibers torn with mild swelling and loss of range of motion. Tenderness is around the anterior talofibular ligament (lateral front side of the foot). Typically one can still weight bear. No laxity/instability is noted with testing.
Grade II has moderate lateral ligamentous complex injury with typically a tear of anterior talofibular ligament and partial tear of calcaneofibular ligament. Typically there is localized swelling, bruising, and tenderness along the front side of the ankle. Upon testing, increase laxity/instability is mild to moderate. Weight bearing may be restricted.
Grade III is a complete tear of the anterior talo-fibular ligament and calcaneofibular ligament. There is moderate diffuse swelling, bruising and tenderness along the side of the ankle and heel. Weight bearing is restricted.