Lateral ankle injuries are among the the most common injuries sustained not just in sport but in working life also. Work related causes include a poor choice of footwear while a sporting injury may be as a result of a tackle or from landing awkwardly from a jump. Lateral ankle injuries can have a re-injury rate as a high as 80%.
The primary ligaments involved in a lateral ankle sprain include the ATFL (anterior talo-fibular ligament), the CFL (calcaneal-fibular ligament) and the PTFL (posterior talo-fibular ligament). Depending on the severity of injury one or all three of this complex may be compromised following an injury.
Following an ankle injury, there can be a loss of range of motion, altered neuromuscular control and an increase in ligament laxity. These changes can increase the risk of re-injury which in turn can lead to the development of chronic ankle instability. To avoid these issues it is important that a progressive rehab program is followed to help reduce the risk of re-injury.
Range of Movement
Research has shown reduced maximal dorsiflexion (toes up) to be significantly associated with an increased risk of future lower extremity injury (Pope et al, 1998). Reduced range of movement is a common complaint following an ankle sprain and if suffiecent movement is not restored then this can lead to an increased risk of re-injury.
The knee to wall or Lunge test can be used to determine maximal dorsiflexion and can be interpreted in a couple of different ways. Scores can be calculated using a tape measure, a score of less than 10cms has been suggested to place a person at an increased risk of lower extremity injury. An alternative method of calculating a persons score is through the use of an inclinometer. The relative angle between the tibia and the ground is calculated with the inclinometer placed at the tibial tuberosity. Reported norms for this method are between 35-38degs (Konor et al, 2012).
Personally I prefer using a tape measure as it is easier to monitor for compensatory patterns peoples form as they complete the test. The video shows how I like to complete the test and also some of the compensatory (cheat) patterns commonly seen. It also can be prescribed as rehab exercise to improve ankle movement.
While it is important to strengthen the muscles at the ankle we also need to consider the impact of weakened hip muscles particularly during the gait cycle. Following an ankle injury there can be altered activation of the hip extensors (gluteal muscles) and we also know that weakened gluteal muscles may contribute to re-injury (Friel et al, 2006). The glute medius in particular works to prevent our knees from collapsing inwards which can also lead to knee pain
In the video I am using mini-bands as a simple way of progressing an exercise aimed at strengthening the muscles on the front and on the outside of the lower leg. The second exercise is a calf raise, with an increased focus on completing the movement throughout full range.
The first exercise works on the muscles that help us at heel strike as we walk while the second exercise works to strengthen the muscles that we use at the push off stage of gait.
Depending on the a clients ability there are a number of ways the glutes can be targeted, I like starting with an exercise known as the clamshell and/ or the glute bridge.
I like performing this exercise against the wall, it helps to reduce variables particularly at the hips which may affect performance. Once the client is set in the correct position their focus should just be on tempo (3-2-3) and the tactile feedback from the working muscle.
The Glute Bridge is a commonly prescribed exercise. Depending on the client the miniband can act as a cue to maintain correct alignment or as a way of progressing this exercise.
Proprioception is the body’s awareness of itself in space. This awareness is due to sensory receptors located throughout the body sending information directly to the brain. Following an ankle sprain, the sensory receptors within the joint can be injured which affects the feedback to the brain. This in turn reduces the body’s awareness of the joint leaving it vulnerable to future re-injury.
When prescribing exercises to improve this awareness I like to progress the exercises by altering the sensory input of the exercise.
Initially the focus is on maintaining the “tripod” (big toe, little toe and heel) of the foot. I find with correct cueing clients tend to struggle in maintaining a neutral foot position and their balance. I progress these types of exercises by including upper-body or lower-body movement, changing the surface or asking the client to close their eyes. The demands of each client is unique and the treatment approach has to be adopted to suit their needs.
Friel, K., McLean, N., Myers, C. and Caceres, M., 2006. Ipsilateral hip abductor weakness after inversion ankle sprain. Journal of athletic training, 41(1), p.74.
Wikstrom, E.A., Hubbard-Turner, T. and McKeon, P.O., 2013. Understanding and treating lateral ankle sprains and their consequences. Sports medicine, 43(6), pp.385-393.
Pope, R., Herbert, R. and Kirwan, J., 1998. Effects of ankle dorsiflexion range and pre-exercise calf muscle stretching on injury risk in Army recruits. Australian Journal of Physiotherapy, 44(3), pp.165-172.
Pourkazemi, F., Hiller, C., Raymond, J., Black, D., Nightingale, E. and Refshauge, K., 2016. Using Balance Tests to Discriminate Between Participants With a Recent Index Lateral Ankle Sprain and Healthy Control Participants: A Cross-Sectional Study. Journal of athletic training.
Konor M.M., Morton S., Eckerson J.M. and Grindstaff T.L., 2012. Reliability of Three measures of Ankle Dorsiflexion Range of Motion. International Journal of Sports Physical Therapy. 2012;7(3):279-287.