Ankle sprains are the #1 most common sports injury. I'm not surprised. Growing up playing baseball, basketball, football, lacrosse, etc I've had countless ankle sprains over the years. Here's what my typical recovery plan would be:
- ICE
- Ankle Brace
- Rest
- Calf Raises
I used that countless time and thought there was no problem with it. Now, as an adult, I have ankle flexibility limitations that not impact the way I move my body, and add stress to areas like my calves and knees and make me more prone to injury. I wish I knew then, what I know now. If you have suffered a recent, or not recent at all ankle injury, this article is for you. We'll be using the combined efforts of chiropractic, sports medicine and physical therapy exercises to help you recover your ankle while avoiding future possibilities of knee pain.
The most common ankle injury is called an 'inversion' sprain the foot tilts inward and we have the tearing of what's known as the 'Anterior Talofibular Ligament' (ATF). The purpose of this ligament is to limit side to side motion of the heel bones. As that ligament becomes deficient (think loosy goosy) after one or recurrent sprains, the foot and ankle will start to have an excessive amount of side to side motion. To counteract that excessive motion, the body will increase the tension in the other ligaments and soft tissues around the ankle (not the ATF). What I see most often is shortening and tension of the Calcaneofibular and Posterior talocalcaneal ligaments. Is it important to know those names? Absolutely not. What's important to know is that back of the ankle starts to become shortened and tightned. This leads to a forward shift of the shin bone (and talus) which leads to pinching in the front of the ankle and decreased front to back (dorsiflexion) flexibility of the foot. Now it's more difficult to squat or move without limiting the depth of squat or you'll fall down from a loss of balance. Eventually, that will lead to increased strain on the knee and eventually knee injury.
After the ankle sprains, it becomes excessively flexible from side to side and excessively limited from front to back. This will then lead to increased foot, calf and knee injury.
So how can we fix this issue?
Immediately After An Ankle Sprain
ICE vs. HEAT
These days the debate of ice vs. heat is raging on. There are sources that point to how placing ice on an acute injury helps to limit swelling, pain and, inflammation and that's it a great idea. Other sources will point to how ice limits the inflammatory process, which is the 'healing' process and so they recommend you never ice. Personally, I tell my patients to do what they have the best experience with. If iceing your ankle makes it feel better, ice it. If heat makes you feel better, heat it. Personally, when I have an injury, I don't do either.
Ankle Wraps
What I do feel is an important step to take it wrapping the ankle. Unfortunately, most people do this wrong. It's important to know that the purpose of the ankle wrap is not to support, it's blood flow. Instead of going for the familiar 'figure 8' wrap that so many people use, instead, start in the arch of the foot and wrap north, towards to knee. Also very important to note is to wrap very tightly at the foot (although not too tight, check the toenails to make sure your note starving them) and as you wrap up to the heel and shin area, wrap more and looser. We're trying to coax the excessive swelling in the foot up toward the knee and back to the heart.
Treatment of the Ankle Sprain
Chiropractic treatment utilizes Active Release Technique (ART) protocol where I release the ligaments in the back of the ankle, which will help to increase the flexibility of the ankle from front to back.
Should You Wear an Ankle Brace?
As a kid, every time I sprained my ankle I'd just get my parents to buy an ankle brace. Eventually, I just ended up wearing ankle braces on both ankles no matter what as a 'preventative' measure. Big mistake. Ankle braces, whether soft or hard, limit your front to back range of motion and contribute to the mechanical issues we discussed earlier. Now before you read this and decide, Dr. Hoar doesn't like ankle braces, cool your jets. I recommended trying to limit brace usage. Sometimes during times of uncertainty, like while playing basketball or when attempting to return to activity when you know your ankle is not 100%, then wear a brace. In the long run, try to rehabilitate your ankle completely to where you no longer need to rely on the brace.
At Home Exercises
Now I know I 'poo-pooed' the calf raises earlier but done correctly (which I was never instructed to as a kid) there is definitely some value in them. By employing 'Eccentric' Calf Raises you can help to increase your dorsiflexion range of motion and increase the stabilizing efforts contributed by the calf. Be sure not to perform the 'concentric' part of the exercise which will increase the shortening aspects of the calf and will not contribute to the rehabilitation of the calf.
Now that we've released the ankle to improve the passive flexibility of the ankle, it's time to start 're-training' your ankle to move with better flexibility. You can start in a partial weight-bearing position to really isolate that ankle.
After we've completed the half kneeling version and our ankle is starting to feel better, feel free to start using the full weight bearing version shown below. You can still add an additional range of motion by you pushing your knee forward with your hands. Don't be surprised if you feel an unpleasant pinching in the front of the ankle as you perform these, it's part of the process.
Full Weight Bearing
The Missing Link
Now that we've addressed the front to back range of motion of the ankle, it's time to address the whole body stability and control that gets really screwed up after an ankle sprain. The heel and the hips. We need to address that 'side to side' excessive motion that we mentioned earlier. There have been many studies that show the correlation that lateral weakness in the hips leads to increased risk or ankle injury. My favorite way of addressing this is through side planks. Be sure to be aware of your ankle posture during the exercises. Keep the feet neutral and dorsiflexed. Do not allow excessive side to side tilting during the exercise.
Now one important factor to remember is that we might not completely fix this issue. After 10 million ankle sprains, I still have a limited front to back flexibility. I still perform the last two exercises whenever I'm active to limit the negative contribution of my ankle towards my whole body movement. I suspect this will be the case with many of you out there. Good luck and leave a comment below to let me know how your ankle recovery goes!
References:
Wolfe MW, Uhl TL, Mattacola CG, McCluskey LC. Management of ankle sprains. Am Fam Physician. 2001;63:93-104
Ipsilateral hip abduction weakness after inversion ankle sprain. Journal of Athletic Training. 2006;41(1):74-78