As The Ankle Rolls
By Candice Brueck MPT, ATC, CLT
You might be ready for the glorious fall hiking and trail running season, but are your ankles? Ankle sprains are a common trail occurrence and repetitive ankle sprains may lead to chronic instability and possible injuries to other joints. Stepping on tree roots, scree, or climbing a rocky path may be very challenging to an unstable ankle. This article will discuss factors that play a role in chronic ankle injuries.
The ankle is made up of several complex joints held together by ligaments (ligaments connect bone to bone). There are two main ligament complexes, one medial (inside), and the other lateral (outside). The medial ligament, or deltoid ligament, is thick, broad, and difficult to injure due to the bony alignment of the ankle. The lateral side of the ankle is composed of three thin ligaments, which are more easily injured. Lateral ligament injuries occur when the ankle rolls into a position of plantarflexion and inversion, in which the toes point downward and the outside of the ankle moves toward the ground. Lateral ankle sprains can occur when slipping on a rock, stepping off a curb, walking on an uneven surface, or coming down on an opponent’s foot while playing sports.
When a ligament is sprained, fibers may be torn in varying degrees, from a few torn fibers to complete severence. An acute ankle sprain causes inflammation in the joint, which may lead to altered gait, decreased strength of surrounding muscles, decreased flexibility, and poor balance. A sprain can also affect joint proprioceptors, or position sense receptors. These receptors tell our body parts where they are in space. For example, when hiking downhill through loose rock, the foot needs to be able to adapt to the unstable surface to maintain balance and not allow the ankle to roll.
Sometimes, a ligament heals in a lengthened state, which may not be strong enough to control complete motion of the joint. Repeat ankle sprains lead to increased tearing of the ligament(s) and increased scar tissue formation. Instability, or frequent giving way/rolling, of the ankle occurs when the external forces overcome the internal force the ligaments generate to keep the joint in a stable position. The surrounding muscles will try to assist the ligaments, but they are overpowered as well.
Another factor to consider with recurrent ankle sprains is weakness further up the body, which may include the back, pelvis, hip, or knee. The foot and ankle are the link to the ground and are the most adaptable segments of the lower body. The muscles that control motion of the foot and ankle may be over stressed while trying to stabilize the entire leg. Combining this with overstretched, or lax, ligaments, can easily lead to recurrent ankle sprains. Weakness of the hip muscles, particularly those that move the hip in rotation or medial/lateral, can lead to imbalances around the knee. As the knee position changes, the foot may excessively pronate or supinate as a compensation. This can lead to increased strain on the muscles that invert and evert the ankle to control foot position during gait. Subtle and or/sudden changes in terrain may not be accommodated for quickly enough, causing the ankle to give way.
Acute treatment for an ankle sprain should include RICE (rest, ice, compression, and elevation). If the injury occurs on the trail, do not take your shoe off immediately. The compression of the shoe will help control edema, or swelling, in the foot. Elevating the foot above the level of the heart will also help reduce edema. Activity should be modified depending on the severity of the sprain. Crutches and/or immobilization may be necessary if weight bearing is not tolerated. Gentle range of motion exercises, such as ankle pumps, circles, and writing the alphabet, can be started early on. As range of motion improves, strengthening and stretching exercises can be initiated. These activities may include tubing exercises, heel raises, and Achilles stretching. The importance of restoring normal gait cannot be stressed enough. Often after an ankle sprain, the foot is turned out during gait due to pain and edema. After a few days, this altered gait pattern feels normal. It would be more beneficial to walk correctly at a slower pace, thus restoring normal mechanics. Recreational activities should be resumed on a gradual basis, with pain and edema as a guide. Physician intervention may be necessary to rule out fractures or evaluate severe injuries.
Many people are familiar with stretching and strengthening to rehabilitate an ankle sprain, but often proprioception (balance awareness) is not included. A quick test of standing on one foot with the knee slightly bent is a great balance/proprioception check. Standing on one foot for 30-60 seconds without touching the other foot down demonstrates good balance. If the foot is wobbly after three to five seconds, the proprioceptors may not be up to par. Proprioception and balance are key factors in restoring ankle static and dynamic stability. Dynamic stability allows the foot and ankle to compensate for changes in position and surfaces without having to even be aware that it is occurring.
Working with a physical therapist, following an ankle sprain or long history of recurrent injury can be highly beneficial. A complete evaluation of the lower extremity, spine, and biomechanics will identify areas of weakness, muscle imbalance, or instability. A comprehensive exercise program will address all problem areas and include activities to improve dynamic stability. These may involve standing on one foot on an unstable surface (trampoline, disc like cushions, foam rollers) and agility activities.
A physical therapist may also evaluate shoes or boots for patterns of wear, overall fit, flexibility/stiffness of shoes, and arch support. Wearing proper shoes on the trail is just as important to the ankle as sufficient strength, flexibility, and balance. A physical therapist can provide information regarding the best type of shoe based on each individual. Orthotics, which can adjust or compensate for foot and ankle mechanics, may also be a consideration. Orthotics should be considered only after a course of rehabilitation, as they may not be necessary if areas of weakness or stiffness are resolved. Occasionally, ankle braces may also be prescribed.
Recurrent ankle sprains do not have to keep you off of the trails this fall. Keeping the trunk and lower extremities strong and having good dynamic stability, along with proper foot wear, will help prevent new injuries.
Candice Brueck is a physical therapist with Timberlane Physical Therapy in Winooski, VT. She is also a certified athletic trainer, who specializes in the rehabilitation of sports and orthopedic injuries. She can be reached at 864-3785 or cgbrueck@yahoo.com.