For others, their sprains are frequent, more severe and seem to occur randomly. Sometimes, the sprain can happen even when standing still! In the medical world this pattern of sprains is known as chronic ankle instability...
PART 1: Understanding Ankle Sprains
Almost any athlete, weekend warrior, dancer, or lover of the highest of heels has experienced an ankle sprain. Most of the time, the sprain was a result of a quick change in movement, poor footing, or stepping on something unstable. For many mild sprains, recovery can occur with a simple protocol of rest, ice, compression, elevation and slowly returning to normal activities.
For others, their sprains are frequent, more severe and seem to occur randomly. Sometimes, the sprain can happen even when standing still! In the medical world this pattern of sprains is known as chronic ankle instability (CAI, for short). CAI can be a frustrating condition, making individuals feel debilitated, fearful of re-injury, and less active as a result. Unless the root of the problem is addressed, the risk of continued sprains remains very high.
So, what are the common problems that need to be addressed? CAI is caused by a mixture of poor ability to sense where the foot is at in space, weakness in the foot and calf, and a lack of mobility in the ankle.
With all due respect to M. Night Shyamalan, all humans possess a sixth sense (and others). Proprioception is a special sense that allows your brain to detect where each part of your body is at in space. When you close your eyes, you still know where your arms, legs, and torso are located. Using this sensory information, you brain can make subtle adjustments to make sure you remain standing. However, in individuals with CAI, many studies have shown their proprioception is not as sharp. As a result, their brain may interpret that their ankle is flat on the ground vs twisted and not have an appropriate corrective muscle response to stabilize their ankle. A simple way to test this is to stand with your feet together, arms folded across your chest, and eyes open. Hold this for 30 seconds. Easy? Next, stand the same way, but close your eyes. Most individuals can hold this position for 30 seconds. If you can’t, your proprioception may be lacking.
It makes sense that weak muscles in your calf can make sprains more frequent. But, weakness in the foot and hip can also decrease your ability to keep your leg and ankle steady. Weakness in the foot can cause your foot to collapse and less able to adapt to uneven surfaces. Hip weakness can cause your leg to rotate too much, collapse and place too much weight on your healing ankle.
Even though it may seem paradoxical, CAI is usually made worse by stiffness in your ankle joint. Due to frequent swelling, lack of motion, and abnormal movement patterns, the ankle joint capsule may become stiff. Stiff joints are less able to adapt and absorb shock and place too much pressure on surrounding ligaments. A good way to test this is with the front lunge test. To do this, simply stand in a lunge with your foot near a wall. Start with your unaffected foot forward. Lean your knee forward and try to touch the wall with your knee without your heel leaving the ground. Move your foot further or closer to the wall until you find the point where the knee just barely touches the wall without your heel lifting. Make a mark on the floor where your big toe was, and repeat this with the affected foot forward. If you notice a difference between sides, your ankle may be stiff.
* There are 7 fundamental senses: Smell, Touch, Taste, Hearing, Sight, Balance, and Movement. The Eighth Sense is a terrible title for a movie.
Part 2: How to Manage, Improve, and Prevent Chronic Ankle Instability
If you read Part 1 of my blog post on Chronic Ankle Instability, you may have found some deficits in your balance, joint mobility and weakness in your calves and feet (if you didn’t read it, check it out here). Please note, this blog post assumes that your ankle is not recently injured and still in the initial stages of healing: think swollen, painful, discolored and highly unstable.
For those readers who found deficits in their balance, a progressive balance program supervised by a physical therapist can help you improve your stability. The best way to retrain your proprioception is to mess with your other senses that keep you in balance, and to progress from stable surfaces to soft, unstable surfaces. The foundation of a good balance program is challenging the right sensory system. In this case, we want to focus on taking away the visual system. So, the vast majority of the training will require closing your eyes. Make sure you are standing next to something to hold onto (if needed) for safety. Stand with feet together, heel-to-toe stance, and on one leg with your eyes closed. Try to hold them for up to 30 seconds. Once you can easily do that, consider standing on a pillow and completing the same exercises. The pillow will make you unstable, and help to train the speed and timing of your muscles to ensure they are able to make the quick, subtle adjustments needed for stability.
To make your calves and feet stronger, I always recommend making sure your muscles are ready for activity. Start with a gastroc and plantar fascia release to make sure your muscles are primed for exercise. Sit on the floor with your legs extended in front of you. Using a lacrosse ball or foam roller, place firm pressure on your calf muscle and move your ankle up and down. Repeat for 30-60 seconds on any areas that feel tight. Next, stand up and place your barefoot on a lacrosse ball. Place firm pressure on the ball, and move your toes up and down, and continue as you did with your calf. (Calf Gastroc Soleus Release), (Plantar Fascia Release)
Now that your muscles are in the correct position to work efficiently, try these two exercises. First, stand with barefeet and try to make your arch higher. Pull your toes back without curling them. Think of making your feet look like suction cups. Next, perform a three-way calf raise to target each portion of your calf muscle. Perform 10-15 reps of heel raises with feet pointed straight, in and out.
Lastly, a good ankle program should focus on restoring mobility. Research has shown that this can have significant effect on helping with recovery, prevention and improving mobility. A PT can assist you to restore your mobility with manual therapy and exercise. Using a firm band to complete a mobilization with movement can help increase your ankle range of motion. Place the band around a stable surface and place the other end right over your ankle with the band pulling back. Place that foot forward in a lunge position. Lunge your knee forward, keeping your heel down. The band should be pulling pretty hard backwards as your knee goes forward. Repeat this 30 times. (Ankle Joint MWM)
If your ankle continues to be a frequent problem, see a physical therapist. A good PT program can help direct, progress and correct your impairments that are causing frequent ankle sprains. In the event you sustain a sprain, see a medical professional and a PT to get good treatment that can help the injury from becoming a chronic problem. And lastly, know that with a disciplined approach, your ankle stability can improve and sprains can become a thing of the past.
*Dr. Dustin Jesberger, PT, DPT is a Cleveland native and die-hard Cleveland sports fan. He periodically remembers the days when Steph Curry had frequent ankle sprains. He clearly has addressed his underlying impairments. In addition, he’s happy Steph found more stability through the addition of a Kevin Durant to a 73-win team.*
Olmsted LC, Carcia CR, Hertel J, Shultz SJ. Efficacy of the Star Excursion Balance Tests in Detecting Reach Deficits in Subjects With Chronic Ankle Instability. Journal of Athletic Training. 2002;37(4):501-506.
Robroy L. Martin, Todd E. Davenport, Stephen Paulseth, Dane K. Wukich, Joseph J. Godges. (2013) Ankle Stability and Movement Coordination Impairments: Ankle Ligament Sprains. Journal of Orthopaedic & Sports Physical Therapy 43:9, A1-A40.
Sheri A. Hale, Jay Hertel, Lauren C. Olmsted-Kramer. (2007) The Effect of a 4-Week Comprehensive Rehabilitation Program on Postural Control and Lower Extremity Function in Individuals With Chronic Ankle Instability. Journal of Orthopaedic & Sports Physical Therapy 37:6, 303-311.