The Ankle Paradox

When Life Throws You a Twist

Six years ago as a freshmen collegiate basketball player, I suffered a temporarily disabling ankle sprain. Being 17 years old, I blindly followed everything that my athletic trainers told me. I had no idea what to do, and sadly, neither did they! It took four months to recover and return to the basketball court. Even to this day, my ankle still looks like those big Italian meatballs that my grandmother cooks.

Since then, I've studied what's going on with our ankles. It wasn't until recently that I really began to see what we were doing wrong. I work with a high school basketball team and recently two of my basketball players suffered ankle related injuries–one a broken ankle and the other a broken foot. Both injuries occurred within 48 hours of each other! That forced me to put everything I knew about the subject into practice and come up with some methods to keep our ankles healthy and our performance high.

Ankle Anatomy

The ankle joint has one degree of freedom, meaning it can only produce movement in one plane. Your ankle is a hinge joint whose actions in the sagittal plane are dorsiflexion (up) and plantarflexion (down).

With assistance from the foot, it can control inversion (turning in) and eversion (turning out) in the frontal plane, as well.

There are numerous muscles that act upon the ankle to cause movement and assist in stabilization. For our purposes, we'll only deal with the heavy hitters affecting proper ankle function.

The largest of the posterior ankle muscles is the gastrocnemius. This muscle affects both the ankle and knee joint by controlling plantarflexion and inversion at the ankle. The soleus also aids with plantarflexion, while the minor posterior muscles of the ankles all act in plantarflexion and inversion.

Our focus on the front of the leg shifts to the peroneals. The importance of the peroneus longus and peroneus brevis is that they're the only muscles that control eversion, in addition to performing plantarflexion.

The tibialis anterior acts to dorsiflex the ankle and control inversion of the foot. The tibialis anterior is often weak when compared to the larger calf muscles, so it can't effectively pull us into dorsiflexion when we attempt to land or cut.

To sum up what all of this nerd anatomy talk means, we see that our ankle is dominated by muscles that plantarflex the foot, while we only have a few muscles that resist inversion. What do the statistics tells us about the majority of ankle injuries? Survey says: Ankles are at the greatest risk of sprain during plantarflexion and inversion. (1)

Why Do We Keep Getting Hurt?

Paradox 1 – High Ankle Restriction

Somewhere along the line in the quest to improve performance, we decided that our players needed to have more and more ankle restriction. It was a knee jerk reaction; we saw more ankle injuries and came to the conclusion that higher support was necessary. The issue with high restriction is twofold.

First, we'll have almost instantaneous peroneal shutdown, since the height of the shoes provides a false sense of stability. We know that the peroneals are essential for eversion strength and provide a dynamic defense mechanism. This reaction is the body's way to limit trauma to the lateral ligament complex during ankle inversion. Follow the progression: inhibited peroneals lead to lax lateral inversion prevention, which leads to increased risk of lateral inversion sprains. Coincidentally, 85% of ankle sprains are lateral sprains. (2)

The second issue applies to tape and braces specifically. Not only do these structures lose their stiff support as we continually move, but they also change the insertion point of muscles that act on the ankle. Any time this occurs we limit the force production potential of the muscle, alter proper functioning patterns, and also cause more force distribution to be transferred to the nearest joints.

Now instead of the ankle, the joints required for mobility are the knee, and while technically not a main joint, the foot. These structures are forced to compensate and absorb higher levels of force than usual. As with anything else that has to compensate, these joints eventually wear down. We created a new injury in the form of high ankle sprains because we were trying to prevent one.

Paradox 2 – Lost Foot Awareness

Our feet contain the most mechanoreceptors in the human body. Mechanoreceptors are cells that are responsible for transmitting mechanical stimuli and relaying information to our central nervous system. They're responsible for our body's position awareness.

By not providing our feet with a consistent barefoot stimulus, we lose our ability to "hear" the messages from those mechanoreceptors. Is it any wonder that many first-time ankle sprains occur when simply stepping off a curb? It's interesting to note that third-world countries have a significantly lower rate of ankle sprains, while we wear Air Jordan's.

Observe the difference between a young infant's foot and an adult's foot. See how the baby can easily curl its feet up? Now you try to do that. Odds are you were just out curled by a baby.

Did your mother ever tell you to let your feet breathe? She was on to something. Sensorimotor control has been shown to be impaired through wearing shoes.(3, 4) Walking in the sand is a perfect example of letting your feet breathe.

Konradsen found that a complete block of afferent feedback from the ankle led to impaired joint position sense(5) This shows that mechanoreceptors in the muscle-tendon system contribute significantly to proprioceptive feedback. After an inversion sprain, the peroneus longus and brevis, which are the primary evertors, become strained and lead to mechanoreceptor damage. (6) According to Konradsen, the most influential trauma to proprioception is trauma to the mechanoreceptors.(7)

Paradox 3 – Continual Sprain

Continual ankle sprain is the single most overlooked issue I see. For one, it's viewed as something that came and went like it never happened. I often hear comments like, "I sprained my ankle a few months ago, but it's fine now." Well, if you keep hitting your head into a wall, I bet it's going to do something to your noggin.

Every time you sprain your ankle, numerous dysfunctional patterns may occur. After a single ankle sprain, 70 to 80% of patients will suffer at least one subsequent sprain.(8) This is termed chronic ankle instability, which is characterized by frequent ankle sprains, and the feeling of "giving way." The majority of ankle sprains will present in this way. Contributing to ankle instability will be peroneal weakness, proprioceptive deficits, and anatomical laxity.(9)

Another issue deals with a neurological deficit. We've already established that the peroneals are strained post-ankle sprain, but what no one focuses on is the peroneal nerve. The peroneal nerve is a branch of the sciatic nerve, which is the largest nerve in the body, and is formed in the pelvis by fibers from the lumbosacral trunk (L4, 5) and the sacrum (S1, 2, 3).

Here's where it begins to get interesting. In the gluteal region, the nerve lies deep in the gluteus maximus. In some individuals, the common peroneal nerve leaves the sciatic nerve high in the pelvis and appears in the gluteal region by passing above or through the piriformis muscle. The superficial peroneal nerve is stretched by inversion and the deep peroneal nerve by plantarflexion. It bears repeating again that typical ankle sprains are inversion and planterflexion injuries.

In case you missed it, the peroneal nerve, which is "shut off" by ankle trauma, may have glute max implications. The glute max also becomes shut off! Still not convinced that ankle trauma, and more specifically peroneal nerve trauma, shut down the glute max? Let's look at two real life cases:

I have a history of ankle trauma in my right ankle. I fail miserably when my hip extension and glute max strength is tested. I also had two bouts of low back strain on my left side that caused me to quit deadlifting until recently. It's my left side, so why should we care?

A missed focus in the industry is on the deep chains that connect the body. There's a connection called the posterior longitudinal chain that connects your right glute max to your left latissimus dorsi.

What most people do not realize is that the glute max serves to provide stability to the low back through this mechanism. My right glute didn't fire and as a result I injured the left side of my low back. I had to flex my lumbar spine to pull the load because I couldn't activate my glutes. I've tested my clients who have a history of ankle trauma and found their glute max on the injured side to be exponentially weaker and unable to fire as fast as the healthy side.

The excellent work of Vladimir Janda has confirmed this concept of gluteal amnesia. Janda et al. found that a significant difference between two groups (one without a history of ankle trauma and one with a history) was the delay in onset of activation of the gluteus maximus(10)

Paradox 4 – Terrible Basic Movement Stability

The popular theme in performance training is to ensure that our athletes can move efficiently while rotating during dynamic tasks. While this theory is correct to a certain degree, what business does an athlete have training with lateral movements if they can't stabilize while moving front to back?

What happens when an athlete who can't stabilize and decelerate their body lands in an awkward position? You guessed it, an inversion ankle sprain. Jumping, cutting, and pivoting place the ankle at risk for inversion injuries. Close body contact between athletes also places the athlete's ankle at risk for inversion injury (e.g. stepping on the opponent's size 13's).

Paradox 5 – Impaired Gait Cycle

Some of my colleagues may want to slap me around a bit, but I'm convinced that the ankle is the primary cause of abnormal gait. Looking at an injured ankle during the gait cycle will show a few discrepancies. Pain or improper movement will cause the individual to compensate for the dysfunction. Another issue I see is that weakness in the anterior portion will cause the foot to slap down due to the inability to control the ankle. Tightness in the calves will result in a bounce during gait since dorsiflexion is limited.

The importance of the peroneals can't be understated. They provide stability of the ankle through control of the tarsal joints, serving a gliding function to make adjustments to the surface. The peroneus longus also serves an important function as a stabilizer of the first metatarsal head to the ground. Bullock-Saxton concluded that both local sensory and proximal muscle action changed in people with unilateral severe ankle sprain.(11)

Those in the athletic population will be interested to know that total foot contact time is longer in those with inversion sprains.(12) If it's a race to the ball, the player who spends less time on the ground will always get there first.

Using myself as a point of reference again, during each step I tend to invert about one to two degrees. It doesn't seem like a big deal, right? When I run it's a completely different story. I have such a degree of peroneal neurological shut down and ligament laxity that I "push" the pressure downward into my foot, causing my foot to take the pressure that should be absorbed by my ankle. It's not just a coincidence that my right hip is more dysfunctional than the Spears family.

What Can We Do About It?

Knowing why our ankles are shot is important, but we need to know what to do to fix 'em back up. Under no condition should we resort to ankle taping or bracing for corrective care. There are far more effective solutions in our tool kit.

Solution 1 – Roll the Plantar Fascia Daily

Running along the bottom of the foot is a paper-like substance known as fascia. According to Thomas Myers in Anatomy Trains, this fascia acts like a wire network to connect muscle to muscle. Being linked would therefore create an injury situation if one segment were out of whack. The plantar fascia is the beginning of one of these wire lines and affects what happens on the posterior side of the body. Plantar fasciitis is a painful condition brought on as a result of tight calves and over-pronation of the foot, both of which are common in 99% of the population.

Rolling a tennis ball or golf ball along the base of your foot on a daily basis will break up the fascia and enable improved function of everything from the ankle to the low back to the neck. Have a go at this test: Perform an old-school hamstring stretch by bending over and trying to touch your toes. Pay attention to how tight your hamstrings feel. Now, roll a tennis ball under each foot for 60 seconds. Bend over and try to stretch again; you should notice a greater stretch. This simple test validates the theory of fascial trains.

Solution 2 – Soft Tissue Work for Everyone

Any form of trauma or repetitive loading to an area of the body will cause a protective shutdown. This shutdown will present itself in the form of scar tissue, adhesions (a muscle-to-muscle sticking effect), a decreased range of motion, and improper gliding of muscles as we move. We might see all kinds of weird pain referral patterns, but the most important is the antagonistic relationship between the adhered muscles and their counterparts.

Decreased strength and increased tightness in our psoas is going to shut down our glute max, while increased tightness in the tensor fasciae latae and adductors will shut off our glute medius. Both of these muscles are of utter importance to our hip mobility. Moving down, the ankle tightness in our calves is going to make it easier to sprain them when we land or change direction. Adhesions to the peroneals will limit the movement of these sprain-restricting muscles.

Solution 3 – Barefoot Warm-Ups

If you've ever seen someone in the gym barefoot, you probably stared and then thankfully realized that the odd odor wasn't you. It's just not something you see every day. While I'm not suggesting that you should train barefoot, I am telling you to perform all of your warm-ups with naked feet. Our feet contain a large number of information producing sensors. We can essentially train our feet to better understand our body position and movements by going barefoot more frequently.

Spending five to ten minutes performing glute bridges, single-leg Romanian deadlifts, and other warm-up drills with our feet in contact with the ground will establish an efficient sense of ankle awareness. When we step off a curb or make a sudden shift, our improved proprioception will allow our ankles to make the move with us. That way, nobody will laugh when you trip and eat asphalt.

Solution 4 – Mobilize the Ankle Joint

Mobility has really come to the forefront in recent months and rightfully so. The ankle is a joint that needs mobility. With all the high sneakers and ankle restrictions that dominate daily life and sports today, our ankles have all the characteristics of a cinder block. Not good for a joint that has to support us every step we take.

After our ankle becomes immobile, the mobility requirements shift to the subtalar joint, which is a mid-foot joint that controls inversion and eversion. This joint will often develop a great degree of mobility if our ankle joint is lacking. This further clarifies why ankle injuries aren't just plantarflexion injuries alone, but plantarflexion and inversion.

The importance of mobilizing the ankle joint can't be understated. The ankle contains a large amount of sensory motor feedback that's imperative to balance. By mobilizing the ankle, we will create more stability at the subtalar joint as well.

I have to credit Mike Boyle with this self-mobilization technique. To perform this movement, line the toes of one foot up to a wall. Shift all your weight onto the heel and attempt to push your knee over your toes toward the wall. As you progress, move further and further away from the wall.

Solution 5 – Glute Max and Glute Medius Activation

The hip drop indicates a weak glute medius

The glutes exert both a front to back and side to side control over our pelvis. One of our main ankle issues is that we can't control our pelvis during dynamic tasks. It's time for another pop quiz. Stand on one leg with the opposite leg slightly bent and lifted off the ground. Now close your eyes. I bet you went flopping side to side. Did you feel a lack of control in your ankle? This is due to glute medius weakness. Another clue to the degree of glute medius weakness is the severity of the opposite hip dropping.

To learn to fire the glute max and glute med, perform bridges and clams. For those who aren't familiar with clams, they're a great exercise to target the glute med. To perform this movement, lie on your side, knees bent at 90 degrees, and push the top hip out to the side. Finish by pushing all the way to the top. If it helps, you can place your hand on the side of your hip and feel the glute med working.

Solution 6 – Daily Isometric Foot Contractions

This simple exercise can really help our ankles out in the long run. Remember the comparison of a baby's foot versus an adult's? As we now know, our ability to curl our feet up worsens with age. This decreased control has a negative impact on our foot's sensory awareness.

Foot isometric holds require very little effort and can be done anywhere. To perform them just curl your toes toward the bottom of your foot and hold for ten seconds. Begin with one set of ten repetitions for ten seconds.

Solution 7 – Peroneal and Tibialis Anterior Exercises Daily

As we've established, our peroneals are essential for long-term ankle health, yet they can be both tight and weak. While we're performing soft-tissue work to free them up, we need to strengthen them as well.

Specific peroneal work consists of band inversion and eversion exercises and cable inversion and eversion isometrics. A combination of soft-tissue, unilateral, and isometric peroneal work will enhance the neural connection to this often dormant area and improve ankle health quickly. As an added bonus, the band exercises can be performed anywhere.

The tibialis anterior is our strongest dorsiflexor, so in the face of tight calves the focus should be on pure dorsiflexion work throughout the day. Just place a light plate on the top of your foot and lift your toes toward your knee.

Solution 8 – More Unilateral Work

When recovering from ankle injuries and while keeping them healthy, single limb training is a must. The fact is that somewhere along the line we've had an injury, pain, or just have bad posture. As a result, we'll overload specific muscles while others are underactive. A typical squat will see an overactive shift in the body towards either the right or left. Not only are we overloading one side of the hip and low back, but we're also causing a strength deficit in the other limb.

This may go unnoticed until you have to make a play or spot that one leg seems to dwarf the other. Unilateral training will correct this deficit and teach more ankle joint awareness since our surface is unstable with only one ankle in contact with the ground. If you're recovering from an ankle injury, then I highly suggest you perform unstable surface training. However, this only applies if you're currently sidelined.

Solution 9 – Force Absorption Work

Ankle trauma is more often than not the result of an inability to land properly. The majority of ankle sprains occur when landing from a jump, changing direction quickly, or moving from a higher surface to a lower surface. These are all examples of an inability to efficiently decelerate your own force, ya' big lug.

The purpose of plyometric or dynamic movements is to increase our ability to absorb force. The ability to produce force is reduced at the expense of absorbing force; you can move significantly faster if you can stop quicker. The more effective you are at absorbing an external force, the quicker you can overcome it. You're only as strong as your weakest link, which in this case is the ability to eccentrically control movement.

I typically have my athletes perform two plyometric movements once they've sufficiently progressed with their ankle rehab. Both of these plyometric drills are excellent for force absorption work, as well as returning the athlete to reactive training. The first is a single-leg altitude landing from a low box (18 to 24 inches). All you do is let yourself fall off the box and attempt to stick the single-leg landing solidly. Hold the landing position for 5 to 30 seconds.

The second is a single-leg altitude landing sprint stance. Very much like the single-leg altitude landing, the only exception being that you switch arms and legs as you fall.

Solution 10 – Acupuncture for the Peroneal and Gluteal Nerves

Nerve entrapment and compression is more common than people think. Our internal network doesn't work the way it should so our muscles scream mercy and shut down. The most efficient way to restore nerve function is acupuncture to the deep and superficial peroneal and gluteal nerves. If you can't consult a qualified practitioner, then you'll need to attempt to restore this function yourself. Before you turn yourself into a human dartboard, check out these puncture-free options.

Some nerve function can be restored through unstable surface training such as wobble boards, balance sandals, and balance disks. Like I mentioned previously, I suggest unstable surface training only if you're currently rehabbing. If it's an old injury, then unilateral training will do the trick.

Another option is self-nerve flossing techniques designed to reeducate our nerve firing patterns. This movement is a reminder that any muscle stretch will likely be a nerve mobilization, especially if the movements that place load on the nerve are included. The flossing movement is a bodyweight-supported mobilization.

In this movement, you'll be standing with the injured ankle close to the opposite leg and rotated inward. Make sure the injured ankle is behind the opposing leg. Push the toes into the floor and twist the foot inward to begin the mobilization. To strengthen the movement, flex the low back and neck slightly. Here's what it looks like:

When performing this mobilization, be sure to hold the position for at least ten seconds, as you would during any stretch.

That's the Wrap on Ankles

You can now see that ankle injuries don't just happen by accident or because you zigged when you should have zagged. If you take away one thing, it's that proper ankle function is vital for both performance and healthy movement. When you can't walk you can't train, so keep your ankles pain-free and enjoy the benefits of improved performance.

References

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