ANKLE SPRAIN REHAB: TIPS FOR A FASTER RECOVERY

If you have had a significant ankle sprain before, you will remember how difficult walking around is and in the acute stage, you will have to limit weight-bearing.  The best way your body knows how to do that itself is by limping.  And even as you start to get better, you will still walk funny.  Sound familiar?  Tips for faster recovery from an ankle sprain involve restoring functional stability via proprioception, dynamic joint stabilization, and reactive neuromuscular control.

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Your feet and ankles are very important and provide a stable foundation for all of your movements.  All the more reason to make sure your recovery optimal function after an injury.

Even just a few days, let alone a few weeks, of limping and/or limited weight-bearing will wreak havoc on your intrinsic foot and ankle function.

Most of the people I see returning from an ankle sprain have not recovered proper foot function, ankle mobility, and specific strength for their activities.  Usually, it is because there is a gap between the conventional therapy that they received to treat their ankle sprain and the rehabilitation they need to get them not only from injured to not injured but from injured to strong.

ACUTE STAGE REHAB

The severity of the sprain certainly guides the rehabilitation concerns.  In a Grade 1 sprain, there is some stretching or potentially partial tearing of ligamentous fibers but there will be little or no instability.  A Grade 2 sprain involves some tearing and separation of ligamentous fibers with moderate instability, and a Grade 3 sprain involves total rupture of ligaments with significant instability.  Grade 3 sprains will require immobilization lasting several weeks.

Rest and protection

Although it may sound counter-intuitive, rest does not mean not doing anything at all.  Rest simply means allowing the normal injury inflammatory process to do its job.  With the exception of Grade 3 sprains, isometrics in plantar flexion, dorsiflexion, inversion, and eversion can be incorporated very early, and active range of motion in plantar flexion and dorsiflexion within pain-free ranges are allowed.

 EARLY ACTIVATION AND STRENGTHENING

In the early phases of rehab, strengthening using tubing or band exercises for the different movements of the ankle: dorsiflexion, plantar flexion, inversion, and eversion.  These are good exercises and can serve to reactivate the different muscles that cross the ankle joint.  When a joint is injured, the muscles that cross that joint become inhibited – this is called atherogenic inhibition.  Open kinetic chain tubing or band exercises allow for reactivation of these muscles while still protecting the injury (ie. non-weight bearing).

It should also be noted that light resistance with higher repetitions is less detrimental to the healing ligaments, which is why we often see 2 to 3 sets of 10 repetitions being prescribed here.

In this stage of rehab, these exercises are certainly appropriate, but problems arise when rehab stops there.  Oftentimes, people will cut their rehab process short as soon as they are out of pain.  But the rate of recurring ankle sprains is high because most people have not recovered optimal function.

FUNCTIONAL ANKLE INSTABILITY

With a Grade II or III sprain, injury to the ligaments will result in some mechanical instability.  The integrity of the ligaments has been perturbed, resulting in laxity: joint range of motion beyond the “normal” limits, “normal” is the amount of passive range of motion that a specific individual previously had.

The common thought process for ankle sprain rehab is to train the muscles that cross the ankle joint with the idea that it is these muscles that will now need to stabilize the joint.

However, we must not confuse this with the previously mentioned tubing or band exercises, for two reasons in particular:

• They are not intense enough to create an adaptation for strength, particularly in weight-bearing
• They are not appropriate for the muscles to even fire at a rate fast enough to stabilize the ankle joint

Sensitivity of the neuromuscular system

Injury to joint structures results in deafferentation – damage to peripheral joint mechanoreceptors responsible for conveying afferent information on joint motion (kinesthesia) and position sense (proprioception).  These perturbations in proprioception result in decreased neuromuscular control and in turn, this leads to

 functional instability: the inability to dynamically stabilize the joint for proper control and movement

 When we increase the sensitivity of the neuromuscular system, it is stimulated more quickly and we can bring muscle activation to a reflex level – this is how we can really get muscles to “do the job” of the ligaments.

So, how do we achieve this?

 UPREGULATING THE FOOT

The foot is a powerful proprioceptive tool.  The cutaneous receptors on the plantar aspect of the foot provide information from the ground that is transferred to the intrinsic muscles of the foot. The cutaneous sensation is closely related to the perception of movement and stability. Upregulating the foot essentially means training the foot to detect more quickly the changes in ground reaction forces.

There are several drills and exercises that you can use to upregulate foot function.  Refer to my blog article Foot Stability is the Foundation for All Your Lifts for more on this.

 ANKLE NEUROMUSCULAR TRAINING

To improve functional stability, we need to restore neuromuscular control.  The muscle that crosses the ankle joint is certainly important for this.  The peroneus longus and the tibialis posterior are of particular importance, as they are the main lateral and medial dynamic stabilizers of the ankle, respectively.

While the initial rehab tubing or band exercises start the job of reactivating the muscles, they are best trained in their individual functions and in a closed kinetic chain:

-The peroneus longus action is plantar flexion and eversion.  As such, it can resist inversion forces at the ankle.  You can target it by rising onto the toes with a focus on pushing the tip of the great toe into the floor.  Here is a good article on the effects of neuromuscular training on the reaction time of the peroneus longus: Effects of Neuromuscular Training on the Reaction Time and Electromechanical Delay of the Peroneus Longus Muscle

-The tibialis posterior’s action is plantar flexion and inversion.  It is the main medial stabilizer of the ankle and also supports the medial arch of the foot.  You can target it by rising onto the toes while squeezing a ball between the feet.

Make sure to watch the main video of this article to see how these exercises are done.

BALANCE TRAINING

The goal of balance training, ideally barefoot, is to increase the sensitivity of the sensory system and increase the reaction time of muscle pathways to bring them to a reflex level.  In other words, we want to increase the speed at which support is provided to the joint by the reactive dynamic restraint of the muscles.

In a typical rehab setting, this is commonly done on balance and wobble boards and BOSUs, and likely wearing shoes.  We have already discussed the importance of working barefoot to upregulate and benefit from the proprioceptive information that is provided by the cutaneous sensation of the foot.

Further, some studies have shown that these methods only train the foot and ankle to sense slow inversion and eversion movements.  Of course, in the early stages, this is can be a good place to start, but it will not be sufficient longer term.  If I had to choose from one of these more traditional modalities, I would likely go with an air disc, because the perturbation it provides is much quicker.

REACTION TRAINING

One thing that is important to remember is that clients and athletes are not always working on unstable or unpredictable surfaces, which is what balance/wobble boards, BOSUs, and air discs provide.  Sometimes the ankle needs to sense and react to a change in ground reaction force and the body’s position and center of mass during movement.

For example, a CrossFit athlete performing an Olympic lift may move their feet from a narrower to a wider stance as they “catch” the barbell.  This is what the ankle needs to react to, even though the ground is flat and stable.

Landing tasks, jump tasks, and other plyometric work is an important element of neuromuscular ankle rehab.  In the earlier stages, think about replacing exercise on an unstable surface with single-leg balance exercises.  I like to use object tracking because it is more challenging than single-leg balance or even single-leg balance with eyes closed.

A CONTINUUM

There are four crucial elements to restoring functional stability: proprioceptive and kinesthetic sensation, dynamic joint stabilization, reactive neuromuscular control, and functional motor patterns.  An effective rehab strategy needs to take into consideration all of these elements.

We need to know which exercises have the potential to help, and where in the continuum they have that potential.  We also need to know that every exercise has limited potential, especially if it does not provide sufficient stimulus to induce adaptation.  If we choose exercises more precisely and integrate them within a structured rehab plan, we can maximize our intervention and cover all the elements to restore functional ankle stability.

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REFERENCES Linford, C., Hopkins, J., Schulthies, S., Freland, B., Draper, D., & Hunter, I. (2006). Effects of Neuromuscular Training on the Reaction Time and Electromechanical Delay of the Peroneus Longus Muscle. Archives Of Physical Medicine And Rehabilitation,  87(3), 395-401. DOI: 10.1016/j.apmr.2005.10.027 van Deursen, R., & Simoneau, G. (1999). Foot and Ankle Sensory Neuropathy, Proprioception, and Postural Stability. Journal Of Orthopaedic & Sports Physical Therapy, 29(12), 718-726. DOIi: 10.2519/jospt.1999.29.12.718