‘Don’t let what you cannot do interfere with what you can do.’ – John Wooden.
Suffering from an injury is a difficult time for any athlete, but there are steps you can take which will help you recover in the most rapid and effective way. The ankle joint is a major weight bearing structure which goes some way to explaining why it is the most commonly injured joint in the human body. The problematic thing about ankle injuries is that once you have suffered with an ankle sprain or the like, there is a 40-70% increased risk of re-injury. This is not a great statistic when the majority of sports rely heavily on the strength of this joint.
Ankle rehabilitation is a balancing act between rest and exercise to optimise muscle tissue recovery. Rehabilitation of athletic injuries requires the prescription of sport-specific exercise and activities that challenge the recovering tendons, ligaments, bones, and muscle fibres without overstressing them. The goal of rehabilitation is to return an athlete to the same or higher level of competition as before the injury. Any rehabilitation program must take into account the normal tissue size, range of movement and strength of the injured joint while maximising overall health, endurance and power. The development of neuromuscular control is vital so that the ankle and foot are better controlled during stance and under impact forces.
During the acute phase of injury, movement of the injured joint is discouraged. The length of this period varies depending on the severity of the injury and whether the damage is predominantly to soft or hard tissue.
Once the early stage of rehabilitation has commenced, the following exercises are recommended to begin to regain flexibility of the joint, reduce swelling and strengthen the damaged and surrounding tissue.
Range of Motion and Strengthening Exercises
To begin the movement phase of rehabilitation, the reintroduction of full weight bearing needs to be a slow and steady process to avoid further injury. The best way to do this is by performing exercises while submerged in water so as to reduce the weight supported by your ankles. This will allow you to make slight movements to reduce swelling and increase the range of movement while not overstressing the ankle joint.
Following this, you can begin ankle exercises on land.
Dorsiflexion is when you flex the foot, pulling the toes up towards your body. To begin with, you should perform this exercise sitting on the floor with legs outstretched to minimise the pressure placed on the ankle joint. Once you feel comfortable with this exercise, you can progress to sitting on a chair with your feet hanging down. This adds more pressure without applying a weight bearing force.
Progression: To progress the strength, stability and flexibility of the joint through this motion, you can use a resistance band. Attach the band to something across from a seated position on the floor. Wrap the band across the top of your foot to form a loop between your post and the site of attachment. Perform the same exercise with the resistance band applying opposite force to your movement.
Plantar flexion or pointing your toes to increase range of motion and strength is another must do exercise. Again, you begin these exercises sitting on the floor and progress to a chair once you feel comfortable.
Progression: Hold the resistance band in both hands and wrap it around the arch of your foot. As you point your toes, hold the resistance band steady or lean back slightly to apply resistance forces in the opposite direction of your movement.
While seated on the floor point your toes inwards toward each other. You can then progress this motion to an upright seated position on a chair and eventually a standing position.
Progression: The progression of this motion from standing (once you are able to bear weight) is to place the inside of your foot against a wall or solid inanimate object and apply pressure inwards. Begin gently and build up your strength. Pushing too hard when you commence this exercise can cause sharp pains and more damage. Initially, hold for 10 seconds and build up the length of time and pressure you apply gradually.
Eversion or ‘ballet’ feet are the opposite of inversion. The aim is to turn your feet outwards so that your heels are closest to each other and toes are furthest away. If you are sitting on the floor aim your little toes towards the floor. Progress this to sitting and standing. Bear in mind that you should gently twist through the ankle joint, do not perform the movement by moving your hips and knees outward and keeping the ankle joint completely stable.
Progression: Place the outer edge of your foot along a solid inanimate surface. Apply pressure towards the wall to cause an isometric contraction.
At this point your ankle should be feeling stronger, more stable and you should feel no pain when bearing total weight on your feet. You will achieve this gradually through changes in ankle supports and progression from walking on crutches, to walking with a little support and eventually no support at all. Walking along soft and springy surfaces is a good progression to increase ankle stability prior to performing calf raises. You should begin calf raises through a small range of motion progressing to full range of movement and eventually weighted and single leg calf raises.
Proprioceptive Balance Board Use
Once you can fully bear weight on your feet without any pain, you can advance to proprioceptive training to recover balance and postural control. The possible variations achieved through altering surfaces and conditions are vast. There are many fresh challenges to be faced with to maximise rehabilitation. Proprioceptive balance board training focuses on the link between sensory input and afferent signals through the central nervous system. These conscious and subconscious alterations in movement protect functional joint stability.
In the later stages of rehabilitation, the focus will continue to be on strengthening the ankle but will include impact forces as well as weight bearing activities. Functional rehabilitation is the basis of this stage and includes any specific sporting requirements necessary for an athlete to return to competitive form. It is important not to focus solely on injury rehabilitation and to ensure the inclusion of activities to help the body adapt to physical demands and return to the same level or better level of physical fitness as before the injury took place.
Jogging and Walking Progression
The steady inclusion of impact forces is important as the ankles are subject to this type of force almost constantly and particularly during training. Running places ~500% bodyweight pressure through our ankles so one can only imagination the forces applied to a gymnast when training.
An example of training progressions for jogging/walking is below:
100m jogging, 400m walking
150m jogging, 350m walking
150m jogging, 400m walking
200m jogging, 500m walking
250m jogging, 500m walking....and so on.
Agility training should begin with jogging and running at varying paces on varying terrains. Runs should then begin to include changes of direction. The introduction of shuttle runs, cone weaving and agility ladder will be introduced as the athlete improves both in fitness level and in ankle strength and stability. At all points in the rehabilitation phases the athlete should continue to perform the exercises from the early stages of rehab to maintain flexibility of the joint.
As was previously stated, the forces placed through the ankle joint are extremely high particularly as intensity of exercise increases. Plyometric training is a necessary addition to an ankle rehabilitation program in the latter stages to help avoid re-injury.
Sport Specific Training
Once the athlete has returned to an appropriate level of fitness and is no longer suffering with ankle pain and instability they can return to sport specific training. This is vital prior to returning to competition to ensure the ankle is strong enough to handle the specific demands placed upon it by the particular sport.
Verhagen E, van der Beek A, Twisk J, Bouter L, Bahr R, van Mechelen W, The Effect of a Proprioceptive Balance Board Training Program for the Prevention of Ankle Sprains, The American Journal of Sports Medicine, 2004, 32(6):1385-93.
Mattacola CG, Dwyer MK, Rehabilitation of the Ankle After Acute Sprain or Chronic Instability, Journal of Athletic Training, 2002, 37(4):413-29.
Osborne MD, Rizzo JTD, Prevention and Treatment of Ankle Sprain in Athletes, Sports Medicine, 2003, 33(15):1145-50.