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| Ref: https://www.aspetar.com/journal/viewarticle.aspx?id=138#.Y0DzTXZBy3A |
The ankle is one of the most commonly injured joints in sports. Many people have asked me about annoyed ankle pain that has the potential to include resting swelling, loose joints, and ankle twist easily. The most resting swelling is always at the location of ATFL (anterior tibiofibular ligament) that can occur from normal standing and walking. Loose joints is the unstable joint feeling or we can call joint laxity that can feel discomfort around the ankle and tight calf muscle. Too easy ankle twisting including walking on normal surfaces or normal stairs.
The cause of these symptoms is poor rehabilitation after an ankle sprain or ankle trauma. Normally, an ankle sprain can heal itself after taking medicine and rest. So, the patients ignore physiotherapy programs for ankle injury. However, the injured structure i.e. ligaments and tendons are weaker than before injury that induce poor circulation, poor joint position sensation, muscle weakness, muscle reaction time, and the injured site become vulnerable.
These mechanics can explain the symptoms as above: resting swelling is made by poor circulation, loose joints are made by muscle weakness, and easy ankle twisting is made by muscle weakness and poor joint position sensation. Therefore, Two theories that cause ankle instability in general are mechanical instability and functional instability. Mechanical instability refers to the measurement of ligamentous weakness, whereas functional instability comes from a neuromuscular system deficit.
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| Left lateral ankle illustrated mild swelling in chronic ankle instability (Ref: https://www.preferredfootankle.com/) |
The therapeutic ankle stabilization exercise is a very essential part after an ankle sprain or injury because the rehabbed ankle will have normal internal structure strength and active neuromuscular function. The program is associated with strengthening muscle around the ankle joint, proprioceptive training, and flexibility.
"To strengthen ankle muscles need some resistance from elastic exercise bands or tubes or cable which is not very heavy. Normally, I arrange for my patients between 2 - 5 kilograms."
Elastic (rubber) band exercise (upper picture) and loop exercise (lower picture)
5 basic ankle stabilizer strengthening exercise
Exercise #1: Alphabet exercise: write the capital letter “A to Z” by toe tip and ankle. It needs 10 - 15 rounds a day. (slow speed)
Exercise #2: Ankle eversion with dorsiflexion: bend ankle upward with outward (little toe side) and hold 5 seconds for 10 - 15 reps/set of 3 sets. (slow speed)
Exercise #3: Ankle eversion with plantar flexion: bend ankle downward with outward (little toe side) and hold 5 seconds for 10 - 15 reps/set of 3 sets. (slow speed)
Exercise #4: Ankle inversion with dorsiflexion: bend ankle upward with inward (big toe finger side) and hold 5 seconds for 10 - 15 reps/set of 3 sets. (slow speed)
Exercise #5: Ankle inversion with plantarflexion: bend ankle downward with inward (little toe side) and hold 5 seconds for 10 - 15 reps/set of 3 sets. (slow speed)
About 85% of ankle sprain occurs due to inversion injury, this injury occurs due to the number of stabilizing bones on the outside or side which causes the pressure on the foot to be reversed. The ankle joint is prone to injury because it is unable to resist medial, lateral, pressure and rotation strength. When an ankle sprain occurs, damage does not only occur to the structure of ligament integrity but also to various mechanoreceptors around the ankle.
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| Inversion ankle twist (sprain) is the most common ankle sprain (Ref: https://www.hprsphysio.com.au/) |
Rehabilitation of athletic injuries requires the prescription of sport-specific exercise and activities that challenge the recovering tendons, ligaments, bones, and muscle fibers without overstressing them. Rehabilitation must take into consideration normal tissue size, flexibility, muscular strength, power, and endurance. Firstly, control of swelling and effusion must be accomplished with frequent application of external pressure, modalities such as cryotherapy, and active range of motion (ROM).
A significant predisposing factor for the development of chronic ankle instability is the history of at least one previous lateral ankle sprain. The risk of developing chronic ankle instability is as great after a severe ankle sprain as after one or more minor sprains. So, inappropriate ankle rehabilitation can induce recurrent ankle sprain and develop chronic ankle instability afterward.
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| Star excursion in ankle joint biofeedback training (Ref: https://www.grsm.ca/) |
One goal of rehabilitation is to develop strength and neuromuscular control so that the ankle and foot are better controlled and protected during stance and impact. Adequate strength is necessary for normal movement patterns. The importance of developing correct motor patterns while subjects perform flexibility and strength exercises cannot be overemphasized.
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| Ankle strengthening by elastic band (Ref: https://www.physioproperth.com.au/resources/exercises/ankle-rehabilitation/) |
We have seen stiffness of calf muscle and achilles tendon in chronic ankle instability patients that make ankle range of motion limitation especially ankle dorsiflexion. By anatomy, the tightness of the achilles tendon tends to be ankle plantarflexion with inversion which is the most common ankle sprain pattern because insertion of medial achilles tendon force direction. Moreover, this stiffness causes discomfort and anterior ankle pain sometimes. So, stretching the calf and achilles tendon is one important part of ankle rehabilitation. (You can research more information on https://yimphysionearme.blogspot.com/2022/07/physiotherapy-with-9-options-to-stretch.html )
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| Advance calf stretching (Ref: https://www.knee-pain-explained.com/) |
Both strength and flexibility are not enough to complete ankle recovery. Balance training in ankle damage patients can improve postural control and the proprioceptive sense and is widely used as a treatment method to improve the stability of the ankle joints. The balance ability associated with ankle damage is affected by various forms of sensations, including visual and cutaneous sensations. Among them, the proprioceptive sense is obtaining stimuli through conscious/unconscious processes in the sensory motor system and is divided into motor sense (kinesthesia) that sense the movements of the limbs and joint position sensation that sense the static positions of the limbs. When the proprioceptive sensory function has deteriorated, the postural control ability, protective reflex ability, joint movement ability, and balance ability to respond to postural sways become more likely to be deteriorated.
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| Balance training on uneven surface (Ref: https://lermagazine.com/) |
The goal of rehabilitation is to return an athlete to the same or higher level of competition as before the injury. Patients have to train sports specific when basic ankle physical fitness is good enough. It includes sports skill, movement, sports postural control, agility, and plyometric. This part of rehabilitation is like a comprehensive exercise before returning to routine training with the team or completion. It can be done by a sports scientist or fitness coach or physiotherapist (as option).
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| Plyometric and agility drill (Ref: https://www.physioroom.com/) |
Reference:
https://ijshr.com/IJSHR_Vol.5_Issue.4_Oct2020/IJSHR0052.pdf
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