Sports Medicine Foot and Ankle Rehabilitation

Injury Rehabilitation and Prevention

by Antanas Sleckus

If you are reading this article I can safely assume that you have sprained your ankle or have had some sort of foot trauma in the past. I will also assume that about half of the readers missed out on some training or playing time because of the injury. There are two things you can do now, either you can wait and pray that your ankle heals or you can do something about it. If you are a competitive athlete you cannot afford to take time off and wish for things to work out. In this article I hope you will learn how to treat and speed up the healing process of ankle sprains.

I've tried making this article easy to understand so I didn’t spend hours on an anatomy lesson. This article also tackles issues like correct footwear, common athlete’s flaws i.e. lack of mobility in the ankle joint. If the ankle is deformed or extremely painful, go see a professional. This guide should not be used to replace a visit to the doctors.

Ankle sprains are one of the most frequent sports injuries and lf left untreated can lead to chronic foot problems. The most common type of ankle sprain is when the foot rolls outwards on its side, causing sharp pain and immediate swelling. This causes the ligament to overstretch or partially tear and in some cases completely tear off. Change of direction or level is what usually causes the sprain.

After you sprain your ankle once, you automatically increase the chance of re-injury. As an athlete your main goal is to try and reduce this risk. This can be easily achieved if you apply the correct post-injury treatment. You need to closely follow a balanced rehabilitation program, to increase the range of motion and the lost strength in the joint.

Post Injury Treatment:
A simple yet affective way of treating any soft tissue injuries is P.R.I.C.E.

Protection - Keep your ankle protected from further damage. Try not to put pressure on the leg.

Rest - Take a couple days off and take the weight of your feet. Avoid pain causing activities; you may use crutches.

Ice - Apply some ice to the ankle, some people use a frozen bag of peas for about 15-20 minutes 3-5 times a day. Don’t over ice it as that may cause further harm.

Compression – Wrap the ankle with a bandage or a towel. Don’t cut of the blood circulation just offer extra support.

Elevation- Raise your ankle high, preferably on a stool or some pillows. This should help to reduce the swelling.

P.R.I.C.E should be applied as soon as possible after the injury. If the pain is very severe you can take anti-inflammatory medicine. Many athletes leave the ankles healing process at that. This is one of the biggest mistakes an athlete can do, not restoring the ankles full range of motion and strength. Not restoring the ankles health fully will lead to chronic foot pains. This will result in the ankle being weak, unstable and inflexible.

All of these things will lead to poor athletic performance for example poor transference of speed during sprints and jumps. Another downside will be a crap Squat. The lack of mobility in the ankle will not allow you to go down deep enough when Squatting and your technique will suffer. The heel will rise off the floor and in some cases cause pain in the Talus, the Tarsal region at the bottom of the Tibia bone, making heavy weight bearing activities that involve the ankles full range of motion near impossible.

Restoring The Ankles Function:
The biggest mistakes I see people do is overstretch the ankle when it’s too weak. Think about it, ligaments in the ankle have been stretched out and maybe even torn. The last thing you should do is try to stretch it even more at this stage as this may cause further damage. Some light stretching is OK if used correctly.

After one week, depending on the individual, of continuous resting and icing you will need to include some range of motion exercises to help restore normal ankle function. Apply Ice after these activities and start off slowly, building your way up. Once you can walk without any support you may start these exercises. Make sure swelling in the ankle has gone down considerably before you start.

Stage 2:
Method: Pull your foot toward and back from your body. Sit on the floor with your knee straight; don’t bend the knee.

Method: Sitting in a chair start to slowly rotate your ankle in a circular manor. At first your ankle will still feel tight and weak, start of slowly and work in both clockwise and anti-clockwise directions.

Method: Seated ankle plantar flexor stretch using a towel. At first ease into this stretch as the joint is usually still sore.

Method: Get a golf ball and roll your foot over it, back and forth. This is a simple method but useful, roll all over the bottom of the foot. This method helps to improve the Achilles. So if you have a tender Achilles heel you need to start doing this.

You may start including these methods into your routine when you are able to stand up without much discomfort.

Method: Towel gathering exercises. There are two methods without going into too much detail, both movements are necessary. Version 1, Place a towel on the floor and try to drag it with your toes. Version 2, Same thing but instead of gathering the towel with your toes, try to pull the towel sideways in a windshield wiper manor. Once this gets too easy add a weight at the end of the towel to offer more resistance.

Method: Single leg balance work, these exercises help to re-establish neuromuscular control of the lower limb. An easy way of making this exercise more difficult is closing your eyes, arm placement or object holding. Placing your arms over head will make it more difficult, taking an object into your hands whilst doing so will also increase difficulty further.

These exercises should be performed frequently for the first 1-2 weeks. Remember to ice after activity’s to reduce the swelling. Try to continue with this phase of the treatment for 1-2 weeks or until your ankle feels much more comfortable. If you are able to walk without having much pain and can bare your bodyweight on your injured limb you should be able to move to the next part. Your ankle will still feel unstable, tight and you will experience pain and swelling after physically demanding activities.

Stage 3:
You will need to perform these strengthening exercises 3-5 times a week. Icing after strenuous activities will still be necessary. For this part you will need to invest in some elastic bands with enough resistance. You will also need an old basketball/football, a wooden plank, wide enough for you to stand on and also a tennis ball.

Method: Tie the elastic band against something solid and loop it over your foot. Pull your foot against the band, perform slow repetitions and at the peak of resistance hold for 5 seconds. Start off slowly and build your way up.

Method: Using the elastic band for resistance, loop over the top of your foot once again and proceed in pulling your foot back against the band. Perform slowly and build your resistance by distancing your foot from the band to increase tension. Perform slow repetitions and hold at the peak of the movement for 5 seconds and repeat.

Method: This is a great exercise, deflate your old ball and place the piece of plank over it. This will act as your wobble board. As you have just injured your ankle, your neuromuscular control will be bad meaning you will have difficulty balancing. Try to balance on the board for as long as possible, once you get better at it try to increase the difficulty by placing your hands over head or holding an object in your hands to create a greater challenge on co-ordination. Performing functional activities on an un-even surface will promote stability in the injured joint. Try to pass or bounce a tennis ball whilst balancing on the wobble board. When you get good at this you may try closing your eyes or even standing on one leg. Single leg work is great, try to involve your un-injured limb when tired. Be careful we don’t want to break anything.

Method: Weighted calf raises, not much to say about this. The next time you are in the gym try these, make sure you go all the way down and hold the stretch for a second or two. Do these without shoes to decrease support by the footwear. Start off light and work your way up, once you feel your ankle is stronger try single leg calf raises.

Mobility and Soft tissue work: this part should start when you ankle feels stronger but still not great.

Method: This exercise will improve your ankles ROM as your ankle is still tight. You will notice how much your movement is restricted when compared to the un-injured leg. Start off slowly and only go as much as your ankle allows without too much pain. Try to improve the distance each time but don’t over stretch. Place your foot on a platform or an incline plank, lean forward and bend your knee slightly. This is a great exercise to help Squatting Depth.

Method: These are great supplementary movements that will improve your ankles health. You will need a tennis ball to perform these, remember your ankle is still injured so take it slowly.

(Credit to Bill Hartman for the great video.)

You will need to rest after activities. The aim is to strengthen and lengthen ligaments but give them sufficient rest, allow time for recovery. You may still strap your ankle when sleeping. No use lying to me, I know many athletes will not take time off and will go back to activity as soon as possible. One thing you can do is use an ankle brace/support to protect your ankle from further injury as your joint is still weak. Continue with this section for 2-4 weeks until your ankle is nearly back to its full range of motion and is stronger. An easy way to tell if you ankle is strong enough is jump of a small platform and absorb the shock. If you ankle doesn’t wobble/buckle on the landing and doesn’t cause too much pain you are on the right track.

Stage 4:
By now your ankle is feeling much better, nearly back to its former glory but long strenuous activities still cause pain, swelling and discomfort. Continue with the wobble board balancing and mobility exercises and add these in.

Method: Start visiting your local swimming pool. Aqua training has always been included in past rehabilitation programs, why not now? The water reduces the weight bearing on your joint and the added resistance will further strengthen your ankle. The continuous Dorsiflexion/Plantarflexion movement with added resistance will improve the ankles continuous-strength. One more reason why swimming-pool work is good: if you are an athlete and missing training, this is a great way of maintaining endurance. At the beginning swimming may feel uncomfortable at the ankle but you will get used to it. If the sensation is really bothering you try to adjust your swimming style for a short while. You can swim up to 3 times a week without over training it.

Method: You should only perform these if you feel your ankle is strong enough, don’t perform these if your ankle still feels unstable and weak as this may be very dangerous and may cause re-injury, if performed improperly. As your ankle is still not 100% you will feel fatigue set in quickly after these activities. A healthy un-injured ankle can perform these for about 2 minutes until muscular fatigue pain sets in, as your ankle is still weak your time will be significantly lower. This will strengthen allot of muscles like Posterior/Anterior Talofibular, Calcaneofibular ligaments, I could go on but I tried to make this guide easy to understand and short.

Side foot walks: walk on the side of your feet.
Heel walks: walk on your heels for as long as possible, this will improve your Dorsiflexion and prevent from most soft tissue knee problems.
Inner foot walks: walk on the inner part of your foot. With all of these start off slowly then increase the time under tension. Do not allow you ankle to buckle as this will cause more injury, when you feel like your ankle is tired and it will buckle any time soon, Stop Immediately!

This part of the rehabilitation phase you will need to continue with until your ankle has returned to full function. Think rationally once your ankle health improves you may reduce the ankle strengthening activities.

One thing you can also try is PNF stretching to improve your ankles ROM. Like any stretch build up the time and force applied, make sure it doesn’t cause too much pain but that sufficient resistance is applied. Remember to ice and ice and ice again after the activity.

Method: Kneeling Dorsiflexion stretch for the Anterior Tibialis.

Method: Plantar Fascia Stretch using the floor, it is similar to a sprinters starting position.

Method: Distal anterior/posterior fibular glides. Stabilise the Tibia by firmly holding on to the lower shin part with one hand as the other hand performs the movement gently. The movement of the ankle in an upwards direction will increase Dorsiflexion and the downwards movement will increase Plantarflexion.

“Full function” Is a term I use very loosely. I’ve heard from many athletes, x athletes and sports medicine educators that “Once your ankle is gone, it will never be the same” Somewhat I question this statement but restoring your ankle to post injury condition can be a difficult process and usually takes time. Many people stop caring once it gets slightly better. To put this in perspective of what they are doing is the same as building a house on sand. Yes, it’s stupid, Yes its idiotic so why are you still doing it?

Still learning as well as assessing my own and other athletes’ ankles, I seem to find answers to the questions that aren’t being asked. I know it may sound cheesy but this is my attempt of bringing the smart athlete to some of my views. This is something you cannot ignore; if you do it’s like a time bomb waiting to reveal itself and sabotage. Now a more interesting point of view I currently try to build on is the restriction of Dorsiflexion in the ankle, post trauma. This seems to be an un-explored area by many self made sports medicine gurus and only well known in the physiotherapist circle.

There are more PNF techniques that you must use but I recommend seeing a sports doctor or physiotherapist as this takes experience to do correctly. A good one at that, remember “You get what you pay for” invest in yourself especially if you are an athlete, you don’t want too cut yourself short at your peak? If you want further reading on this subject it may be in your interest to invest in a book called “Techniques in Musculoskeletal Rehabilitation by William E. Prentice Michael L. Voight “ A great read into sports therapy and on ankle rehabilitating methods ,especially PNF stretching and mobilisation.

Your aim now should be to improve the quality off tissue around the joint. Allot of deep tissue massage, Careful PNF and mobility work which is only accessible via a great physiotherapist. The only help I can give you here is emphasize the Dorsiflexion stretch for the Anterior Tibialis. Another great way to perform a stretch for The AT is by using the kneeling Dorsiflexion stretch but increasing the leverage by placing a platform under the top of your foot. This will feel very uncomfortable at first so take it easy.

Also you need to emphasise the mini squat like movement to improve ROM. Perform the Anterior Tibialis stretch in combination with the squat like mobility movement and the calf stretch, 3-5 times a week. Perform a weighted movement for the AT 2-3 times a week, next time you are at the gym grab a couple 20kg plates place them on top of your ankle whilst seated and perform the Dorsiflexion movement.

“Soft Tissue Work for Tough Guys” on T-nation offers extra information on soft tissue work. The part that should interest you is soft tissue work on Soleus/Gastrocs and Hip Rotators. Once you progress from a foam roller and a tennis ball, try using a golf ball. That will surely make you cry.

Performing these exercises will continue to strengthen your ankle, also use an ankle support whilst taking part in physically demanding sports like football or basketball. Some people see the use of supports and strapping as bad because they say it will make the ankle joint weaker. Well this is correct to an extent but if you keep on doing strengthening exercises your ankle will only become stronger and stronger. A support can prevent injury by improving the ankles balance, also high top basketball shoes for the time of “weakness and insecurity” are ok but don’t over use them by wearing them everywhere.

Too much cushioning all the time will protect your ankles too well. Walk around the house barefoot to make the small muscles in the ankle work harder, this will continue to strengthen your ankles and feet. This brings me on to another subject in foot and ankle health, footwear. This is an article in itself but I will try to keep it brief. People in today’s society like to look “flash”, this means over padded, and uncomfortable shoes are a must. This is a nightmare for your feet, if you want healthy feet, to prevent knee problems and high ankle sprains GET GOOD SHOES! Barefoot training is a great way of keeping your ankles in check; some people even take it to the extreme of barefoot running. Actually on this subject many top functional trainers (I really hate using the term) perform their warm up barefoot. You may want to do further research into this.

Your body is a very complex machine; if one place is weak, unbalanced or immobile this will lead to something else in the body to fail. In this case poor ankle function will lead to knee pains and when the ankle doesn’t function correctly the knee will take the slack. This can lead to premature arthritis in the long run.

If your gym doesn’t allow barefoot training the next best option is investing in some good footwear. Some good brands are Nike Frees version 3.0 preferably as they give very little support and your foot will continue strengthening. Another favourite in the Powerlifting community is the Converse All Stars. Anything that has a firm flat sole and isn’t too “cushioned” is great, the closer to the ground you are the better. Try to wear these types of shoes for most of your day and bask in healthy lower limbs. Another stupid move is buying small shoes; if it doesn’t fit it won’t fit period. When investing in athletic footwear buy something that you could wear all the time but remember the guidelines above.

----------------------------------------------------------------------------------------------------------------------------------