Like with most body parts, one can take the ankle for granted until pain or injury draws your attention to it. However when things are pain free and running smoothly, then it generally isn’t given a second thought. Today I wish to highlight the importance of the ankle, and how dysfunction can have knock on effects for your musculoskeletal health.
Being bipedal, the ankle joint is one of the first points of contact with the ground and has to deal with the entire body weight. In fact, the small surface area of the ankle joint means that the joint itself can be subject to anything from 5-10 times the body’s weight. As with most joints in the body, there needs to be a trade off between mobility and stability. Ankle stability comes primarily from ligaments and tendons, which keep the joint where it needs to be. In fact, the ligaments in the ankle are so strong that severe ankle sprains can often pull the bone away from itself before the ligament snaps. This is called an avulsion fracture and is why it important to get an x-ray following severe ankle sprains.
Further stability is provided by the “wedged” shape of the joint, offering the most stability when the foot is dorsiflexed. A plantar flexed foot is therefore less stable and is when most injuries occur.
Inversion sprains, when the ankle turns inwards are by far the most common ankle injury. When this happens, the two most commonly sprained ligaments are the anterior tibio-fibular (ATF) ligament, which anchors the distal fibular to the talus, and the calcaneo-fibular ligament, which connects the distal fibular head.
The severity of the sprain is graded on how much damage is done to the ligament, for example; a Grade 1 sprain is minimal damage to some ligament fibers with no major changes to the function. Grade 2 sprains involve a partial tear of the ligament with moderate loss of function, and Grade 3 sprain are a complete tear of the ligament, with total loss of function.
Healing times will vary dependent on the grade.
Stability aside, the ankle also needs a certain degree of mobility to allow for the variety of terrain it may be presented with. Like with most joints, the ankle is laden with proprioceptors, which feed back to the balance centers in the brain, informing it of its current position in space and time, and allowing any adjustments to be made.
The simplest of movements require a complex set of neurological instructions to be sent to a variety of muscles in perfect sequence and force, to provide nice smooth movements. This set of instructions can be seen as a “program”, and gets engrained in the nervous system so it becomes second nature.
When proprioceptors become injured and damaged, (as with an ankle injury) they can no longer relay accurate information from the joint to the brain, which results in dysfunctional movement patterns. Further more, in a bid to reduce discomfort, the body will develop coping strategies, and recalibrate the original “program” to recruit other muscles to unload the strain.
This is a beautiful example of how the body adapts to adversity, and serves us well in times of need. But here in lies the problem with injuring the ankle. Once pain has diminished and healing has occurred, the compensatory “program” is still dominant even though it no longer serves us. Inappropriate muscles will be recruited for inappropriate movement patterns, and is one of the reasons recurrent ankle injuries can occur. Over time, the newly engrained “program” will cause undue stress on the kinetic chain upstream.
It is for this reason that it is important for one to properly rehabilitate the ankle following an injury. As mentioned earlier, healing times will vary depending of the grade of the sprain. Ligaments themselves take a little longer than other tissue to heal and repair on account of their relatively poor bloody supply, and a Grade3 sprain may take 6-12weeks to repair. Vitamin C is important in the growth a regeneration of collagen fibers and help speed up the process. It is also necessary to start using the ankle as soon as is physically possible, as this will help align the healing collagen fibers in the correct orientation. If this doesn’t happen, adhesions can form, which results in restrictions and dysfunction.
Rehabilitating ligaments requires three stages.
- Phase1 – Usually the first 48hrs post injury, should involve R.I.C.E. Rest the ankle by Compressing it with a tubigrip and Elevating it. Ice for 20minutes every 2hrs. Where possible, unless absolutely necessary, avoid anti-inflammatory medications. Whist good at easing pain, they actually suppress the body’s own healing mechanism and therefore prolong the healing process.
- Phase2 – This involves restoring the ankles strength, mobility and flexibility. Following an injury, there will be some muscle atrophy due to lack of use. It is therefore necessary to do gentle stretches and strengthening exercises for the muscles that support the ankle (particularly tibialis anterior/posterior and the peroneals) as well as weight bearing in pain free ranges of motion.
- Phase3 – Once the swelling is down, gently resuming usual activities is recommended, whilst continuing with the exercises until full function is restored.
Imagine the upright skeleton as a set of blocks stacked on top of each other. If there is instability or dysfunction in the bottom block, this will be felt by all the other blocks on top of it. Using this analogy, it can be easily seen how a poorly managed ankle injury can in the long term lead to knee, hip and low back problems, and even neck and shoulder problems further up stream. Following an ankle injury, it is important to restore the correct range of motion, movement patterns and rehabilitate the proprioceptors.
If you have injured your ankle in the past or recently, it may be wise to get it assessed professionally to prevent some of the potential long term effects mentioned above.