“May those who love us, love us;
And for those who don’t love us,
May God turn their hearts;
And if He doesn’t turn their hearts,
May He turn their ankles,
So we will know them by their limping.” – Irish curse
The ankle is like your neighborhood garbage man. Humble, under-appreciated, hard-working and vitally important. The level of function of your ankles has a direct impact on how the rest of your body will perform, most directly the knees, hips and low back. Most articles about the ankle also discuss the foot, the ankle’s smelly cousin to the South. Not this one. It’s time to give the ankle it’s due, relative to just how important it is for the function of the rest of the body. So, today I’ll cover basic anatomy, injuries/conditions and exercises of only et tarso (Latin): The Ankle.
The ankle is a synovial joint made up of three bones: the tibia, the fibula and the talus. A synovial joint is the most common and movable joint in the body and is filled with synovial fluid, which has a consistency similar to an egg white and this fluid serves to reduce friction during movement. Boom. You already know more about joints than 90% of the population!
Check out this great illustration of the ankle joint, as seen from the front:
And, I’m a firm believer that you can never have too many pictures, so here are two additional views, from the front and the side:
In addition to being a synovial joint (think egg whites!), the ankle is also a hinge joint. Hinge, like a door hinge and this means that it only allows for movement in one plane: plantarflexion and dorsiflexion.
I know what you’re thinking. My ankle joint can move in a lot more directions than just front and back! No, no it can’t. The true ankle joint can only move the foot front and back. The other primary movements in that area are inversion and eversion, tilting the foot towards and away from the midline of the body.
These movements happen primarily at the Talocalcaneonavicular joint and Subtalar (talocalcaneal) joint, which are in the foot and, remember, this is an ankle only discussion. We’ll get into that other anatomy when I write an article on the foot, which is tentatively titled “And This Little Piggy: The Untold Story of Betty the Bunion”.
For now, the only relevance that inversion and eversion have to our discussion is ankle sprains, which we’ll roll into shortly (puns are fun!).
Let’s do a swan dive into more anatomy, starting with the ultra-important concept of the Kinetic Chain.
The human system of movement consisting of muscular, articular and neural components that are interdependently related. This concept fits with the joint-by-joint alternating pattern of stability / mobility, developed by Michael Boyle and Gray Cook. More information here.
This is a fundamentally important concept of human movement that says everything is connected and it involves:
- The Nervous System
What happens in the ankle, does not stay in the ankle. I’m gonna go all double negative on you and say you CAN’T NOT have compensation elsewhere in the kinetic chain if one part of that chain is not working properly. This concept must be adhered to when it comes to exercising, diagnosing and treating.
The entire kinetic chain must be investigated for level of function and all three components dealt with, if real and permanent change is to occur <—- Highlight, asterisk, underline!
In my clinical practice, I have seen a number of patients who had chronic headaches that we ultimately traced back to a biomechanical issue in the lower body, often the foot or ankle. I am being repetitive and placing such emphasis on this foundational principle because it’s important to understand that any limitations in the ankle will eventually show up elsewhere in the body. Maybe as pain. Maybe as range of motion limitations. Or, maybe as your hip giving out in the middle of doing The Dougie at your sister’s wedding, causing you to crumple pathetically to the floor while the other guests laugh and immediately post the video to YouTube where you become a viral sensation of the worst kind. It could happen.
Look again at the skeleton diagrams above and think about your exercise program. Are you training for mobility in the ankles? Stability in the knees? Mobility in the hips?
I’ll move on to common injuries but keep the kinetic chain and mobility/stability patterns in mind.
Common Ankle Injuries/Conditions
As we see above, the ankle should be a mobile segment but sometimes, it becomes too mobile and you sprain it. Most often, you “roll” your ankle and an inversion sprain occurs. The ligaments on the lateral (outside) aspect of the ankle are damaged and, occasionally a fracture will result, as well. There are a set of rules that work well in diagnosing a possible ankle fracture, called the Ottawa Rules. A good rule of thumb for someone not trained to diagnose injuries is if the injured person cannot put any weight on the injured leg immediately after the injury, an X-ray or, at least further investigation, may be warranted to rule out fracture.
So, you’re playing a pickup basketball game at your gym on Saturday morning and the guy who used to play for Duke is guarding you. Your son is watching and you want to show him that his pops can handle the rock. Your buddy passes you the ball and you start to back down Mr. Blue Devil in the paint. You fake a pass to the top of the key and with all the velocity your aged body can muster, spin the other way for what you imagine will be a Superman moment in your boy’s brain forever and * POP * your right ankle gives out and DOWN you go with a high-pitched whelp that sounds like it should have come from a Pomeranian named Mitzy.
You end up in my clinic on Monday morning, we rule out fracture and I would most likely start you on a progression like the one below.
Exercise #1: Single-leg Balance
Just as it sounds, you do your best flamingo impersonation and stand on one leg, barefoot. You should be able to do this comfortably for at least 60 seconds. Practice with each leg, not just the injured side and I recommend starting out with a hand on a wall or something stable for when you inevitably lose your balance. If you’re comfortable with 60 seconds, try closing your eyes. By taking away visual cues, you’re taking away one of your brain’s tools to maintain balance and it will force the ankle to work harder. If you want an even harder challenge, go fix the U.S. tax code. Or, balance on an unstable object like a thick, folded towel, a balance pad or a BOSU ball.
Exercise #2: Resisted Inversion + Eversion
This is a deceptively difficult exercise, especially if the injury is still relatively acute (within the last 6 weeks or so). You will be sitting on the ground and use a resistance band to…provide resistance. Be sure to perform both inversion and eversion, as shown below. Approximately 20 repetitions and 2-3 sets should do it. The band should be tied to something heavy like a table leg or my Aunt Peggy.
Aunt Peggy not pictured.
Exercise #3: BOSU Ball Lunges
I’m assuming here that you have a decent working knowledge of proper lunge form. If not, look it up or e-mail me and we’ll have a little chat. There are multiple ways to do this lunge but for ankle sprains specifically, I prefer the method shown below. You can either keep the front foot on the BOSU throughout the set or do the lunge, step off of the BOSU and then step back on for the next repetition.
You should go down until the back knee nearly touches the ground and push back up with the heel of the front foot. Dumbbells optional. If you do not have a BOSU handy, try a folded towel or a couch cushion.
Note that this model’s head and neck posture is terrible!
An ankle sprain disrupts not just the physical structures of the ankle but the proprioception of the body, as well. That means that the brain loses track of exactly where the ankle and foot are in space, thereby reducing stability. Rehab exercises repair the physical damage but also help rebuild the brain’s connection to the injured area, greatly decreasing the chance of a recurring injury. The longer you wait to start rehab, the harder it will be to fully repair the damage and you risk chronic re-injury.
Loss of Ankle Mobility
A very common, albeit, less dramatic ankle issue is the gradual loss of optimum ankle mobility. When a joint and its supporting soft tissues (muscles, tendons, fascia, etc.) are not consistently mobilized into their full and normal range of motion, they physiologically adapt in a very unfortunate way: the tissues becomes shorter and tighter, arthritis can develop in the joint and that limited range of motion becomes the “new normal”. This process forces adjacent areas of the body to compensate for the lazy joint and voila, you have an increased risk of injury and/or chronic pain and dysfunction.
Your ankles become like that kid in your 9th grade Chemistry class that would always just take a nap during group projects. “ Dude! Do some work. Wake up!” Are your ankles that guy in Chemistry class? Let’s see.
Since the vast majority of mobility and injury issues in the ankle come from a loss of dorsiflexion, this a great test. Here’s how it goes:
- Be in socks or barefoot
- The leg that you’re testing is the front leg
- Position the front leg so that the big toe is about 5″ from the wall
- Shift your front knee forward while keeping your heel on the ground
- If your kneecap can touch the wall with the heel on the ground, you have sufficient dorsiflexion
- Note that the back leg can limit this test, if hip extension is restricted. In this case, perform the test standing with the tested ankle elevated on a chair
If you find that you cannot get your kneecap to the wall, don’t lose heart! The body will always adapt to whatever stimulus it is given, so with some consistent work, you’ll improve your ankle mobility and decrease your risk of injury and compensation. There is a very good chance that the slacker in Chemistry will wake up and do his work! Here are my top 3 exercises for improving ankle dorsiflexion:
1. The foam roller! If you’re not familiar with it, make yourself so because it is fantastic and horrific at the same time. Be sure to roll all the way down to the Achilles tendon at the heel and all the way up to the knee. The roller is a great tool to help increase tissue mobility. Just like any mobility/flexibility activity, the tissues will respond best when they are warm. So, before you roll, it’s best to get your body temp up with some light cardio. Eating a PB&J sandwich really fast doesn’t count. Soreness is acceptable while you’re rolling but if the soreness becomes true pain, then back off of the pressure. Spending 3-5 minutes per calf is typically enough.
2. Stretch! This is my favorite calf stretch and be sure to do it when the body is nice and warm and perform it with both a totally straight leg and then with a bent knee. One muscle of the calf crosses the knee joint (Gastrocnemius) and one does not (Soleus) and you need to target them differently. No bouncing, just slow and steady, amigo.
The final exercise that completes the trifecta is doing the Ankle Alphabet. This involves “air writing” the letters of the alphabet with your foot. You don’t need a picture of that, do you? No? Good. This exercise is effective at mobilizing the ankle in all of its various planes of motion and is also a good warm up prior to exercise.
This is all just scratching the surface of The Proper Care and Feeding of Your Ankles and if you have specific questions, I’d love to hear from you. But, use e-mail. Don’t show up on my front lawn at 3 in the morning after a night of Lemon Drops, lamenting your lack of dorsiflexion.
Dr. Todd Thistle, DC, CCSP