Ankle Pain and Treatment
Ankle injuries - Inversion and Eversion - An MSK Therapy perspective
Ankle injuries are extremely common in daily life and unresolved injuries can create a many other problems. Sports injuries involving the ankle are extremely common in many types of sport, involving uneven ground, rapid changes in direction or jumping. Most runners will have twisted their ankle at some point and often thought nothing of it. However, the foot has a significant impact on the "Kinetic Chain" and everything above the foot/ankle. The foot and ankle are also load bearing joint complexes, with loads increasing with certain types of activity (jumping, fast changes in direction, carrying heavy equipment). Furthermore, ankle injuries affect a wide variety of tissues within the injury area including fascia, ligaments, tendons, muscles. The most severe cases can also lead to joint dislocations and bone breakages Unresolved ankle and foot injuries can often lead to other injuries/conditions such as Plantar Fasciitis, Achilles Tendinopathy, Shin Splints, Knee, Hip and back problems. Again, this is in part due to the “Kinetic Chain”, and the impact the unresolved ankle injury has on other joints structures and tissues. The author knows much of this all to well from bitter experience of such injuries during his time within the British Military. Ankle injuries were relatively common due to a combination of factors including, terrain, extreme loads, weather, the speed of movement and general fatigue. The author has had multiple ankle injuries and at least two grade two ankle inversion injuries on the same ankle over the years.
Types of Ankle injuries
The two most prevalent types of ankle injury are Ankle Inversion and Ankle Eversion injuries, though other types of damage can occur. This article is going to concentrate on the most common type of ankle injury, inversion injuries.
The ankle consists of multiple joints complexes including the foot, ankle and lower leg. The design of these structures helps to explain why ankle inversion injuries tend to be more common. An inversion injury involves rolling over the outside of the ankle, which in essences stretches tissues on the lateral aspect of the lower leg. Ankle eversion injuries tend to be less frequent and involve rolling over the inside portion of the ankle and lower leg. Eversion injuries tend to be worse when they occur, as the structure of the lower leg, ankle and foot make it harder to injure the ankle this way. Hence, usually, the force required to create an ankle eversion injury is higher, than that of an ankle inversion injury. Ankle injuries are relatively common in certain types of sports, which typically involve a one or a combination of rapid changes in direction, full body contact, jumping and landing, moving over uneven terrain and running. Examples of such sports might include, Basketball, Football, Tennis, Squash, Running, Rugby, Netball, some Martial Arts. That said it is relatively easy to sprain an ankle when walking or going about one's everyday activities. Another typical and non-sports related injury mechanism is high heels, which can quite quickly lead to either ankle inversion or eversion injuries and in some cases both. Mixing high heels and alcohol can increase the risks further, due to the effect that alcohol has on the cerebellum. The cerebellum plays a massive part in motor control, balance, spatial awareness and gait (our walking ability). Alcohol impairs functions of the cerebellum, which is why Police in some countries use sobriety tests as indicators of drink driving. Walking on high heels must be challenging enough for the cerebellum, even when it is functioning normally and without any additional alcohol impairment. Ankle injuries are typically graded from 1 to 3 in terms of severity, with three being the most severe. The following two images demonstrate the bone structure of the lower leg, ankle and foot complex without any connective tissues.
Image of Foot and Ankle Joint Bones (Left Foot)
Images produced with kind permission of 3d4medical.com from Essential Anatomy 5
(Copyright © 2018 - 2023 3D4Medical. All rights reserved.)
Ligaments of the ankle and the shear complexity
Ankle injuries rarely affect just the ankle and frequently impact the foot and lower leg too. The vast majority of lower leg muscles pass over the ankle joint complex and attach to various parts of the foot via tendons. As was discussed in the Plantar Fasciitis article, the foot is exceptionally complicated, consisting of 26 bones, 33 joints and around 100 muscles, tendons, ligaments, bursa and fascia. The foot and ankle complex has many ligaments, which anchor bones to bones, reinforce/stabilize joint complexes and limit movement at each joint structure. Coupled motion is essential in allowing the body to move and perform without pain or discomfort. Although each joint within the foot and ankle complex may have limited motion, the overall level of motion occurs through the cumulative effect of each motion segment (coupled motion). As mentioned, there is a massive number of ligaments within the foot and ankle complex. Ankle injuries can easily involve a combination of the following ligaments, plus other connective tissue structures:-
- Anterior tibiofibular ligament
- Anterior talofibular ligament
- Anterior tibiotalar ligament
- Tibionavicular ligament
- Tibiocalcaneal ligament
- Posterior tibiotalar ligament
- Deltoid ligament
- Posterior talocalcaneal ligament
- Posterior talofibular ligament
- Posterior tibiofibular ligament
- Calcaneofibular ligament
The two images below demonstrate the number of tissues and structures exceptionally well.
Image of Foot and Ankle Joint Complex and some ligaments of the ankle
Images produced with kind permission of 3d4medical.com from Essential Anatomy 5
(Copyright © 2018 - 2023 3D4Medical. All rights reserved.)
Any of these structures can become damaged during an ankle injury, and each part has an impact on lower leg mechanics and overall mobility. Research also suggests that trauma is a primary cause of myofascial trigger point formation within muscle tissues. Furthermore, an injury can compromise the fascial system, affecting biomechanics and resulting in myofascial pain.
The article on "Runners Knee, the ITB Syndrome version" can also have relevance to unresolved ankle injuries.
The human GPS and sensors
The human body also has multiple sensors within it which provide essential functions and are highly relevant to ankle injury rehabilitation. Everybody is aware of the five primal senses; touch (somatosensation), smell (olfaction), hearing (audition), taste (gustation), sight (vision). The human body also has other sensory receptors which detect; Temperature (thermoception), Pain (nociception), Chemical changes within the body (chemoreceptors), Mechanical pressure or distortion affecting the body (mechanoreception), Balance (equilibrioception) and Kinesthetic awareness (proprioception). An ankle injury is likely to involve all of these sensors at some point through the injury healing process (see Soft tissue repair, healing and scar tissue article). However, the impact an injury can have on Kinesthetic awareness and proprioception can be profound. Proprioreceptor sensors occur throughout the body, in muscles, joints and fascia and are a kind of GPS for the body. The proprioceptors provide information to the brain about the position of various joints at any given point in time, and in the space, they occupy. The brain can process the information from the multiple proprioceptors to form a kinesthetic awareness of our surroundings and thus enable one to move around and perform tasks. Injuries generally create trauma to soft tissues which can impact joint position. Furthermore, injuries can also mess up the bodies Kinesthetic awareness and proprioception of the damaged area's place in the space. For example, after an ankle inversion injury, the foot tends to have a slightly altered position. The altered position often means that when the foot plants on the ground, it does so more on the lateral edge (the side with little toe) or supinates. As far as the body is concerned this post-injury foot position is normal or learnt as the new normal following on from the initial trauma. Everything else in the “Kinetic Chain” then has to alter or adapt (see Soft Tissue Adaptation to activity and injury article) according to the new foot position, which not only changes the loads but even the angles of load application. Hence, it is no surprise that many other injuries can occur due to unresolved historical ankle traumas. Unresolved trauma affects the injured joint structure and others, leading to different types of injury and re-injury. Conditions can become chronic with repeated trauma, and this can lead to Persistent Pain (see article) and restricted mobility. Once a condition is Chronic, it is harder to treat due to the various tissues adaptations due to healing and learnt movement patterns affecting many areas. The altered position of the foot, post ankle injury also means it is more likely to get re-injured, as one would be running on the lateral aspect of the foot supinating. Walking or running on the lateral edge of the foot, positions the foot in a prime position for a further ankle inversion injury. In essence, this is why many people have a subsequent history of additional ankle injuries. Also, tissue adaptations and changes in mechanics impacts tensional forces elsewhere in the body and thus other types of injury can occur over time (see the Biotensegrity and how everything is connected article for further details)
Ankle Injury treatment options
As with many types of injury, there are multiple treatment options available. Ankle injuries can be severe, depending on the forces involved, the injury mechanism and the grade of injury/tissue damage. In less, severe injury cases Rest, Ice, Compression and Elevation (R.I.C.E.) are often prescribed or advised within the first 72 hours post-injury. However, it is worth getting an ankle injury checked by a suitably qualified professional in the first instance. See the article on Finding a good, ethical Musculoskeletal health professional, which covers what to look for and avoid. Any treatment or successful rehabilitation post injury is likely to have many aims or goals.
Critical goals of treatment:-
- Address the damaged soft tissues.
- Regain full or as near to full range of motion/mobility as possible.
- Retrain/relearn kinaesthetic awareness and proprioception (see the article).
- Regain muscle strength.
- Compensate for increased ligament laxity (in many cases).
It is complicated to attempt to self-treat an ankle injury, due to the steps required for successful rehabilitation. Treating the soft tissues and regaining full mobility of the foot, ankle and lower leg complex is best left to a professional with training in these areas. Useful skills can include soft tissue therapy education, joint mobilisation training and in some cases adjustive knowledge and experience. Hence, Osteopaths, a proportion of Chiropractors, and some Physiotherapists and Myotherapists have training in all these areas. The remaining aspects of treatment are usually performed in conjunction with professional guidance and often as aftercare advice (homework). Typically the patient is required to complete specific proprioceptive exercises with a wobble board or rocker board etc. Graded conditioning exercises are usually prescribed to strengthen damaged muscle tissues and help compensate for any joint ligament laxity post-injury. Recovery times can vary according to the severity or grading of the injury, how soon appropriate treatment is sort and importantly if the patient follows the rehabilitation aftercare advice.
The article was written by Terry Davis MChiro, BSc (Hons), Adv. Dip. Rem. Massag., Cert. WHS.
The Morningside clinic occasionally runs promotional treatment rates for new and existing patients, which are available via the online booking calendar. If you liked this article or found it interesting, feel free to share the content with others. There are lots more articles available via the TotalMSK main Health, Wellness and Sports Injury blog page, which has a brief description of all the articles to date.
About the Author
As of December 31st 2020, the author chose to leave the Chiropractic profession due to a planned move back to Australia, where his training and education are not recognised. Terry no longer works as a Chiropractor and works as a Myotherapist in Morningside, Brisbane. He developed an early interest in soft tissue therapy techniques and advanced myofascial release methods in 2006 for treating various conditions. Terry's interests in human performance and trauma have naturally led to him developing a specialism in treating work and sports-related musculoskeletal injuries and Chronic Pain symptoms.
The author possesses an unusual background for somebody who trained in the McTimoney Chiropractic technique. His education, training, and practical experience span over two decades and relate to health's physical and mental aspects. He also needed to push his body and mind to the limits of physical and psychological endurance as part of his time serving in Britain's elite military forces. His education includes a bachelor of science degree in Business Management, with a specialisation in psychology and mental health in the workplace, an Integrated Masters in Chiropractic, MChiro and a multitude of soft-tissue therapy qualifications (see the about section for more details). His soft tissue qualifications range from certificate level right through to a BTEC Level 5 Advanced Diploma in Clinical Sports and Remedial Massage Therapy. He has also taught as a senior course coach at the Advanced Diploma level (Myotherapy / Musculoskeletal Therapy) in Australia, both theoretical and practical aspects, including advanced Myofascial Release Techniques and has certification in training and assessment. Terry will have taught many of the first students to train as Myotherapists in Brisbane. Terry's combination of knowledge through education, training, elite military service, and personal injury history has paid dividends for the patients he sees and has treated over the last 16 years. Terry is still extremely active and enjoys distance running, kayaking, mountain biking and endurance-type activities.