The ankle sprain.
It’s an incredibly common injury among athletes.
But what actually happens when you sprain your ankle? And what causes them to happen? Consider this article a simple guide that will cover the anatomy of your ankle, the common problems that occur within and about the ankle, and ways you can rehab/prevent ankle sprains.
What Is the Ankle?
The term “ankle” isn’t as specific as its frequent usage might suggest.
The “ankle” is actually a series of joints that work to provide static support of the most distal (meaning furthest from the center of the body) part of the lower extremity.
That’s why when people tell me that they injured their ankle, I’m always curious to what specific structure they’re actually referring to. Because in honesty, there’s a ton going on inside our ankles and feet.
The foot itself is divided into three zones: rearfoot, midfoot and forefoot. These three zones contain a total of 26 bones!
These bones act as the structural base for our entire body. But for us to move efficiently, we need to have adequate range of motion (ROM). The combination of joints in the foot and ankle allow us to have various types of motion, including plantar flexion (movement of the foot where the toes flex downward toward the sole), dorsiflexion (movement of the foot where the toes come toward the shin), inversion (rolling of the foot in the direction of the big toe), eversion (rolling of the foot in the direction of the pinky toe), abduction and adduction (rotation of the foot at the ankle), and more.
Let’s talk about the major joints of the ankle. There are four: distal tibiofibular, talocrural, subtalar and transverse tarsal.
The first joint, closest to the shin, is the distal tibiofibular joint. It is a syndesmotic joint, which means there’s no movement at the joint and it’s joined by connective tissue (in this case, the tibia and fibula). Since this joint is not moveable, it takes a high amount of force for it to be injured, and injuries here are very uncommon.
The next two joints are the main articulations for the “ankle.”
The first being the talocrural joint, which is made up of the tibiotalar and tibiofibular complexes. It is a synovial hinge joint, which means it’s responsible for dorsiflexion and plantar flexion, or bringing the foot up and pushing it down. The talocrural joint forms the ankle mortise, where the fibula, tibia and talus all meet to create the hinge. This joint relies on static support from the lateral ankle complex (anterior/posterior talofibular ligaments and calcaneofibular ligaments) and the medial ankle ligaments or “deltoid” complex (anterior/posterior tibiotalar, tibionavicular and tibiocalcaneal).
Yes, I know that sounds like a mouthful! And it is, but these two ligament complexes are the two most commonly injured in ankle sprains. 85% percent of all ankle sprains are lateral ankle sprains, 10-14% are medial ankle sprains, and the remaining 1% consist of syndesmotic or high ankle sprains.
The second main articulation of the ankle is the subtalar joint. It which mainly allows for inversion, eversion and some gliding. This joint is very important in allowing your foot to adjust to uneven terrain while moving by shifting from side to side. It is also very important in athletic movements such as pivoting or turning with a fixed foot. This movement is essential for proper gait, but can lead to increased risk of injury if excessive laxity in this joint becomes present, which can lead to hypermobility and overpronation.
The final joint of the ankle is the transverse tarsal joint, which involves a slew of bone articulations and ligaments. It is farther away from the shin than the previous three joints we have talked about, being located near the midfoot. It is a synovial joint that assists in inversion and eversion of the foot. The ligaments that support this joint include: the long and short planar ligaments, the “spring” ligament (which plays a vital role in arch type), calcaneonavicular ligament and calcaneocuboid ligament.
As you can see, there are dozens of bones, ligaments and tendons in the foot and ankle. And that was just the abridged version! When it comes to muscular aspects of this area, we must hit on the ankle stabilizers.
The plantar fascia and four layers of intrinsic foot musculature provide dynamic support to the sole surface of the foot and form lateral, medial and transverse arches that are vital in gait, weight distribution, balance and force absorption. The antagonist muscles on the dorsal, or top surface of the foot, provide much of the dorsiflexion for the ankle and metatarsals to allow us proper heel strike and weight transfer throughout the gait cycle.
The next group of dynamic stabilizers come from the posterior compartment of the leg—the gastrocnemius, soleus, tibialis posterior, flexor digitorum longus and flexor hallicus longus. These are mainly plantar flexors, but the deep compartment muscles span the posterior leg and wrap around the medial malleolus (through the tarsal tunnel) into the bottom of the foot and account for some of the muscle bellies in the plantar surface of the foot. The final group of dynamic stabilizers of the foot and ankle are the lateral compartment muscles of the leg. These muscles include the peroneal or fibular muscles; the peroneus longus, peroneus brevis and peroneus tertius, which span the lateral leg and wrap around the lateral malleolus and attach to both the top and bottom of the foot.
How Do We Prevent Ankle Sprains?
When we talk about injury rehabilitation, we first need to have an accurate idea of what injury has occurred. When we talk about injury prevention, we like to have an idea of what deficiencies or asymmetries an athlete has (which can be identified through a comprehensive functional assessment), and then address those in an individualized program.
Unfortunately, diagnosis over the internet is extremely tough. However, I’ve provided a prehab and rehab program below that hones in on strengthening the dynamic stabilizers of the ankle and foot using a combination of eccentric, concentric and isometric work. This program will lead to a more resilient foot and ankle, and a foot and ankle that’s better able to attenuate force and activate often-neglected muscles. The other portion of the program will focus on tissue flexibility and joint mobility, which will allow your ankle and foot to move properly and efficiently.
When you take away stabilization from an area, whether that is from joint mobilizations, soft tissue mobilizations, stretching or mobility work, you have to add that stabilization somewhere else. The goal of the general guide below is to provide you with both increased tissue flexibility and joint mobility but also increased muscle stabilization. The program should come in handy if you’ve sustained an ankle injury and are looking to rehab back to your sport/activity, or if you’re striving to prevent an injury like this from occurring.
As someone who has had chronic ankle instability and dozens of sprains in both ankles spanning back to middle school, I have found a special passion for this area of the body, because I know how aggravating it can be when you are suffering through it. Give these a shot and let me know if you have any questions or feedback.
*Repeat 2-3 times per week for rehabilitation purposes
*If in the acute stage of healing, these ROM exercises should be completed in an elevated position, and if tolerable, in a compression wrap, as well.
*Full ROM should be attained before progressing to strengthening and balance exercises
Range of Motion Warm-Up
- Ankle Circles Counterclockwise: 3×15
- Ankle Circles Clockwise: 3×15
- Ankle Pumps Up/Down: 3×15 (Up and down is 1 rep)
- Ankle Pumps Side-to-side: 3×15 (Side to side is 1 rep)
Mobility (As Allowed By Pain Tolerance And Time Since Injury)
- Kneeling Forward Lunge (Pushing Knee Over Foot): 4x30sec
- Straight Leg Calf Stretch: 4x30secBent Knee Calf Stretch: 4x30sec
- Iso-Goblet Squat: 1 minute at bottom of squat, rest, then perform one more rep
- Banded Ankle Dorsiflexion: 3×15 (Slow eccentric portion)
- Banded Ankle Eversion: 3×15 (Slow eccentric portion)
- Banded Ankle Inversion: 3×15 (Slow eccentric portion)
- Banded Ankle Plantarflexion: 3×15 (Slow eccentric portion)
- Calf Raises on Slanted Surface: 3×15 (Slow eccentric portion)
- Toe Walks: 3×20 Steps
- Heel Walks: 3×20 Steps
- Single-Leg Balance (Eyes Open): 3x20sec
- Single-Leg Balance (Eyes Closed): 3x20sec
- Single-Leg Balance, Standing on Towel (Eyes Open): 3x20sec
- Single-Leg Balance, Standing on Towel (Eyes Closed): 3x20sec
- Lateral Skater Jump and Land (hold landing for 1 second) – 10 Jumps Each Leg
Photo Credit: tommaso79/iStock, spukkato/iStock