High Ankle Sprain: How to rehab or defend against them

The International Stunt Academy's guide to High Ankle Sprain Injuries.  Stunt people are in the ultra-high risk category for Ankle injury. It's not uncommon to see sprains and over-rotation issues, but these very easily lead to ligament and tendon damage that can be long term.   Also, not all sprains are the same. There are different types and in this article we focus on the "High Ankle Sprain".  Beware taking general sprain advice, especially if you have had repeated sprains on the same ankle, as often this is a signal you can muscle imbalance that's leaving you wide open to repeated injuries  

While a doctor may casually diagnose a 'sprained ankle', there are in fact different types of sprain and different grades of severity. Each has a different treatment path. 

The categories of ankle sprains (grades 1, 2, and 3) are based on the severity of the injury, which ligaments are affected and the level of tearing.

But the different types of ankle sprains are based on how the injury occurred and which ligaments are more involved. The most common types of ankle sprains are:
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1. Inversion ankle sprain 
   This is the most common type of ankle sprain and occurs when the ankle rolls inward, stretching or tearing the ligaments on the outside of the ankle. Inversion ankle sprains can be mild to severe, depending on the extent of ligament damage.
2. Eversion ankle sprain 
   This type of ankle sprain is less common and occurs when the ankle rolls outward, stretching or tearing the ligaments on the inside of the ankle. Eversion ankle sprains can also be mild to severe.
3. High ankle sprain 
   Also known as a syndesmosis injury, this type of ankle sprain occurs when there is a sprain to the ligaments that connect the tibia and fibula bones in the lower leg. High ankle sprains are less common than inversion or eversion sprains but can be more severe and take longer to heal.
4. Syndesmotic ankle sprain
   This type of ankle sprain involves injury to the syndesmotic ligaments, which are located above the ankle joint and help stabilize the ankle joint during movement.

Let's explore the High Ankle Sprain, and why its likely to become a repetitive injury. 

​Repetitive high ankle sprains can be challenging to treat and require a comprehensive approach that includes both strengthening and flexibility exercises to help stabilize the ankle joint and prevent further injury. Here are some physio activities and exercises that may be helpful:

1. Range of motion exercises
   Perform ankle range of motion exercises to improve the flexibility of the ankle joint. This includes ankle circles, alphabet exercises, and heel-to-toe rocking.
2. Strengthening exercises
   Strengthen the muscles surrounding the ankle joint, including the calf, shin, and foot muscles. This includes heel raises, toe raises, single-leg balance exercises, and resistance band exercises.
3. Proprioception and balance training
   Proprioception exercises can help improve joint stability and reduce the risk of future ankle sprains. This includes standing on one leg with your eyes closed or standing on an unstable surface like a balance board or foam pad.
4. Plyometric exercises
   Plyometric exercises, such as jumping and hopping drills, can help improve ankle stability and prevent future ankle sprains.
5. Sports / Activity specific drills
   Depending on the specific activity that caused the ankle sprain, your physiotherapist may recommend specific drills to help improve your performance and reduce the risk of future injuries.

But which muscles in particular are more likely to be related to the cause of a high ankle sprain?

High ankle sprains typically occur when there is a sudden twisting or rotating of the ankle, which can cause injury to the ligaments that connect the tibia and fibula bones in the lower leg. While there is no one muscle group that is solely responsible for causing high ankle sprains, there are certain muscles that may play a role in increasing the risk of injury.

The muscles that are most commonly associated with high ankle sprains include:

1. Tibialis anterior
   This muscle runs along the front of the shin and is responsible for dorsiflexion (lifting the foot up) and inversion (turning the foot inward). Weakness in this muscle can make it harder to control the foot and ankle during sudden movements, increasing the risk of injury.
2. Peroneals
   These muscles are located on the outside of the lower leg and are responsible for eversion (turning the foot outward) and plantarflexion (pointing the foot down). Weakness in these muscles can also contribute to ankle instability and increase the risk of sprains.
3. Gastrocnemius and Soleus
   These muscles make up the calf and are responsible for plantarflexion (pointing the foot down). Tightness in these muscles can limit ankle dorsiflexion and increase stress on the ankle joint, making it more susceptible to injury.

Testing for imbalance
​An easy test to sense out which muscle groups are out of balance is the single-leg balance test. This test can help identify any weaknesses or imbalances in the ankle and foot muscles, including the Tibialis anterior, Peroneals, and Gastrocnemius/Soleus.

Here are the steps to perform the single-leg balance test:

1. Stand near a wall or sturdy object that you can use for support if needed.
2. Stand on one foot with your knee slightly bent and your foot flat on the ground.
3. Try to maintain your balance for 30 seconds without touching the wall or object for support.
4. Repeat the test on the other foot.

While performing the test, pay attention to any wobbling or shaking in your ankle and foot, as well as any difficulty maintaining your balance. If you notice that you have more difficulty balancing on one foot than the other, this may indicate a weakness or imbalance in the ankle and foot muscles on that side.
It's important to note that the single-leg balance test is not a definitive diagnosis, and a healthcare professional or physiotherapist can provide a more detailed assessment and treatment plan. However, it can be a useful tool for identifying any imbalances and weaknesses in the ankle and foot muscles.
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How can people tackle tightness in Gastrocnemius and Soleus? (short / tight calves)

Tightness in the Gastrocnemius and Soleus muscles can contribute to ankle instability and increase the risk of injury. Here are some ways that you can tackle tightness in these muscles:

1. Stretching
   Regular stretching of the gastrocnemius and soleus muscles can help improve ankle range of motion and reduce the risk of injury. Some effective stretches include calf raises, wall stretches, and stair stretches. Hold each stretch for 30 seconds and repeat several times per day.
2. Foam rolling
   Foam rolling can help release tension and tightness in the gastrocnemius and soleus muscles. Roll the foam roller along the back of the calf, focusing on any areas that feel particularly tight. Spend 30 seconds on each spot and repeat several times per day.
3. Massage
   Massage can also help release tension and tightness in the calf muscles. Use your hands or a massage ball to apply pressure to the back of the calf, focusing on any areas that feel particularly tight.
4. Strengthening exercises
   Strengthening exercises can also help reduce tightness in the calf muscles. Calf raises, ankle dorsiflexion exercises, and resistance band exercises are all effective ways to strengthen the calf muscles.
5. Proper footwear
   Wearing proper footwear that supports the arch of the foot and provides adequate cushioning can help reduce stress on the calf muscles and prevent tightness.

Which exercises can increase strength of the Peroneals, if they are weaker and the sprain comes from muscle imbalance caused by this?

If the peroneal muscles are weaker and contributing to muscle imbalances that increase the risk of ankle sprains, it's important to include exercises that specifically target these muscles in your rehabilitation program.

Here are some exercises that can help increase strength of the peroneals:

1. Ankle eversion exercises 
   Ankle eversion exercises involve turning the foot outward against resistance to target the peroneal muscles. This can be done with a resistance band or cable machine. Start with low resistance and gradually increase over time.
2. Resisted dorsiflexion exercises
   These exercises involve lifting the foot up against resistance, which can help target the peroneal muscles. This can be done with a resistance band or ankle weights.
3. Balance exercises
   Balance exercises that challenge your ability to maintain stability on one foot can also help target the peroneal muscles. Examples include standing on one foot with your eyes closed or standing on an unstable surface like a foam pad or balance board.
4. Strengthening exercises for the foot
   Strengthening the muscles in the foot can also help improve ankle stability and reduce the risk of ankle sprains. Exercises such as toe curls, marble pickups, and towel scrunches can all be effective.

Exploring the cause of muscle imbalance (over or under development of specific muscles and their functions)

Tibialis Imbalances 
The Tibialis anterior is a muscle located on the front of the lower leg and is responsible for dorsiflexion (lifting the foot up) and inversion (turning the foot inward). While any activity that involves these movements can help develop the Tibialis anterior, there are certain sports or activities that may lead to an under or over development of this muscle:

1. Running:
   Running involves repetitive dorsiflexion, which can help develop the Tibialis anterior. However, running on uneven surfaces or with improper footwear can increase the risk of developing muscle imbalances and lead to an underdeveloped Tibialis anterior.
2. Jumping and plyometrics: Activities that involve jumping, such as basketball or volleyball, can help develop the Tibialis anterior. However, overdoing these activities without proper rest and recovery can lead to overuse injuries and muscle imbalances.
3. Cycling: Cycling primarily involves plantarflexion (pointing the foot down) and does not involve much dorsiflexion, which can lead to an underdeveloped Tibialis anterior.
4. Soccer: Soccer involves a combination of running, jumping, and change of direction movements, which can help develop the Tibialis anterior. However, playing on uneven surfaces or with improper footwear can increase the risk of injury and lead to muscle imbalances.
5. Walking: Walking involves repetitive dorsiflexion, which can help develop the Tibialis anterior. However, walking in shoes with a high heel or with poor arch support can lead to muscle imbalances and an underdeveloped Tibialis anterior.

Peroneals Imbalances
The Peroneals are a group of muscles located on the outside of the lower leg and are responsible for eversion (turning the foot outward) and plantarflexion (pointing the foot down). While any activity that involves these movements can help develop the Peroneals, there are certain sports or activities that may lead to an under or over development of these muscles:

1. Dance
   Dance involves a lot of foot and ankle movements, including eversion and plantarflexion, which can help develop the Peroneals. However, over-practicing without proper rest and recovery can lead to overuse injuries and muscle imbalances.
2. Football (Soccer)
   Football involves a combination of running, jumping, and change of direction movements, which can help develop the Peroneals. However, playing on uneven surfaces or with improper footwear can increase the risk of injury and lead to muscle imbalances.
3. Basketball
   Basketball involves a lot of lateral movement and change of direction, which can help develop the Peroneals. However, overdoing these activities without proper rest and recovery can lead to overuse injuries and muscle imbalances.
4. Running
   Running primarily involves plantarflexion and dorsiflexion (lifting the foot up), and does not involve much eversion, which can lead to an underdeveloped Peroneals.
5. Cycling
   Cycling primarily involves plantarflexion and does not involve much eversion, which can lead to an underdeveloped Peroneals.

Gastrocnemius and Soleus Imbalances
​The Gastrocnemius and Soleus muscles are the muscles of the calf and are responsible for plantarflexion (pointing the foot down). While any activity that involves this movement can help develop the Gastrocnemius and Soleus, there are certain sports or activities that may lead to an under or over development of these muscles:

1. Dance
   Dance involves a lot of foot and ankle movements, including plantarflexion, which can help develop the Gastrocnemius and Soleus. However, over-practicing without proper rest and recovery can lead to overuse injuries and muscle imbalances.
2. Jumping and plyometrics
   Activities that involve jumping, such as basketball or volleyball, can help develop the Gastrocnemius and Soleus. However, overdoing these activities without proper rest and recovery can lead to overuse injuries and muscle imbalances.
3. Cycling
   Cycling primarily involves plantarflexion and does not involve much dorsiflexion or eversion, which can lead to an underdeveloped Gastrocnemius and Soleus.
4. Swimming
   Swimming primarily involves dorsiflexion and not much plantarflexion, which can lead to an underdeveloped Gastrocnemius and Soleus.
5. Running
   Running involves a lot of plantarflexion, which can help develop the Gastrocnemius and Soleus. However, running on uneven surfaces or with improper footwear can increase the risk of injury and lead to muscle imbalances.

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Note: this is not medical advice and as athletes and performers you should always seek proper help and diagnosis from a licensed medical professional with a specialism in your specific type of injury, not just the advice of a general practitioner.  It's important to work with a qualified physiotherapist to create an individualized plan that addresses your specific needs and goals. They can also help monitor your progress and adjust your program as needed.