One of the biggest mistakes I have ever made in sporting career is not treating my ankle sprains with enough respect and ensuring I had full mobility, stability and strength before going back to playing and training. I cannot tell you how many times I sprained my ankles, my left in particular suffered at least 3 grade 3 tears! Nearly all of us have sprained our ankle at one point in our life and almost all of us are also guilty of under-playing the consequences just like me. After the initial searing pain, we limp home, reach for the pain-killers, get the frozen peas out of the freezer and on the swollen ankle, before resting on the couch with our foot up for an hour or two. After a few days of hopping around we try to soldier our way on, and before you know it the pain has gone, the ankle is a bit stiff, but we feel we will be back to normal in a week or two. It is about this time we think we are okay have got away with just a sprain. But, as I am going to show in this article it is at this time that even the simple grade 1 sprains can create a dangerous chain reaction of compensatory movements that are conspiring to create much more severe and painful problem. Like I said at the beginning I have made this mistake myself many times and this year I have been involved with 4 people, myself being one of them, that suffered a devastating ACL Tear, and in EVERY case the ankles were either the main cause of the problem or played a big part in creating it!

How Important Is Ankle Mobility For Movement?

Above I have provided pictures of different grades of ankle sprains and a picture of just how many ligaments surround the ankle joint. As I mentioned in the introduction this year (2016), I have seen several severe injuries all created from ankle mobility restrictions. These severe injuries potentially could have been avoided if a correct rehabilitation program was put in place. Now while ankle sprains is one reason for ankle stiffness, it is not the only reason! For while the ankle needs mobility, the feet need stability! That sounds like a real mouthful and I will explain in more detail shortly. One of the most important lessons I learned this year is what is known as the "Joint by Joint" approach which was invented by Mike Boyle. This gives great insight into how many movement problems are often created somewhere else and to correct the problem using this approach can help identify the right course of action. I found this extremely helpful in narrowing down the right test, but also the right corrective exercise or stretch. What you will see is that every second joint needs flexibility and mobility, and the other joints need the exact opposite being stability and strength. Here is how it works.

1. Feet - The feet have a tendency to being lazy, and easily losing strength and motor control. From poor footwear, to sitting too much, and even the lack of barefoot walking, the feet need exercises to make them stronger and more stable.
2. Ankle - The ankle tends to develop stiffness very easily and needs more focus on mobility and flexibility.
3. Knee - The knee like the feet becomes weak and sloppy easily, (VMO for instance completely shuts down with as little as 10ml of fluid present). This in turn creates severe knee injuries and if left untreated eventually chronic stiffness in an attempt to stabilize it. Stability and strength work is needed for this joint.
4. Hip - This joint is often the cause of many problems. The hips have a tendency towards stiffness and as a result benefit from flexibility and mobility work.
5. Lumbar Spine - The lumbar spine needs stability to prevent unwanted flexion or extension.
   

As you continue up the body each main joint is the opposite to the one below and above. This is very important when trying to work out what is going on with lower limb injuries in finding the original cause.

This year we have also worked with many people with walking impairments that also had similar ankle stiffness and lack of motor control, but not previous history of ankle sprains or trauma! In some cases the original problem was loss of strength with the feet first that then developed ankle problems. And in other cases it was hip & pelvis injury causing glute weakness and hip stiffness that caused the leg to pronate in. This tells you that you can develop ankle stiffness, without ever spraining your ankle!

The main thing to understand though is if you have tight ankles they need to be mobilized in order to strengthen the weak areas.

A tell tale sign of ankle restriction is the if person has restricted dorsiflexion (pulling your toes back towards your shin).  You can easily assess your own ankle mobility by using what is known as the wall test (see below).

How To Do The Wall Test

1. Kneeling on the floor in front of a wall with the stiff ankle the (front) leg
2. Slowly try to move your foot back as far as possible, while still being able to dorsiflex with the heel on the ground so the knee touches the wall in front.
3. The foot should point directly ahead and the knee should move directly over this.
4. The distance from great toe (the end of the big toe) to wall is measured. Score 0 for normal; 1 for abnormal or 2 for very abnormal.

The Chain Reaction Of Injuries

The chain reactions of problems and new injuries begin to develop the minute you need to execute any movement that will require your legs. The body will need to compensate at other joints in order to move due to the loss of ankle mobility. Dorsiflexion is something we all tend to take for granted in daily life and in sport and trust me you can ask the people with walking impairments how hard it is to walk when your foot does not do this. Every time you squat, lunge, and move your legs for almost any daily activity you require it. In sports even more so with high powered multi-directional movement patterns (eg, tennis, football, basketball etc), requiring high levels of ankle mobility to be able to move in several directions all in a split second, while maintaining perfect balance and control. The risk is much higher for this reason which is why any sportspeople who suffers recurring ankle ligament injury must have a strong focus on regaining optimal mobility as fast as they can.

The common chain reaction from loss of ankle mobility is often seen easily with the feet moving into excessive pronation, otherwise known as flat feet. As the person begins to try and move with this excessive pronation and flat feet, a chain reaction of new problems is beginning to surface. Injuries like plantar fasciitis and achilles strain are common at this stage.

The next step results in the knee tending to turn inwards on the tibia, producing an exaggerated quadriceps angle (Q angle) that now exposes the knee joint to injury. This is where patella tracking, ITB friction syndrome and ACL injuries happen.

Lastly the poor position of the lower limb then in turn creates strength deficits in glute strength and control at the hip. The glutes provide external rotation of the femur, but like the muscles in the feet and the VMO are a phasic muscle that is prone to weakness and laziness.  The longer this dysfunction remains in place they begin to lose their effectiveness in controlling this faulty alignment and now it is just a matter of time for something worse to develop. This is where you see hip problems like Piriformis Syndrome develop and lower back problems from poor hip control.

All of these just the end result of not rehabilitating your ankle sprain properly!

The picture below helps to explain this chain reaction. The picture alongside of a single leg squat test highlights this faulty movement, and we see this in 99% of all knee and ankle injuries.

Something like an ankle sprain that most of us take for granted now sets in motion a series of compensatory movements that begin to corrupt many of your movement patterns. Almost every lower limb injury you can attribute to a hip / glute problem or an ankle problem. The knee joint stuck in between these two is very limited with it's function for doing anything other than working like a hinge. It does not have the ability to rotate and complete all the complex movements that the ankle and hip can do. You can now also see why so many people keep getting new injuries or re-injure themselves and why many traditional treatments fail. For they focus only on the area in pain, but as you have just seen now, it is so easy to create the problem from somewhere else, and often that joint is not in any pain at all! Always remember this:

THE AREA IN PAIN IS MOST LIKELY NOT WHERE THE PROBLEM IS!

To give you a picture of what the chain reaction looks like and the potential injuries resulting from loss of mobility or stability, here is a very simple chart showing what we often see happen. This is not all of the potential injuries just the main ones!

Where Do You Start Trying To Correct These Faults?

I wish I could give you a simple answer, but as you probably guessed that is not likely.

The problem we are always faced with is what started first? Was it the foot rolling in? Was it the ankle becoming stiff and immobile? Or was it the glutes becoming weak, or maybe the hips becoming tight? And after you find that out, your next question might be even harder to answer, WHY did that happen? It is hard to say which one started the dysfunction, but you can narrow the problem down by gathering as much information as you can.

Firstly you will need to take into account previous history of injuries and very importantly when they happened, to help trace the original problem.

Secondly using postural assessments in both static and dynamic positions can gather some important clues that may guide you in your quest. Read our article on Posture for more detail on how to do a detailed assessment on yourself. I have found this to be extremely useful recently with people suffering multiple injuries as the body will often show a weight shift away from either the area in pain, or sometimes the area that is weak and unstable. An example is of a lady who came to see me for a right foot problem that was causing all sorts of trouble with her feet, and now beginning to work up into her right knee and right hip. On our assessment her body was not moving away from the right but instead it was all shifted onto that side. This seemed odd, for usually the side in pain will move away from it just like when you limp after spraining your ankle. When I asked her if she had hurt her left side she mentioned she had a car accident 20 years ago that left her left hip with plates and screws in it and took a year and half to get back to normal. She forgot to mention this in our first assessment and did not put it on her form as she did not think it was relevant as her left side was not in pain and had not given her any trouble for a long time.  Armed with this new information made me look deeper into the left leg to see if there was weakness and stability deficits, which there was.

Thirdly you need to use tests and assessments for flexibility, stability, isolated strength and most importantly MOVEMENT PATTERNS. The results of the tests will tell you where to start and often as you dig deeper into the program you will find the original leak. The best thing to do here is find a qualified therapist, CHEK Pracitioner, Exercise physiologist or trainer who understands these movement patterns and has tests to determine your current status. You don't want to guess, as you could start working on the wrong thing! By the way we when we test people for ankle mobility and find it is very stiff many people never knew it was. To them the ankle was normal! This is proof of a corrupted program for the stiff ankle is now the new normal.

To list all of the tests we would use in our rehab program would make this article 10,000 words long, and to be honest we add things based on what we see. All of our Online download programs include these tests with video and ebook instructions so if you have knee pain, back pain or piriformis syndrome you can access the tests via these programs.

But in all cases we start with flexibility and mobility exercises first.

Why? Because as I mentioned earlier tight muscles inhibit weak muscles. This means they steal the workload and create a faulty movement. The Tonic and Phasic muscle system was first termed by Vladimir Janda and it helps to explain why people do not improve their weakness, if mobility and flexibility is not addressed first, even when they are using the right exercise. For example a hip extension to strengthen weak glutes will not have much effect while your hips remain dominant and tight. For the minute you stand up and try to do a functional movement like a squat or lunge your dominating hips and quads will take over and make you do the exercise wrong, leaving the glutes weak and lazy. The exercise is right, just the body's program for doing it is wrong. The only way to shut down the tight, dominating muscles is to weaken them using stretches and massage.

Good articles to read on this are:

Lower Back Pain & Why It Is Important To Loosen Tight Muscles Before Strengthening

How To Loosen Tight Hips

To help you with a stretching program watch the video below as I show you how to do this.

Using The Single Leg Squat As An Assessment

Once you have implemented your flexibility and mobility program you can begin with your stability training. Of all the tests the single leg squat is really the best as it combines all the weakness, tightness, lack of stability and poor coordination all at once. The test also becomes the best corrective exercise, for if you can master this movement your problems will be gone forever as all of the risky movements are made from this pattern. At first this is more of a stability and coordination problem than just a lack of strength which is why it comes ahead of isolated exercises and even great strength exercises like the deadlift. This exercise exposes people's stability deficits very easily. Make sure you read our full article on the Single Leg Squat as we show you everything you need to know about it to do it right every time.

We like to use the sensa mat to emphasize this and also bring into play the stability of the ankle and feet. Below is a picture of this and alongside a simple checklist to assess your single leg squat.

Assessing Movement Patterns & Motor Control

You will need to make sure you assess each one of these to ensure any corrections you have made to your flexibility and strength actually work as they are supposed to. This is a big mistake so many health practitioners make with injuries by just treating the area in pain, or using stretches to make range of motion better without looking at how you actually move. I have seen many people pass every one of our flexibility tests only to move very poorly and appear very stiff. It makes no sense that their body is pretty much normal when lying down but when they stand it stiffens right up and restricts their movement. This is a sign of instability and movement dysfunction. This is the body's attempt at stabilizing itself by stiffening the joints up, anticipating problems for it lacks the sufficient skills to move correctly. As long as the faulty movement remains, no stretching or strengthening will make any difference.

To make this easier I have put together a great Free Report on Functional Training that details ALL of these movement patterns in great detail and also provides regressions and progressions of each to help you. You can get that by clicking here.

I also encourage you to watch the videos below that explain what the 4 keys to stability training are and how movement patterns are assessed and relate to daily life.

Progressions of ankle stability involve moving at high speeds on single leg stance. This is an absolute must for any sports people out there and the test below I put all of our athletes through before giving them a pass to play. They must be able to demonstrate perfect timing and balance with both legs with this test over 5 sets to pass! The second video is a video showing poor form vs good form with single leg landing, which is often where most injuries will occur. You can see how the single leg squat relates so closely to sports now when you see this and why regard that exercise as the best to do for all lower limb injuries.

Conclusion

I hope this article sheds some light on an area that many of us do not give the respect it really deserves. I learned this the hard way, so I hope you can not make the mistake that I have made. The joint by joint approach is a great way of really highlighting just how easy a foot or ankle injury can become a much bigger problem if left unattended. If you have had any history of ankle problems I suggest you begin testing your ankle right now and working your way through the mobility, stability and strength phases, in particular if you are in your rehabilitation phase for a knee problem. This problem is not just limited to ankle sprains or even sports, we see so many older adults with balance problems caused from feet and ankle stiffness. You must assess your body to find the weaknesses and correct them. If you cannot do this yourself seek a professional to help, it will be the best thing you ever do. By finding where your problem began you can make some serious changes to your body and prevent any further damage, pain and compensatory movement.

The take home point from this is to always assess what is happening with your feet and ankle for often they are not in pain, but they are the problem.

I hope you have enjoyed this article and if you live in Melbourne and would like to know more about our Personal Training or Rehabilitation programs click the image below to schedule a free movement and postural assessment.

And if you live overseas don't forget you can get our online programs for Knee Pain, Back Pain and Piriformis Syndrome by going to our online shop