Advanced Ankle Rehab Strengthening

Most ankle rehab programs focus on balance and proprioception.  These are without a doubt important components of early ankle rehab because the ankle needs to adapt and respond to perturbation.

However, where most rehab programs fall short is progressing to advanced ankle rehab strengthening.

Injuries to the lateral ligaments of the ankle, or inversion sprains, are the most common, but high ankle sprains are more common in sports than has been realized in the past (1).  

These occur via forceful external rotation of the ankle (or forceful dorsiflexion), but they can also occur along with an inversion ankle sprain (2).

Understanding these mechanisms of injury is important for advanced ankle rehab exercises.  We need to work beyond foot exercises, tubing exercises and calf raises.  

Again, these ARE important in the early ankle rehab phases, but do not translate to the actual complex function of the foot and ankle in the dynamic sports environment.

Rather, what I will be discussing in this article is advanced ankle rehab strengthening to restore the very important functional demand of the foot and ankle for accepting and absorbing external forces to ensure a return to performance.

Ditch the BOSU and bring on the load!

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ANKLE REHAB STRENGTHENING: IMPORTANT CONSIDERATIONS

Walking, running, landing, cutting, etc. are complex activities that essentially rely on the foot and ankle’s capacity for absorption, propulsion and stability.  According to Prentice (1), these activities involve “several determinants based on pelvic, hip, knee, and foot/ankle motions”.  

The lower extremity functions as a kinetic chain to absorb, distribute and transfer ground reaction forces.  The foot, ankle, knee and hip need mobility to meet the demands of absorption and propulsion.  

But,

stability is required to limit motion and switch back and forth between absorption and propulsion

For example, in my previous article on hip stiffness, I discuss the importance of hip mobility in absorption of trunk motion and along the lower extremity kinetic chain.  

On the other hand, too much mobility can also lead to decreased stability.  Not all hips need mobility, as discussed in this article.

Back to the ankle, though.  

You can guess that mobility is going to be an important factor to address in ankle rehab.  

? If you are looking for specific ankle mobility exercises for absorption and deceleration, make sure to read Ankle Mobility Impacts High Ankle Sprains: 3 Exercises to Address it.

In terms of stability, one important point to consider is plantar flexion and inversion strength.  According to Dr. Chris Bleakly, following an ankle sprain, many people lack plantar flexion strength,  especially at end range.  

Using a wedge to work on end range plantar flexion can be quite useful, especially in the earlier stages:

Now, while stability involves motor control, it also involves strength.

After we have gone through our tubing and calf raises, how do we build our ankle rehab to include strength specific to the demands of absorption?  Because simply returning the athlete to sport participation won’t cut it.

LOAD THE PATTERN

Among other things, when I think “strength”, I think “load”.  You?

In an ankle rehab process, once mobility is restored and we have trained the ankle to sense, adapt and respond to perturbation (aka motor control), we can shift our focus to strength.

Simply put, we also need to train the ankle to tolerate, absorb and distribute the rotational forces of deceleration and change of direction.  What better way to do this than to load these specific patterns?

All of the structures within the foot and ankle complex are capable of absorbing external forces.  The ligaments of the ankle absorb forces, along with muscles and tendons via eccentric contraction – or deceleration.

Following injury to ligaments, optimal load distribution via these eccentric contractions is even more important because the ligaments are no longer capable of restricting range to the same extent.

So, an important aspect of advanced ankle rehab strengthening is loading the ankle by applying intentional force in specific ranges of motion.  This can be either in the ranges of motion we have restored, or in the affected planes.

For a lateral ankle sprain, for example, we would be concerned with loading the ankle as the body is moving laterally in the frontal plane:

If we’re thinking high ankle sprain, we may want to load the ankle in a position that creates some external rotation torque.  I really like this heavy ball rotation:

The use of a wedge helps bring the athlete into more end range eversion, you could do the same for inversion, or you could also do this in neutral without the wedge.

These exercises find their way in the loaded integration sequence and the focus should be heavier weight in a more slow and controlled manner.

For these Loaded Integration exercises, I like to use 3-5 sets of anywhere from 6-12 repetitions depending on the exercise.

MAKE SURE TO WATCH THE MAIN VIDEO OF THIS ARTICLE TO LEARN ALL ABOUT THIS EXERCISE

MIMIC THE PATTERN

As I’m sure you know, movements in the sports environment don’t happen slowly.  In the dynamic integration sequence, we want to prepare the ankle for specific, fast movements that mimic those encountered in the sports environment.

The capacity to absorb the load is important, but so is the timing of this absorption

The more a movement has been previously encountered by the neuromuscular system, the more advanced information and preparatory activity is available to control this movement.  This is a process called feed forward control.

Specific movements performed repetitively make the neuromuscular system more efficient, which is particularly important to prevent excessive stress on ligaments.

Earlier, I like to start with exercises that are still focused on deceleration, but at higher speeds than those in the loaded integration sequence.

For example, you could start with a banded cross-body lunge:

The resistance of the band increases the deceleration demand.

This could then progress to a rhythmic drop into a cross-body lunge, as demonstrated in the second part of this short video:

For Dynamic Integration exercises, I like to use 3-5 sets.  For deceleration focused exercises, I will use between 6-10 repetitions, whereas for acceleration or more explosive exercises, I will use 5-8 exercises.

APPLYING SIGNIFICANT LOAD

While balance, proprioception and isolated strength are important components of early ankle rehab, most rehab programs fall short of where advanced ankle rehab strengthening is concerned.

The ankle needs to be sufficiently exposed to the stresses it will encounter in the sports environment.  It needs to actually absorb and tolerate significant load way beyond calf raises. 

After all, during running, ground reaction force has been shown to increase to more than 2.5 times body weight.  

If we hope to better prepare the ankle for the rotational forces it will encounter in the athletic environment, we need to load it by applying intentional force in key ranges of motion and by utilizing specific, fast movements that mimic these forces.

Ditch the BOSU and bring on the load!

REFERENCES

1. Prentice, William E.. Rehabilitation Techniques for Sports Medicine and Athletic Training (p. 1763). SLACK Incorporated. Kindle Edition.
2. Lynch S. A. (2002). Assessment of the Injured Ankle in the Athlete. Journal of athletic training, 37(4), 406–412.
3. Haff G & Triplett T. (2016). Essentials of Strength Training and Conditioning, fourth edition, Human Kinetics.

Mai-Linh Dovan M.SC., CAT(C)
Certified Athletic Therapist
Founder of Rehab-U