Chronic instability after recurring ankle sprains is common. But there are some things we can do to help.
Here are some strategies to best manage these injuries.
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#AskMikeReinold Episode 258: How to Manage Recurring Ankle Sprains
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Transcript
Student:
So Josh from Boston, “I recently evaluated a patient with an inversion ankle sprain, as well as subluxing peroneal tendons with resistant eversion, dorsiflexion. How do you manage young active patients with recurrent ankle sprains, and does your plan of care change if a subluxation is present?”
Mike Reinold:
That’s a good question, I like how you threw the curve ball. Resisting eversion has a active subluxation of the peroneal tendon and that stinks. That’s interesting.
Lenny Macrina:
Yeah, when we’re not just getting surgery.
Mike Scaduto:
They ruptured the retinaculum, I would have assumed.
Lenny Macrina:
This sounds like a surgical candidate, I’m just throwing that out there in my experience. If somebody’s getting back presentation, if that grows, where you can just sublux the tendons by resisting. The way we’re setting this person up, especially a young person, we’re setting them up for fail for a while.
Mike Scaduto:
I have that myself sometimes. My peroneals will slide forward over the malleolus there, and it doesn’t feel terrible, it feels weird. My ankle locks up sometimes, but I definitely have a history of ankle sprains.
Mike Reinold:
We’re going to need to see proof of this at some point.
Mike Scaduto:
I could probably do it right now if I tried.
Mike Reinold:
Please, don’t. You’re at home, it’s not technically worker’s comp, I guess, but let’s not do that.
Mike Scaduto:
Oh, we’re not on the clock?
Mike Reinold:
You’re getting back to the profession right now, Mike. So I think that’s a good point. So we have people with subluxing ECUs, and the rare subluxing ulnar nerves. I know that’s different from a tendon, like in the elbow. I do wonder though, our ankle is so important to our life, like with gait. I feel like your hand, you can stabilize a little bit better sometimes. I don’t know, that’s interesting. I would assume the subluxation isn’t irritable and isn’t gigantic, right? So maybe it’s just like a mild version of that, and it’s still kind of working a little bit. But yeah, that’s an interesting point. Let’s take a step back and just talk about recurring ankle sprains in general, because I think the real goal here would be is, if we treat this as a recurring ankle sprain, I wonder if that helps the perineal tendons. I wonder if the retinac treats your scars down a little bit and helps kind of stabilize that, if we just work on that. But who wants to kick this one off? Pun intended. Who wants to kick this one off talking about a chronic recurring ankle subluxation?
Mike Scaduto:
Inversion sprain.
Mike Reinold:
Yeah, inversion sprains, which is super common. But Mike, what do you think?
Mike Scaduto:
Yeah, I think from a diagnostic specificity standpoint, I think you want to get an idea of which ligaments are involved in the ankle. Obviously with an inversion plantar flexion sprain, the ATFL would be the most commonly involved, but then sometimes it can wrap around posteriorly around the ankle. So you can have calcaneofibular ligament, you can have PTFL. And then, if they’re having any pain or symptoms immediately, that can give you an idea of the severity of the sprain. So just the general rule of thumb is the more ligaments that are involved, and they’re usually tender to palpation if they’ve sprained those ligaments in the ankle, more ligaments involved as the higher grade sprain, potentially. And then, trying to get an idea of ankle stability. So an anterior drawer test can give you a good idea of the function of the ATFL. And if they’ve ruptured their ATFL because they have chronic ankle sprains, they may have pretty good difficulty stabilizing the ankle and some proprioception deficits as well.
Mike Scaduto:
So getting a good idea of where they are in terms of ankle and foot function early on can help. And then I think we also know that potentially with chronic ankle sprains, you start to lose the function of the peroneals to stabilize the ankle elaborately. If they’re having subluxation, you may want to be careful, but trying to pick exercises that engage the peroneals. And when they’re doing heel raises, make sure they’re not flying into inversion of the foot or calcaneal inversion. And trying to keep them relatively neutral, I think can be helpful to strengthen the peroneals and hopefully help with the subluxation as well.
Mike Reinold:
I like that. I think that’s a good point. I think it’s super, super important to make sure that you have as thorough of a diagnosis. And, like Mike said, identifying how much instability do they have, not just that it sprains frequently, but how much instability do they have? How many ligaments are involved? Because that’s going to really give you probably some tidbits on prognosis, like how well this is going to go, but also give you some ideas on the severity of it. So it’s a lot of strength, right? It’s a lot of dynamics, stability, it’s a lot of neuromuscular control. It’s about getting those peroneals to be able to function and to make sure they’re stabilizing here. And that’s hard at the ankle, right? Because you have your whole body and all your momentum, right?
Mike Reinold:
Creating such huge torques at the ankle joint during functional movements, right? That this isn’t as simple as saying, “well, get your muscles super strong so that way they can support the ankle,” well sometimes that’s not enough. That’s why we sprain our ankle so much, because the force of the body, with that long lever all the way down to the foot, is causing a lot of issues with them. So these are tough ones in there. Would anybody do anything else, treatment-wise? Obviously, there’s a bunch of external stuff we can do, but anything else anybody would want to jump in and do?
Dave Tilley:
Yeah, I think that is a situation, I think which means a lot in the ankle on other sports. But I think we’re pretty good at chronically under loading the ankle in the PT world. I think 4-Way TheraBand ankles are, you know, everyone’s doing those, but after that we’re like, “All right, let’s do some Airex Pad stuff, and I think we’re good.” I think that’s just really, really under preparing the amount of force that’s going to go through the ankle. I think every condition that we used to think, maybe we were good with, we want to try to load a little bit more than we are. So direct ankle strengthening is very, very important. Obviously sitting calf raises, standing calf raises, stuff like that, are important. But just really directly loading the peroneals.
Dave Tilley:
If this is obviously not a surgical candidate, a candidate that went through procedure, or their ATFL and CFL are all intact, stability-wise. But yeah, sitting with a band around your ankles and doing really heavy hypertrophy eversion, stuff like that, or posterior tib strengthening, like heel raises with a ball between your heels. I think a lot of times we’re just not great at loading. You know, some of the people that I work with gymnastics-wise have really bad chronic ankle sprains, but doing heavy high load eccentrics with like 40, 50, 60, 70-pound kettlebells on their knees and a deficit riser along with that and some other stuff, makes them feel better because, like you said, you’re tightening up some of that musculature and you’re giving them some high load stress. Along with really good instability training and balance stuff and all that stuff’s good, like just single leg exercises step-ups and RDLs and lateral caustic squats along with direct ankle strengthening, that goes a long way for these people.
Mike Reinold:
I like that. And I think you’re right, we do a lot of 4-Way TheraBand and Airex Pads, and then they’re doing great and their pain’s gone. They’re like, “All right, let’s start running,” right? And that’s a big thing we do in PT. But, man, getting through a strength training program and actually being active with that, I think that’s phenomenal advice, Dave. And I really think that’s the key. I mean, if you get them that far in the progression, I think that’s the difference with recurring ankle sprains. Anytime we have a recurring injury, my mind I always just wondered, did we load them enough right in our rehab progression before they returned? But what else, Dan?
Dan Pope:
Yeah, one thing I was going to say is that if you’ve got especially recurrent ankle sprains, you probably have a lot of laxity in certain places, the ankle. But one of the things we know happens is we tend to lose dorsiflexion just because you do have some scar, some synovium gets caught within the joint. So you lose the dorsiflexion, and for a lot of athletes, that’s challenging because you need that for a sport. I worked a lot of people that go into a deep squat all the time. So if they’re lacking that mobility, it causes a bunch of issues up the chain can kind of hurt their performance. So I will say that make sure you stabilize this thing as much as possible, but make sure there’s no gross mobility limitation and work on some of those if they are present.
Mike Reinold:
Nice. Nice. And then I guess I’ll just wrap it up with the obvious, right? Don’t be afraid to externally support this and depending on the severity of this, especially with recurring subluxations of the peroneal tendons, right? Don’t be afraid, external support is huge. I mean, I have plenty of people. I have professional athletes, baseball players that sprain their ankle a bunch of times in high school basketball and they still stabilize their ankle, right? So there’s numerous ways to do that. I personally don’t think that by wearing a ankle brace or any ankle stability thing, these things aren’t perfect, like a lace up or something. I’m not talking about like an ASO, right? I’m talking about something you’d wear functionally in sports, right? I don’t think you wearing that in your sport is going to cause long-term problems.
Mike Reinold:
If you wore it all day, then yes. You’re relying on the external support. You’re not developing the stability of the neuromuscular control yourself. But to perform your sport and just make sure that something silly doesn’t happen with a quick change direction or uncertain thing, and you roll your ankle. Yep. I think we know for you, if you roll your ankle a little bit, that might bang the bone immediately because you have instability. And then you’re flared up and you’re annoyed and you’re losing some time in your sport, so we don’t want to do that. So keep that in mind as well. I don’t think it’s a bad thing to just say, “I’m playing my sport and I don’t want to focus on this, I want to make sure I’m okay. I’ve strengthened it a bunch. I got my motion back.
Mike Reinold:
I’ve done a ton of neuromuscular control, but I’m still going to put this lace up on when I play, because I don’t want to miss time.” I don’t think that’s a bad strategy from the sports medicine aspect of that, makes sense? So, awesome. Great question. I like it, Josh. Good luck with that. If you have questions like Josh, head to mikereinat.com, click on that podcast link, and fill out the form to ask us a question. But more importantly, please, please, please subscribe. Apple Podcast, Spotify, whatever you listen to your podcast on, please subscribe, rate and review us and we’ll see you on the next episode. Thanks again.
