Posted by Steve Middleton, MS, ATC, CSCS, CES, CKTP
Sports Specifics: Ankle Sprains
Why do we limp after an ankle sprain? The primary mechanism of injury is inversion and dorsiflexion (the ankle rolling in) which stresses the anterior talo-fibular (ATF) ligament. However, as the anterior drawer test shows us, the ATF’s role is to keep the talus from sliding anteriorly. This, theoretically, should not lead to a limp.
In 2010, a group of researchers(1) examined why this happens. They determined the stress of the sprain causes reorganization of the central nervous system. In turn, this causes inhibition of the ipsilateral gluteus medius whose functional role during gait is to prevent hip adduction(2). When the muscle becomes inhibited, the contralateral pelvis drops as that leg moves into flexion during the gait cycle. This is also known as a Trendelenburg gait.
How this happens was addressed by Thomas Myers(3). The sprain involves the lateral fascial line: the peroneal group, ilitotibal (IT) band, external obliques, intercostals, scalenes group and scalp fascia. The inversion of the ankle often leads to adduction of the hip which also strains the IT band. Rapid movements of the fascia lead to tearing with subsequent soft tissue remodeling involving scarring(4). The scarring leads to a loss of mobility and synergestic dominance of synergestic (helpler) muscle groups(5). Often, physicians will place the patient in a brace or, in more severe cases, a walking boot that further exacerbates the problem via immobilization(6). This leads to further shortening which can alter the alignment of the lumbo-pelvic-hip complex creating an anterior pelvic tilt or lateral tilt of the ilium on the sacrum. This changes the alignment of the myofascia where the IT band becomes the primary hip stabilizer during ambulation and, in advanced stages, hip flexor. This leads to further inhibition of the gluteus medius as stabilizer and the psoas as a hip flexor.
Often, rehabilitation specialists inadvertently facilitate dysfunction. Too often, patients are progressed to standing balance activities before there is appropriate strength, endurance and neuromuscular control to maintain proper hip position. This can lead to chronic hip instability and continued limping even after the ankle sprain has resolved. Also, “Monster Walks”/lateral walking with a Thera-band loop further increases the activation of the IT band because of the knee and hip flexion which leads to increased activation of the IT band and gluteus medius inhibition. Often, patients with past inversion ankle injuries tend to have recurring sprains due to the lateral tilt of the SI joint which leads to hip adduction changing foot strike from the plantar surface to the lateral portion of the foot which predisposes it to recurrent eversion. Others will present with calcaneal eversion due to shortening of the lateral fasical line or, more often, Thera-band exercises that teach the peroneals to be everters instead of a stabilizer to prevent inversion.
A better approach:
Kinesiology taping can be utilized to facilitate lymphatic drainage during the acute phase. Once the edema and pain have begun to resolve, functional or rehabilitative tapings can be utilized. The peroneals can be treated by combining a facilitation technique with a mechanical correction to pull the calcaneus into eversion thus limiting further inversion. To address the Trendelenburg gait, a facilitation technique can be used on the gluteus medius as well. In Fascial Movement Taping, both of these techniques could be combined into a single strip via a lateral chain correction.
For rehabilitation, have the patient supine with a Thera-Band loop around the feet. The supine position places the hip in slight extension to better activate the gluteus medius and limit the role of the IT band in the movement. The patient must hold the feet in neutral (no inversion/eversion, no plantar/dorsiflexion). The patient proceeds to abduct the hips to hip width apart holding for 2 seconds initially with a progression to a 5 second hold for 10 reps. This works to increase the activation of the entire lateral line, specifically the gluteus medius and peroneals, as stabilizers instead of conditioning them to be phasic muscles.
1. Hass, CJ. Bishop, MD. Doidge, D. Wikstrom, EA. (2010). “Chronic ankle instability alters central organization of movement.” Am J Sports Med. 38(4):829-34.
2. Neuman, DA. Ankle and Foot. In: Neuman, DA. Kinesiology of the Musculoskeletal System: Foundations for Physical Rehabilitation. St. Louis, MO:Mosby. 2002. 477-521.
3. Myers, TW. (2001) Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists. China:Churchill-Livingston.
4. Mollier (1938) Plastiche Anatomie.
5. Kottke, FJ. Pauley, DL. Ptak, RA. (1966) The rationale for prolonged stretching for correction of shortening connective tissue. Arch Phys Medic Rehab. 47:345-52.
6. Kottke, FJ. Lehman, JF. (1990) Kruzen’s Handbook of Physical Medicine and Rehabilitation, 4th edition. Philadelphia:Sanders.