Prehabilitation to prevent ankle sprain
Ankle sprain is one of the most common injuries among the general population (Hiller et al., 2012) and in sport (Hootman, Dick, & Agel, 2007). Seventy percent of individuals will experience an ankle sprain at least once in their lifetime (Delahunt et al., 2018). Lateral ankle sprain (LAS) occurs more often than medial ankle sprain (McCollum, van den Bekerom, Kerkhoffs, Calder, & van Dijk, 2013) and is caused by excessive plantarflexion and inversion after landing awkwardly from a jump or during dynamic movements. The excessive stress in this position can cause damage to the anterior talo-fibular ligament, the posterior talo-fibular ligament and the calcaneal talo-fibular ligament. All three ligaments and the peroneal muscles, provide support and stability on the lateral side of the ankle (Figure 1). After the initial injury the ankle is more unstable and there is a risk of a recurring LAS within 12 months (Gutierrez, Jackson, Dorr, Margiotta, & Kaminski, 2007) or chronic ankle instability (Attenborough et al., 2014).
Figure 1. Damage caused to lateral ankle as a result of excessive plantarflexion and inversion
A number of risk factors for LAS have been identified:
- A previous LAS within the past 12-24 months (Verhagen, Van Der Beek, Bouter, Bahr, & Van Mechelen, 2004).
- After a LAS proprioception is affected (Willems, Witvrouw, Verstuyft, Vaes, & De Clercq, 2002), resulting in poor postural control, greater inverted positions of the ankle upon jumping and landing, poor muscular control of the muscles that stabilise the foot and ankle.
- An increase in the magnitude and velocity of postural sway may result in problems with stability (Huurnink, Fransz, Kingma, Verhagen, & Van Dieën, 2014). Postural sway is the horizontal movement around the body’s centre of gravity coordinated by input from the vestibular, visual and somatosensory systems to maintain balance. When the body is standing still there is a small amount of movement, usually no more than 10mm, as the body manages changes in the centre of gravity for normal functions. The single-leg stance test, which measures the length of time an individual can maintain a single-leg stance without losing their balance, is used to identify problems with postural sway. The inability to hold the stance for more than 15 seconds, indicates abnormal posture.
- Poor rehabilitation from a previous injury (Kerkhoffs et al., 2012; van der Wees et al., 2006). When a client does not adhere to a prescribed rehabilitation programme, their body creates compensatory movement patterns in order to adapt to limited mobility and stability. This leads to muscle imbalance, altered muscle recruitment and joint motion, which in turn results in changes in structural alignment and neuromuscular control.
- Reduced dorsiflexion was identified as a risk factor for recurring LAS in a systematic review by De Noronha and colleagues (2006).
- Hip muscle weakness may also contribute to an increased risk of LAS due to greater biomechanical and neuromuscular demands placed upon the ankle to maintain stability (Friel, McLean, Myers, & Caceres, 2006; Kulig, Popovich, Noceti-Dewit, Reischl, & Kim, 2011; Lee & Powers, 2014).
Other risk factors such as sex, height, weight, limb dominance, foot size, foot type, ankle and joint laxity have also been suggested as being associated with an increased risk of LAS, however a strong relationship between these factors and injury risk has not been established (Karlsson, Verhagen, Beynnon & Amendola 2009).
The risk of LAS can be reduced by adopting a prehabilitation programme to improve balance, core strength, ankle strength and flexibility. Inclusion of bracing and taping in a prehabilitation programme to support the ankle, restrict inversion and enhance proprioceptive awareness has also been recommended and shown to reduce the risk of recurring LAS (Verhagen & Bay, 2010).
Currently there is no clear evidence in the research literature that a particular injury prevention programme is effective in the reduction of sports injuries (Bolling, van Mechelen, Pasman, & Verhagen, 2018; Keats, Emery, & Finch, 2012; Klügl et al., 2010; Lauersen, Bertelsen, & Andersen, 2014). The National Academy of Sports Medicine (NASM) recommend developing a prevention programme using their Corrective Exercise Continuum (Brown, 2011) to address foot and ankle impairments. The programme consists of four phases as detailed in the table below:
|
Phase |
Modality |
Muscles/Exercise |
Frequency & Dosage |
| Inhibition |
Self-myofascial release |
Peroneals
Lateral gastrocnemius/soleus Biceps femoris (short head) TFL Rectus Femoris |
Daily
Roll slowly over tight muscle Hold on tender area for 30-sec |
| Lengthen | Static stretching
OR Neuromuscular stretching |
Gastrocnemius/soleus
Biceps femoris (short head) TFL Hip Flexors |
Daily
30-sec hold OR 7 to 10-sec isometric contraction, 30-sec hold |
| Activate | Positional isometrics
AND/OR isolated strengthening |
Posterior tibialis
Anterior tibialis Medial hamstrings Intrinsic core stabilisers Erector Spinae Hip adductors & abductors
|
3-5 days per week
4 reps of increasing intensity 25, 50, 75, 100% OR 1-2 sets of 10-15 reps with 2-secs isometric hold & 4-sec eccentric |
| Integrate | Integrated dynamic movement
(provide easier exercise options if client finds exercise difficult) |
Single-leg balance reach
Step-up to balance from lunge position & step box Single-leg squat Squat with overhead press (with pilates ball agains the wall) |
3-5 days per week
1-3 sets of 10-15 reps under control |
Table 1. Sample corrective exercise programme for foot and ankle impairment adapted from (Brown, 2011)
Inhibition, using self-myofascial release, can be performed daily to prepare the soft tissue for progression. Self-myofascial release eases tension in overactive muscles, improves blood flow, oxygen and lymphatic circulation, reduces pain and treats active trigger points.
Lengthening improves flexibility. As a result the muscles don’t need to work so hard or absorb as much energy to move a limb, reducing the risk of injury (Hadzic et al., 2009; Witvrouw, Danneels, Asselman, D’Have, & Cambier, 2003). There are two techniques: Static stretching which involves low force, long duration stretches (30 seconds) held at the first point of tension; Neuromuscular stretching where the muscle is taken to its end of ROM by active contraction for 7-15 seconds with resistance applied by a partner. The joint is then passively moved to its new end of ROM and held for 20-30 seconds. This is repeated a number of times until improvement in end of ROM is achieved. Both techniques stimulate autogenic inhibition, which decreases muscle spindle activity and motor neuron excitability;
Activation re-educates and increases activation of under-active or weak muscles. This is achieved by performing isolated strengthening or positional isometric strengthening techniques, using concentric and eccentric muscle actions. Isolated strengthening involves resistance exercises that focus on a specific muscle to increase intramuscular coordination. One-two sets of 10-15 repetitions of each exercise, performed three-five days per week, is recommended. Each repetition should be performed with a two-second isometric hold at end of range and the eccentric component performed slowly for four seconds.
Positional isometric contractions are performed at joint end of ROM to activate underactive muscles when required. It is a static technique performed with a qualified health and fitness professional and involves higher intensity contractions or force. The recommended dosage is one set of four repetitions. Each contraction is held for four seconds with a two-second rest in between each repetition, at increasing intensities of 25%, 50%, 70% and 100%.
Integrated dynamic movement involves dynamic, multi-joint exercises in all planes of motion to increase intermuscular coordination and improve postural alignment. The exercises are performed in both a bilateral and unilateral stance, with low load and controlled movement in the correct posture. This ensures that muscles work in their correct force-couple relationships and there is optimal recruitment of the synergist muscles during the different movement patterns. The recommended dosage is one-three sets of 10-15 repetitions, three-five days per week.
A video demonstrating a prehabilitation programme of exercises to reduce the risk of ankle sprain, adopting the NASM Corrective Exercise Continuum, can be viewed via the link below:
References
Attenborough, A. S., Hiller, C. E., Smith, R. M., Stuelcken, M., Greene, A., & Sinclair, P. J. (2014). Chronic Ankle Instability in Sporting Populations. Sports Medicine, 44(11), 1545–1556.
Bolling, C., van Mechelen, W., Pasman, H. R., & Verhagen, E. (2018). Context Matters: Revisiting the First Step of the ‘Sequence of Prevention’ of Sports Injuries. Sports Medicine, 48(10), 2227–2234.
Brown, C. N. (2011). Corrective strategies for foot and ankle impairments. In M. A. Clark & S. C. Lucett (Eds.), NASM’s essentials of corrective exercise training (First edit, pp. 252–266). Baltimore, MD: Lippincott Williams & Wilkins.
De Noronha, M., Refshauge, K. M., Herbert, R. D., & Kilbreath, S. L. (2006). Do voluntary strength, proprioception, range of motion, or postural sway predict occurrence of lateral ankle sprain? British Journal of Sports Medicine, 40(10), 824–828.
Delahunt, E., Bleakley, C. M., Bossard, D. S., Caulfield, B. M., Docherty, C. L., Doherty, C., … Gribble, P. A. (2018). Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 consensus statement and recommendations of the International Ankle Consortium. British Journal of Sports Medicine, 52(20), 1304–1310.
Friel, K., McLean, N., Myers, C., & Caceres, M. (2006). Ipsilateral hip abductor weakness after inversion ankle sprain. Journal of Athletic Training, 41(1), 74–78.
Gutierrez, G. M., Jackson, N. D., Dorr, K. A., Margiotta, S. E., & Kaminski, T. W. (2007). Effect of fatigue on neuromuscular function at the ankle. Journal of Sport Rehabilitation, 16(4), 295–306.
Hadzic, V., Sattler, T., Topole, E., Jarnovic, Z., Burger, H., & Dervisevic, E. (2009). Risk factors for ankle sprain in volleyball players: A preliminary analysis. Isokinetics and Exercise Science, 17(3), 155–160.
Hiller, C. E., Nightingale, E. J., Raymond, J., Kilbreath, S. L., Burns, J., Black, D. A., & Refshauge, K. M. (2012). Prevalence and impact of chronic musculoskeletal ankle disorders in the community. Archives of Physical Medicine and Rehabilitation, 93(10), 1801–1807.
Hootman, J. M., Dick, R., & Agel, J. (2007). Epidemiology of collegiate injuries for 15 sports: Summary and recommendations for injury prevention initiatives. Journal of Athletic Training, 42(2), 311–319.
Huurnink, A., Fransz, D. P., Kingma, I., Verhagen, E. A. L. M., & Van Dieën, J. H. (2014). Postural stability and ankle sprain history in athletes compared to uninjured controls. Clinical Biomechanics, 29(2), 183–188.
Keats, M. R., Emery, C. A., & Finch, C. F. (2012). Are we having fun yet?: Fostering adherence to injury preventive exercise recommendations in young athletes. Sports Medicine, 42(3), 175–184.
Kerkhoffs, G. M., Van Den Bekerom, M., Elders, L. A. M., Van Beek, P. A., Hullegie, W. A. M., Bloemers, G. M. F. M., … De Bie, R. A. (2012). Diagnosis, treatment and prevention of ankle sprains: An evidence-based clinical guideline. British Journal of Sports Medicine, 46(12), 854–860.
Klügl, M., Shrier, I., McBain, K., Shultz, R., Meeuwisse, W. H., Garza, D., & Matheson, G. O. (2010). The prevention of sport injury: An analysis of 12 000 published manuscripts. Clinical Journal of Sport Medicine, 20(6), 407–412.
Kulig, K., Popovich, J. M., Noceti-Dewit, L. M., Reischl, S. F., & Kim, D. (2011). Women with posterior tibial tendon dysfunction have diminished ankle and hip muscle performancedecreased. Journal of Orthopaedic and Sports Physical Therapy, 41(9), 687–694.
Lauersen, J. B., Bertelsen, D. M., & Andersen, L. B. (2014). The effectiveness of exercise interventions to prevent sports injuries: A systematic review and meta-analysis of randomised controlled trials. British Journal of Sports Medicine, 48(11), 871–877.
Lee, S. P., & Powers, C. M. (2014). Individuals with diminished hip abductor muscle strength exhibit altered ankle biomechanics and neuromuscular activation during unipedal balance tasks. Gait and Posture, 39(3), 933–938.
McCollum, G. A., van den Bekerom, M. P. J., Kerkhoffs, G. M. M. J., Calder, J. D. F., & van Dijk, C. N. (2013). Syndesmosis and deltoid ligament injuries in the athlete. Knee Surgery, Sports Traumatology, Arthroscopy, 21(6), 1328–1337.
van der Wees, P. J., Lenssen, A. F., Hendriks, E. J. M., Stomp, D. J., Dekker, J., & de Bie, R. A. (2006). Effectiveness of exercise therapy and manual mobilisation in acute ankle sprain and functional instability: A systematic review. Australian Journal of Physiotherapy, 52(1), 27–37.
Verhagen, E. A. L. M., & Bay, K. (2010). Optimising ankle sprain prevention: A critical review and practical appraisal of the literature. British Journal of Sports Medicine, 44(15), 1082–1088.
Verhagen, E. A. L. M., Van Der Beek, A. J., Bouter, L. M., Bahr, R. M., & Van Mechelen, W. (2004). A one season prospective cohort study of volleyball injuries. British Journal of Sports Medicine, 38(4), 477–481.
Willems, T., Witvrouw, E., Verstuyft, J., Vaes, P., & De Clercq, D. (2002). Proprioception and muscle strength in subjects with a history of ankle sprains and chronic instability. Journal of Athletic Training, 37(4), 487–493.
Witvrouw, E., Danneels, L., Asselman, P., D’Have, T., & Cambier, D. (2003). Muscle flexibility as a risk factor for developing muscle injuries in male professional soccer players: A prospective study. American Journal of Sports Medicine, 31(1), 41–46.
Posted 16.04.2020
Expanding the debate on stretching
Stretching is a common feature of sports training programmes both before and after exercise. The benefits of stretching however have long been debated in the research literature as Baxter, McNaughton, Sparks, Norton & Bentleys’ (2017) review of the literature, examining the effects of stretching on the performance and injury-risk of long distance runners, clearly demonstrates.
What is the purpose of stretching? In a clinical commentary, Page (2012) suggests ‘stretching generally focuses on increasing the length of a musculotendinous unit, in essence increasing the distance between a muscle’s origin and insertion’ and ‘decreased muscular tension is related to increased muscle length’. There are many types of stretching techniques but three techniques, frequently described in the literature are static stretching, ballistic stretching (dynamic) and proprioceptive neuromuscular facilitation (Michalski et al., 2018; Page, 2012). Static stretching involves the athlete stretching a specific muscle and holding the stretch for 1—30 seconds. Static stretches are easy to perform and the least likely to result in injury compared to other forms of stretching. Ballistic stretching is more dynamic and involves using the same positions as static stretches but with bouncing, rhythmical movement to push the stretch further. Ballistic stretching or dynamic stretching has been shown to be more beneficial before physical activity as a warm up rather than post activity (American College of Sports Medicine, 2014; Parrott & Zhu, 2013). Proprioceptive Neuromuscular facilitation is pre-contractual stretching. A common pre-contractual stretching technique used by physiotherapists and sports therapists is Post-Isometric Relaxation (PIR). This technique uses a 30-40% muscle contraction followed by a stretch to improve range of movement (ROM).
What are the benefits of stretching? It is believed that stretching enhances athletic performance, improves ROM, reduces muscle soreness after exercise and reduces the risk of injury however Daub (2013) states that none of these benefits have been proven in the research literature. A review of the literature into the benefits of stretching for long distance runners by Baxter et al., (2017) found no conclusive evidence that stretching before and after exercise improved flexibility, reduced delayed onset muscle soreness (DOMS) or reduced the athletes’ risk to injury.
Perhaps the benefit of stretching is that it is a relaxing activity and more effective psychologically rather than physically. The psychology literature suggests that there is a stress-injury relationship (Andersen & Williams, 1988). Including a regular programme of stretching as part of stress management may be the key to reducing injury. The evidence in the research literature remains inconclusive and the debate about the pros and cons of stretching continues on and on.
References
American College of Sports Medicine. (2014). ACSM Guidelines for Exercise Testing and Prescription. American College of Sports Medicine.
Andersen, M. B., & Williams, J. M. (1988). A Model of Stress and Athletic Injury: Prediction and Prevention.: Discovery Service. Journal of Sport & Exercise Psychology, 10(3), 294–306.
Baxter, C., Mc Naughton, L. R., Sparks, A., Norton, L., & Bentley, D. (2017). Impact of stretching on the performance and injury risk of long-distance runners. Research in Sports Medicine, 25(1), 78–90.
Daub, Clifford, W. (2013). The Five Persistent Myths of Stretching. AMAA Journal, Vol. 26(No. 3), 7–8.
Michalski, T., Michalik, P., Dąbrowska-Galas, M., Król, T., Hadała, M., & Rutkowska, M. (2018). Efficacy of stretching in physiotherapy and sports. Polish Annals of Medicine, 25(2), 277–282.
Page, P. (2012). Clinical Commentary Current Concepts in Muscle Stretching. International Journal of Sports Physical Therapy, 7(1), 109–119.
Parrott, J., & Zhu, X. (2013). A Critical View of Static Stretching and Its Relevance in Physical Education. The Physical Educator, 70, 395–412.
Posted 10.02.19