In my last blog post, I discussed how weak hip muscles can cause bunions to develop at the base of the first toe. For this post, I would like to continue down this “footpath” of weak hip muscles and their relationship to ankle function.
A commonly misunderstood phenomenon known as recurrent ankle sprains shares the same perception as bunions—a nuisance that you can’t prevent. People who find themselves having recurrent ankle sprains seem to have a tendency to invert, or turn in, their ankles over and over again without any obvious reason.
For the typical person, turning one’s ankle has an obvious cause—the person steps on terrain or an object of unanticipated level or shape, and accidentally steps on the outside of the ankle, preventing the ankle/foot from properly supporting his/her body weight. This leads the ankle to turn in excessively, stressing the ligaments that support the outer ankle and oftentimes becoming sprained. Over time, the ankle usually heals itself and an ankle sprain does not recur.
For some, however, it seems that no altered terrain or unforeseen object needs to be stepped on to create this turning in of the ankle. And it happens somewhat frequently, leading to pain and a sense of instability that can cause the person to fear weight-bearing on the affected leg. If the person seeks medical attention, in most cases he will be told he has loose ligaments and it is something he just has to live with.
To say the problem is laxity of the ligaments is, simply, foolish. Ligaments are always lax except when a joint reaches the end of its range of motion. A ligament is a flat connective band. It has no contractile force associated with it like muscle. It is the equivalent of a rope.
Others will be given the proverbial orthotic—the “answer to all problems foot and ankle.” The problem with this scenario is that you are replacing muscular force to stabilize the ankle with an external appliance. This allows the muscles that support the ankle to weaken further and makes you even more susceptible to turning your ankle.
The correct question to ask: Why does the person continue to step on the outside of the foot enough to turn it in so often? The answer: A person with recurrent ankle sprains is standing and walking with their feet too close together. This is the result of the weak gluteus medius—the hip muscle, which sits on the side of the pelvis. These muscles are responsible for creating stability and balance. It also plays a key role in putting the foot down in the proper position whenever you take a step. Let me explain…
When you lift your foot to place in front of you, there are two forces acting on the leg and where the foot will be placed.
- The groin muscles will want to bring your leg toward the midline of the body and have you place your foot more toward the middle of your body.
- The gluteus medius (hip muscle) is trying to oppose that force and have you place your foot down so it is directly under the hip joint, with the leg is completely vertical to the ground. When this occurs, the foot is placed down with all five balls of the feet impacting the floor at the same time. There is no opportunity to step on the outside of the foot.
With a weak gluteus medius, the groin muscles tend to be shorter and pull the foot so it lands toward the midline of the body. This greatly increases the chance that the outer portion of the foot will impact the floor first…and that is what leads to the ankle turning and spraining. While the result is a continuously straining ligament and lateral ankle (and so it seems like a ligament problem), the cause is a mechanical (i.e. muscular) failure to properly place the foot
In the years I have been treating patients diagnosed with recurrent ankle sprains, I have done virtually nothing to the ankle itself. I spend the majority of my time working to strengthen the gluteus medius muscles. It turns out that it takes about 21 days for a movement pattern to change, so for at least 21 days a person must consciously focus on keeping his feet hip-width apart both with stance and walking. After that, the new movement pattern is sustained subconsciously.
So if you’re suffering from recurrent ankle sprains, take heart. It is not something you have to live with. It is not something that an external appliance will ever fix. It is something that is under your control with the right exercises. In fact, they’re the very same exercises as the ones I shared last month to prevent bunions and previously for plantar fasciitis, among other types of pain.
Exercises to prevent recurrent ankle sprains.
Perform these exercises three times a week. For each, do three sets of 10 repetitions with a one-minute break between sets. Continually increase the resistance used until the muscles involved are strong enough to perform your functional activities without straining and emitting symptoms.
Hip Abduction (gluteus medius): This exercise can be performed either lying on your side or standing. To do it correctly, make sure you do not go too far when moving your leg outward. People falsely believe that more range of motion is better, but in this case too much range of motion means you are using the lower back muscle to create the motion, not the gluteus medius (hip muscle). The gluteus medius muscle can only move the leg out to the point where it is parallel with the hip joint. Any outward motion beyond that is created by the lower back muscle.
To do the exercise lying down, lie on your side with the knee of the bottom leg bent and the top leg straight. The top leg should run in a continuous line from the torso—if the leg is angled in front of the torso, you would use the wrong muscle. Start to raise the top leg off the supporting leg until your top leg is parallel with the floor. As you lift, try to turn the leg in slightly so the heel is the first part of the foot that is moving. This puts the gluteus medius in the optimal position to raise the leg. Once your leg reaches parallel to the floor, begin to lower it back onto the supporting leg.
If you prefer to stand, the outward movement is similar to when lying down—lead with the heel, and don’t move your leg too far to keep the exercise focused on the gluteus medius. Holding on to a sturdy table or chair while you perform the exercise will make it easier to use proper form.
Dorsiflexion (anterior tibialis): Secure a resistance band under a sturdy table or knot one end and put the knot behind a closed door. Sit on the floor and extend your weak leg but keep your knee bent. Slip the end of the resistance band over your foot so that it is supported on the front of the foot in the mid-foot region. Start with the ankle angled about 30 degrees forward. Next flex your foot, pulling it toward you about 10 degrees beyond perpendicular. Return to the start position.
Inversion (posterior tibialis): Secure a resistance band as described above. Sit in a chair placed parallel to the door or table. The resistance needs to come from the side of the leg to be exercised—so if it’s your right food, the band should be secured from the outside of the right foot at about the same level as your foot. Place the resistance band around your instep and sit with your working leg at a 90-degree angle so that your heel is under the knee. Keeping your heel touching the ground, raise the rest of your foot and place the toes outside the line of the ankle. Slowly pull the toes inward until they are inside the line of the ankle. (The foot will turn upward slightly as the foot is moved inward at the end of the range.) Place your hand on the side of the knee of the working leg to make sure it does not move. You do not want any movement or rotation of the working leg. The only motion should be at the ankle. Return to the start position.
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