When we are dealing with ankle injuries in the clinic we follow a basic protocol with them regardless of the injury. This doesn’t mean that we treat each one the same but rather that to ensure that each injury is addressed fully we require each individual section to be run through. In doing this we can ensure that there is the highest chance of a successful recovery.
The stages that we require to move through are;
- Restore full range ankle dorsi-flexion and plantar flexion
- Restore normal motor output of all ankle muscles
- Ensure there is good motor output in posterior knee stability tests
- Full range calf raise for 5 powerful reps
- Posterior knee stability progressions applied
- Ability to execute ankling correctly and symptom free
- Hopping progressions through all 3 planes and levels
Restoring full range of movement in both dorsi-flexion and plantar flexion, pointing your toes away and pulling them up towards you, may seem obvious but if missed will guarantee problems later. Ensuring full ROM in P-flex and D-flex goes hand in hand with restoring normal motor output of all the muscles around the ankle.
If you can’t dorsi-flex fully it indicates that 1. there may still be tension in the one or more of the posterior leg muscles or that the posterior talofibular and talotibular ligaments have protective tone which isn’t allowing the talus to slide backwards. An inability to plantar flex gives us information about the flexor retinaculum on the front of the ankle and the likes of anterior tibilais.
The posterior knee stability tests allow us to check the ability of the hamstrings and gastrocnemius to distribute force well through the leg. If working well the gastroc both plantar flexes the foot and flexes the knee during gait but if it isn’t we can see the knee “snap” into knee extension. If this is what is happening then we can get problems in the gastroc itself, the achilles tendon or the plantar fascia.
The ability to perform 5 strong calf raises without compensations lets us know that the strength is returning to the muscles and that you are beginning to recruit efficiently across the musculature. If we see that you are favouring putting weigh through just one side of the foot we know that there is still work to be done before progressing.
The posterior knee stability progressions work along side the work on returning the ability to perform the calf raise and target the ability to effectively recruit the hamstrings and gastroc as a unit. The progressions run from low load isometrics up to aggressive hopping where we are working on the ability to effectively decelerate the body.
Ankling is where you are walking on the balls of your feet in full planter flexion. During this movement we are looking for you to be putting weight evenly across the ball of the foot as in the calf raise. We begin this fairly stationary simply moving from foot to foot as we look for good weight distribution and hip hiking before progressing on to more active walking.
Once the ankling is performed well and symptom free we move onto hopping. Here we begin with simple hopping from one foot to the other and progress to more aggressive and multi direction variations.
Once all these phases are completed we can be fairly comfortable that you can “return to play” without much chance of re-injury.