Sprained Ankles - is there anyway to avoid them?!

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I've been reading a lot about sprained ankles recently, mainly from fell runners (what a surprise), though it's also quite a common thing for people to do even in the city, on pavements, and other such seemingly innocuous surfaces.

The reasons for spraining, or, at the least, turning an ankle are many and varied, from "having weak ankles" to "running over tussoky moorland" and "turning round a corner with shoes that are grippier than you expect" (that'd be me).

Its been a while since I properly turned either ankle, the last time was a few years ago, and when it went, it went quite significantly, I won't go into gory details, but I was a good few miles from home, and very glad I had a mobile, and that Dad had his mobile switched on (a minor miracle, but never mind that here).
In the past few years I have NEARLY sprained my ankle innumerable times, catching it just as it is about to go, or being able to retain balance where I thought it impossible, or simply by letting the rest of my leg give way and letting the other leg take up the slack as I head groundward - this seems to work quite well, but you need to be quite alert to do it without face-planting.

I knew someone who had particularly weak ankles, I swear she could twist her ankle in a pair of Converse on a flat piece of asphalt. Did she just have weak ankles? And more importantly, was there anything she could do to strengthen them in order to prevent constant pain and concern about going over on them?
Equally, if you are prone to twisted/turned anklage, what can you do to prevent it from happening, and ruining your normal running/walking/water skiing schedule?

First, let's look at the ankle and which bits of it are the bits that you physically "sprain" as you turn your ankle. There are generally 2 ways in which the ankle can go when you sprain it, inversion (inward, big toe eventually becoming vertical to your little) and Eversion (outward, little toe going higher than your big).

Inversion. Most common way to sprain your ankle

Eversion, less common way to sprain your ankle (its more likely to break than sprain)

Inversion is much more common than Eversion for several reasons. The medial malleolus (inside ankle) goes much further down the leg than the lateral malleolus (outside ankle). Also, the lateral ligaments (outside) are smaller than the medial ones (inside). To be brutally honest, if you Evert your foot so hard that it sprains, you are more likely to break the bone than you are to sprain the ligament - that's how strong it is, not really soft tissue damage.

When you Invert your foot there are 3 ligaments that are likely to "go". The Anterior Talofibular Ligament and the Calcaneofibular ligament. There are a few more ligaments around the area, but they are less likely to sprain.

Highlighted - CF= Calcaneofibular ligament (7'o'clock position), AT= Anterior talofibular ligament. (3'o'clock position)

Ligaments hold bones to other bones. They are not like muscles and cannot be strengthened by lifting weights or making them move in a certain way. Ligaments are made of collagen fibre and have a "crimp" in the fibres which give a certain amount of "give" in them to allow some movement. They provide support for boney structures but have very bad blood supply - hence are very slow at healing. Once the ligament has been stretched beyond its "normal" length, it never goes back to its original length. Hence a once sprained ankle has a certain laxity to it that a never-sprained ankle does not have, in other words, it is weaker.

So, when you step on an uneven surface and you "go over" on the ankle, it is the ligaments which hold the various structures of the ankle which are the things which end up being damaged, sometimes to the point that they can't recover very easily - especially if they keep getting run on without any support. I think its quite important to emphasise here that it is not weakness of the ligaments, or even necessarily laxity of the ligaments which make an ankle more or less likely to twist or turn, they are merely the bits that end up hurting.

All the text above is to say that if you keep twisting your ankle, its not lax ligaments, it's your MUSCLES that are weak or not firing fast enough to stop you from going over on the ankle.
Let me explain.
When the ankle begins to Invert (big toe up, little toe down) it is the structures on the outside of the ankle that are in danger of being damaged. The muscles that prevent excessive inversion are based around the outside of the leg - they are Peroneus Longus, (sometimes called fibularis longus), Peroneus Brevis, and, to a point, Extensor Digitorum Longus (which I haven't bothered drawing, so don't worry about it). If these muscles are not firing optimally - and by that I mean, they are not reacting fast enough to stimuli around your foot as you walk/stand/run, it is more likely that you are going to turn your ankle.

Peroneus Longus (blue) and Brevis (red) stabilise the foot from this side as you can see from where they insert- Brevis on the 5th metatarsal (outside of the foot) and Longus on the first- going right underneath the sole to the other side)

You cannot do a lot about tightening ligaments without some fairly radical surgery, but you can make the reaction time of the muscles surrounding the joint faster by increasing the firing rate.
The issue about being mobile AND being stable is interesting because the muscles that are involved in ankle stability are involved in deceleration during the gait cycle. As the foot hits the ground, they are loaded eccentrically, to provide deceleration - however, if more stability is needed, the muscles need to be CONCENTRICALLY loaded almost immediately afterward - it's the transition from controlled lengthening contraction to controlled shortening contraction that would seem to be one of the more important things which will help with unstable ankles.

It is actually the reaction time of the peroneals - measured in milliseconds which provide the stability which the unstable lack.
There are of course a number of other factors in ankles that tend to twist more than others, including a tendency to over pronate, bunions etc. However, I suspect that weak, and slow reacting peroneals are a major issue in terms of unstable ankles. A lot can be said for encouraging these stabilising muscles to be developed and their proprioceptive reactions sped up.

How to do that?
What you are basically doing is improving your proprioception. Proprioception is the knowledge of where your body is in space in real time - or, put another way, knowing where your foot is and what it is doing as it hits the floor, be it on smooth asphalt, or unstable boggy hellhole. 

The best way to do this is on a balance board or a hedgehog - balance on it, one legged. If you can't do that, practice until you can.

Hedgehog

Then practice until you can do it for a minute without thinking about it.
Then practice until you can do it for a minute with your eyes closed.
At that point, you probably have a pretty good sense of what your muscles are doing, and should have a better chance of not twisting your ankle every time you go for a run on dodgy ground.

If you don't have a balance board or a hedgehog, buy one.
Alternatively you could roll up a towel and use that as an improvised balance tool. However, its not quite as good (unstable) as something that has been made to be unstable.

Please don't get confused and use one of these.

I'm not saying that this is the be all and end all of how to stop twisting your ankle - a lot of that comes from observation, but much more actually comes from being able to quickly react to what is under your feet at any one time - the best way to do that is to train the muscles to react fast to what is happening underneath them.

Now, a lot of people with unstable ankles do this for a while, and then, when they think they are strong enough, or (more often) they get bored or forget, they stop.
Your body adapts to what is going on around it and what is happening to it. If you are not stimulating the muscles by doing exercises like this, and they are not being stimulated by walking on unstable ground, they are not being worked and will go back to the way that they were. Unstable and unsupporting.
If you want stable ankles, and to be able to run effectively without twisting or turning anything in the supporting structures, keep at it. Yes it might be tiresome, yes it might be annoying, but being laid up with an ankle the size of a melon is a whole other level of tiresome annoyance.

A word about strength training on balance balls etc - don't bother. You won't get any better at balancing, and you won't get any stronger. If you want to get stronger, just weight train. If you want to be more stable, work on that on its own, you generally don't need anything heavier than body weight unless you are training specifically for something (like racing on balance balls with heavy weights, but I can't imagine a race like that catching on so well).

Also, there are the times when you fall down stairs, stick your leg in a hole, fall off a pavement when tired (or drunk). The balance exercises will help to a point, but it won't make you invulnerable. (sorry)

Osteopathy

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The introductory page on the General Osteopathic Council website defines osteopathy as:

"Osteopathy is a system of diagnosis and treatment for a wide range of medical conditions.  It works with the structure and function of the body, and is based on the principle that the well-being of an individual depends on the skeleton, muscles, ligaments and connective tissues functioning smoothly together.

To an osteopath, for your body to work well, its structure must also work well.  So osteopaths work to restore your body to a state of balance, where possible without the use of drugs or surgery.  Osteopaths use touch, physical manipulation, stretching and massage to increase the mobility of joints, to relieve muscle tension, to enhance the blood and nerve supply to tissues, and to help your body’s own healing mechanisms.  They may also provide advice on posture and exercise to aid recovery, promote health and prevent symptoms recurring."

I've included the full introduction, as it is important for a well rounded understanding of what this modality is about. I particularly like the quote that they "work to restore your body to a state of balance". 


My reason for posting about osteopathy is because I have just seen one. My reason for this was twofold. Firstly, from a professional viewpoint I need to know who in my local area is good, and who I can refer my own clients to. I found this particular practitioner on recommendation from a good friend - the best way to find a therapist in my view. But, I do not blindly send my own clients to someone unless that person has treated me personally.


The second reason I saw the osteopath is because I felt wonky! I have no serious or acute issue, I just felt like something wasn't quite right with my alignment, and no quantity or sports massage from my colleague was going to fix that as we don't manipulate hard structures, i.e. bones. I have had neck ache on and off for some time, putting it down to perhaps stress of relocation, entering the world of self-employment, or perhaps an underlying and long standing issue from some years back when my neck "froze"...I had a period of about three weeks six or seven years ago when I couldn't turn my neck at all. Perhaps that was a precursur to me becoming a sports massage therapist, but I digress. 


So, professional curiosity and personal need for perhaps a little realignment took me to the osteopath today.


He did quite a lot of work on me, partly because he knew I understood the anatomy and reasoning behind his treatment. This meant that he could reduce the amount of time explaining what he was working on and spend more time treating, but mostly because he know I was prepared and understood what was happening.


Realigned were:

• Left tibia/fibula (the two bones in your lower leg) - the head (top) of the tibia was too high - this caused me pain on the bone at the outside of my lower leg, just below my knee. Because of that my ITB was tight and caused me knee pain when running. Was this travelling up the body and giving me pains in my neck? Who knows...everything is linked afterall!
• Pelvis - slightly misaligned, with tenderness, especially at the iliosacral joint. Could this have been causing the neck pain? 
• T5 and T8 - two vertebrae around shoulder blade area . Were these responsible for my neck pain?
• C2 - a vertebrae in my neck - rotation of my neck wasn't quite so free looking round to the right, which is where the pain was manifesting, but not necessarily the key cause. (I think my fellow writer, Tim, refers to smoke and fire, and this analogy springs to mind here).
• C1 - the top vertebrae - this one wasn't going to play today. I was holding or protecting it too much and like all good practitioners, if something isn't allowing you to treat it, it is for a reason so leave it alone for now.

All the time he was realigning bones he kept checking and rechecking how my range of movement was, how joints felt - whether they were springy, hard, blocked - and asking me for feedback.


Muscle testing also took place, the result being that I have an overly tense (hypertonic) right psoas muscle. This muscle attaches from the vertabrae in your lower back to the inside of your thigh bone (lesser trochanter of the femur). It's deep inside your abdomen and you have one on each side. For me, my left psoas muscle has become weak so we did some work on strengthening it. I've also got an exercise I can do at home (with help from someone) to continue to strengthen that side. I may need a little work to ease the tension on the right side, but with the left becomes stronger it should ease the right side naturally - thereby creating balance - which is what this is all about! 


How do I feel now? At the end of the session the tension and blocked feeling on the right of my pelvis had gone, and my neck rotation improved, it certainly feels easier. A few hours later and I still feel good. It feels like I want, and more importantly can, stand upright on two feet. Now that might sound funny, but for ages now I've tended to put most of the weight through one leg - something that's bound to cause an imbalance, or be the cause of an imbalance.  I'll certainly be recommending more clients to see osteopaths after my experience today.