Chronic Ankle Instability

with Rehab

ExitCare ImageChronic ankle instability is characterized by instability of the ankle for a prolonged period of time. There are two types of ankle instability.

  • A functionally unstable ankle is one that gives way; however, it may or may not be loose.

  • A mechanically unstable ankle is one that is loose due to a problem with the ligaments. However, not all loose ankles are unstable or give way.

SYMPTOMS

  • Recurrent ankle pain and giving way of the ankle.

  • Difficulty running on uneven surfaces, jumping, or changing directions while running (cutting).

  • Pain, tenderness, swelling, and bruising at the site of injury.

  • Weakness or looseness in the ankle joint.

  • Occasionally, impaired ability to walk soon after injury.

CAUSES

  • Ankle instability is most commonly caused by a previous ankle injury that did not completely heal.

  • Ankle instability may also be caused by stress imposed from either side of the ankle joint that can temporarily force or pry the ankle bone (talus) out of its normal alignment. The ligaments that hold the joint in place are stretched and torn.

RISK INCREASES WITH:

  • Previous ankle injury.

  • You were born with (congenital) joint looseness.

  • Too-rapid return to activity after previous ankle sprain.

  • Activities in which the foot may land sideways while running, walking, and jumping (basketball, volleyball, or soccer) or walking or running on uneven or rough surfaces.

  • Inadequate ankle support during athletics.

  • Poor strength and flexibility.

  • Poor balance skills.

PREVENTION

  • Warm up and stretch properly before activity.

  • Maintain physical fitness:

  • Ankle and leg flexibility, muscle strength, and endurance.

  • Balanced training activities.

  • Cardiovascular fitness.

  • Learn and use proper technique during sports and have a coach correct improper technique.

  • Taping, protective strapping, bracing, or high-top tennis shoes may be used. Initially, tape is best; however, it loses most of its support function within 10 to 15 minutes.

  • Wear proper protective shoes (high-top shoes with taping or bracing).

  • Provide the ankle with support during sports and practice activities for 12 months following injury.

  • Complete rehabilitation after initial injury.

PROGNOSIS

If treated properly, ankle instability normally resolves with non-surgical treatment. However, for certain cases of mechanical instability surgery is necessary.

RELATED COMPLICATIONS

  • Frequent recurrence of symptoms is possible. Following rehabilitation guidelines correctly decreases the frequency of recurrence and optimizes healing time.

  • Injury to other structures (bone, cartilage, or tendon).

  • Chronically unstable or arthritic ankle joint.

  • Complications of surgery including infection, bleeding, injury to nerves, continued giving way, ankle stiffness, and ankle weakness.

TREATMENT

Treatment initially involves ice, medication, and compression bandages are used to help reduce pain and inflammation, It may be necessary to immobilize the joint for a period of time to allow for healing. Strengthening and stretching exercises are recommended after immobilization to help regain strength and flexibility. These exercises may be completed at home or with a therapist. Some individuals find placing a heel wedge in the shoe, taping or bracing, and wearing high-top shoes helpful. If symptoms last for longer than 3 months, despite treatment, then surgery may be recommended.

HEAT AND COLD

  • Cold treatment (icing) relieves pain and reduces inflammation. Cold treatment should be applied for 10 to 15 minutes every 2 to 3 hours for inflammation and pain and immediately after any activity that aggravates your symptoms. Use ice packs or an ice massage.

  • Heat treatment may be used prior to performing the stretching and strengthening activities prescribed by your caregiver, physical therapist, or athletic trainer. Use a heat pack or a warm soak.

MEDICATION

  • There are no specific medications to improve the stability of your ankle.

  • If pain medication is necessary, then nonsteroidal anti-inflammatory medications, such as aspirin and ibuprofen, or other minor pain relievers, such as acetaminophen, are often recommended.

  • Do not take pain medication within 7 days before surgery.

  • Prescription pain relievers may be prescribed if deemed necessary by your caregiver. Use only as directed and only as much as you need.

  • Ointments applied to the skin may be helpful.

SEEK MEDICAL CARE IF:

  • Pain, swelling, or bruising worsens despite treatment.

  • You develop locking or catching in the ankle.

  • You have pain, numbness, or coldness in the foot.

  • You develop giving way of the ankle which persists after 3 to 6 months of rehabilitation.

EXERCISES

RANGE OF MOTION AND STRETCHING EXERCISES - Ankle Instability, Chronic, Non-Surgical Intervention

Since ankles demonstrate instability when they have too much motion throughout the joints, range of motion and stretching exercises are not helpful and can even be harmful. Only complete range of motion and stretching exercises for your ankle if instructed by your physician, physical therapist or athletic trainer. An effective rehabilitation program for unstable ankles will include mostly strengthening and balance exercises.

STRENGTHENING EXERCISES - Ankle Instability, Chronic, Non-Surgical Intervention

  • These exercises may help you when beginning to rehabilitate your injury. They may resolve your symptoms with or without further involvement from your physician, physical therapist or athletic trainer. While completing these exercises, remember:

  • Muscles can gain both the endurance and the strength needed for everyday activities through controlled exercises.

  • Complete these exercises as instructed by your physician, physical therapist or athletic trainer. Progress the resistance and repetitions only as guided.

  • You may experience muscle soreness or fatigue, but the pain or discomfort you are trying to eliminate should never worsen during these exercises. If this pain does worsen, stop and make certain you are following the directions exactly. If the pain is still present after adjustments, discontinue the exercise until you can discuss the trouble with your clinician.

ExitCare Image STRENGTH - Dorsiflexors

  • Secure a rubber exercise band/tubing to a fixed object (table, pole) and loop the other end around your right / left foot.

  • Sit on the floor facing the fixed object. The band/tubing should be slightly tense when your foot is relaxed.

  • Slowly draw your foot back toward you using your ankle and toes.

  • Hold this position for __________ seconds. Slowly release the tension in the band and return your foot to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Plantar-flexors

  • Sit with your right / left leg extended. Holding onto both ends of a rubber exercise band/tubing, loop it around the ball of your foot. Keep a slight tension in the band.

  • Slowly push your toes away from you, pointing them downward.

  • Hold this position for __________ seconds. Return slowly, controlling the tension in the band/tubing.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Plantar-flexors, Standing

  • Stand with your feet shoulder width apart. Steady yourself with a wall or table using as little support as needed.

  • Keeping your weight evenly spread over the width of your feet, rise up on your toes.*

  • Hold this position for __________ seconds.

Repeat __________ times. Complete this exercise __________ times per day.

*If this is too easy, shift your weight toward your right / left leg until you feel challenged. Ultimately, you may be asked to do this exercise with your right / left foot only.

ExitCare Image STRENGTH - Ankle Eversion

  • Secure one end of a rubber exercise band/tubing to a fixed object (table, pole). Loop the other end around your foot just before your toes.

  • Place your fists between your knees. This will focus your strengthening at your ankle.

  • Drawing the band/tubing across your opposite foot, slowly, pull your little toe out and up. Make sure the band/tubing is positioned to resist the entire motion.

  • Hold this position for __________ seconds.

  • Have your muscles resist the band/tubing as it slowly pulls your foot back to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Ankle Inversion

  • Secure one end of a rubber exercise band/tubing to a fixed object (table, pole). Loop the other end around your foot just before your toes.

  • Place your fists between your knees. This will focus your strengthening at your ankle.

  • Slowly, pull your big toe up and in, making sure the band/tubing is positioned to resist the entire motion.

  • Hold this position for __________ seconds.

  • Have your muscles resist the band/tubing as it slowly pulls your foot back to the starting position.

Repeat __________ times. Complete this exercises __________ times per day.

ExitCare Image STRENGTH - Towel Curls

  • Sit in a chair positioned on a non-carpeted surface.

  • Place your foot on a towel, keeping your heel on the floor.

  • Pull the towel toward your heel by only curling your toes. Keep your heel on the floor.

  • If instructed by your physician, physical therapist or athletic trainer, add weight to the end of the towel.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH – Dorsiflexors and Plantar-flexors, Heel/toe Walking

  • Dorsiflexion: Walk on your heels only. Keep your toes as high as possible.

  • Repeat __________ times. Complete __________ times per day.

  • Plantar flexion: Walk on your toes only. Keep your heels as high as possible.

  • Walk for ____________________ seconds/feet.

Repeat __________ times. Complete __________ times per day.

ExitCare Image BALANCE – Tandem Walking

  • Place your uninjured foot on a line 2-4 inches wide and at least 10 feet long.

  • Keeping your balance without using anything for extra support, place your right / left heel directly in front of your other foot.

  • Slowly raise your back foot up, lifting from the heel to the toes, and place it directly in front of the right / left foot.

  • Continue to walk along the line slowly. Walk for ____________________ feet.

Repeat ____________________ times. Complete ____________________ times per day.

ExitCare Image BALANCE - Inversion/Eversion

Use caution, these are advanced level exercises. Do not begin them until you are advised to do so.

  • Create a balance board using a sturdy board about 1 ½ feet long and at 1-1 ½ feet wide and a 1 ½ inch diameter rod or pipe that is as long as the board's width. A copper pipe or a solid broomstick work well.

  • Stand on a non-carpeted surface near a countertop or wall. Step onto the board so that your feet are hip-width apart and equally straddle the rod/pipe.

  • Keeping your feet in place, complete these two exercises without shifting your upper body or hips:

  • Tip the board from side-to-side. Control the movement so the board does not forcefully strike the ground. The board should silently tap the ground.

  • Tip the board side-to-side without striking the ground. Occasionally pause and maintain a steady position at various points.

  • Repeat the first two exercises, but use only your right / left foot. Place your right / left foot directly over the rod/pipe.

Repeat __________ times. Complete this exercise __________ times a day.

ExitCare Image BALANCE - Plantar/Dorsi Flexion

Use caution, these are advanced level exercises. Do not begin them until you are advised to do so.

  • Create a balance board using a sturdy board about 1 ½ feet long and at 1-1 ½ feet wide and a 1 ½ inch diameter rod or pipe that is as long as the board's width. A copper pipe or a solid broomstick work well.

  • Stand on a non-carpeted surface near a countertop or wall. Stand on the board so that the rod/pipe runs under the arches in your feet.

  • Keeping your feet in place, complete these two exercises without shifting your upper body or hips:

  • Tip the board from side-to-side. Control the movement so the board does not forcefully strike the ground. The board should silently tap the ground.

  • Tip the board side-to-side without striking the ground. Occasionally pause and maintain a steady position at various points.

  • Repeat the first two exercises, but use only your right / left foot. Stand in the center of the board.

Repeat __________ times. Complete this exercise __________ times a day.

ExitCare Image STRENGTH – Plantar-flexors, Eccentric

Note: This exercise can place a lot of stress on your foot and ankle. Please complete this exercise only if specifically instructed by your caregiver.

  • Place the balls of your feet on a step. With your hands, use only enough support from a wall or rail to keep your balance.

  • Keep your knees straight and rise up on your toes.

  • Slowly shift your weight entirely to your toes and pick up your opposite foot. Gently and with controlled movement, lower your weight through your right / left foot so that your heel drops below the level of the step. You will feel a slight stretch in the back of your calf at the ending position.

  • Use the healthy leg to help rise up onto the balls of both feet, then lower weight only on the right / left leg again. Build up to 15 repetitions. Then progress to 3 consecutive sets of 15 repetitions.*

  • After completing the above exercise, complete the same exercise with a slight knee bend (about 30 degrees). Again, build up to 15 repetitions. Then progress to 3 consecutive sets of 15 repetitions.*

Perform this exercise __________ times per day.

*When you easily complete 3 sets of 15, your physician, physical therapist or athletic trainer may advise you to add resistance by wearing a backpack filled with additional weight.