Case Study: Multiple ankle sprains and functional instability in a professional runner

We treat ankle sprains and ankle pain seriously in our clinic. The main reason is that history of an ankle sprain (or “rolling your ankles”) is perhaps the greatest predictor for future ankle injuries. It also increases the likelihood of subsequent knee or hip injuries. The reasons why are complex, but are probably related to altered muscle activation, neuromuscular control, and gait patterns after an ankle injury.

There are also many differential diagnosis to consider after an ankle sprain. The obvious is a sprain of the anterior talofibular ligament (the most commonly injured ligament). Other often missed diagnoses include traumatic arthritis of the talocrural or subtalar joints, or a tenosynovitis of one of the lower leg muscles, such as the peroneals or anterior tibialis. Getting the diagnosis is correct is crucial, because the acute management of each is different, and what works for one can make another worse. For example, stretching, commonly recommended to runners, is the primary exacerbator of a tenosynovitis.

Another vague diagnosis is functional or clinical “ankle instability.” This was defined in Tropp, 2011 as “the subjective feeling of ankle instability or recurrent, symptomatic ankle sprains (or both) due to proprioceptive and neuromuscular deficits.” It differs from “mechanical instability” in that there is no true ligament or laxity in the system. Often, athletes who have had one or multiple ankle sprains will experience symptoms of functional instability even after we manage their primary pain generators. These symptoms can include anterolateral ankle pain, feelings of stiffness or, conversely, laxity, a lack of “trust” in the ankle, or a general sense of instability. Given the vague nature of these symptoms, it is always a diagnosis of exclusion, and must be corroborated by several objective examination measures, such as the Y-balance or star-balance test.

The management of “functional ankle instability” is nuanced because it requires a thorough management of (or exclusion of) other pain generators, followed by a longer-term approach to restore muscle activation, neuromuscular control, balance, proprioception, and ability of the system to absorb force and impact.


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To illustrate how we might manage an athlete with ankle pain, below is a case study of a 28-year old professional male runner who presented to our clinic after multiple ankle sprains and rolled ankles in only a couple of months.

Initial Examination Findings:

  • Subjective history:

    • Professional ultramarathon runner. Averages 100+ miles/week running volume.

    • Several lateral ankle sprains “rolled my ankles” in recent past.

    • Primary complaint of lateral ankle pain with running, particularly running on uneven surfaces. Also reported sensations of lateral ankle stiffness, instability, and “just feeling off.”

  • Basic local foot/ankle exam

    • Ankle Dorsiflexion - L: 15º; R: 11º

    • Ankle Plantarflexion - L: 60º, R: 52º

    • Subtalar and midfoot range of motion normal

    • Some discomfort with anterior talofibular ligament stress test, but no laxity.

    • All other ligamentous stress tests negative.

    • Weakness and report of stiffness with resistive testing of right peroneals

    • Stretch testing of peroneals painful

    • Strength and stretch testing of posterior tibialis, anterior tibialis, and extensor digitorum normal bilaterally.

    • Calf strength (calf raises):  L: 20 reps; R: 17 reps, with more difficulty, less height

    • Palpation: Pain with deep palpation over anterior talofibular ligament.

  • Functional Examination:

    • Star balance test - Anterior-medial direction: 9.5cm left-to-right difference (left further). Medial and posteriormedial both less than 4 cm difference.

    • Side hop test - Left: 12 seconds, no misses. Right: 15 seconds, one miss, greater effort/torso/upper extremity involvement

    • Eccentric step down test - Hip adduction, knee valgus, near fall bilaterally, right worse than left.

  • Other objective Findings

    • Gluteus maximus, gluteus medius, and hamstring resistive testing -  4-/5 bilaterally

    • Hip internal rotation -  L: 30º, R: 12º

    • Running gait analysis - Contralateral pelvic drop during right midstance approx 8 degrees.

Diagnosis and prognosis:

  • Grade 1 anterior talofibular ligament sprain, peroneal tenosynovitis, and traumatic talocrural arthritis, with clinical signs and symptoms of functional ankle instability.

  • Excellent potential for full recovery with conservative treatment.

Treatment:

  • Initial Treatment to manage pain generators: Manual lymphatic drainage and soft tissue mobilization of the anterior/lateral ankle and peroneals. Cross friction massage of anterior talofibular ligament. Talocrural traction and mobilizations. Hip internal rotation mobilization.

    • In two visits, the majority of the athlete’s pain was resolved, talocrural/hip range of motion was restored, and he was back to running on the road.

  • Subsequent treatment to eliminate “functional ankle instability”: 2x per week strength and motor control training to resolve deficits discovered during his examination. Program focused on the following:

    • Muscle Activation

      • Focus on gluteus medius, posterior tibialis, calves, and peroneals.

    • Motor Control

      • Focusing on single leg eccentric squats to improve eccentric control (analogous to running downhill), and increasingly challenging reactie balance activities (to improve neuromuscular control and perception of ankle).

    • Force Absorption

      • Multiplanar plyometrics including side hops, single leg hops to improve ability to absorb force.

    • Durability

      • Well-rounded lower extremity strengthening program, with a focus on large movements (squat, deadlift, lunges), at a relatively high weight, for a low amount of repetition. Greater focus on the posterior chain than anterior given his examination findings.

The athlete was also given a daily warm-up routine focusing on muscle activation and motor control to use before running.

Results:

  • After one month, the athlete had returned to his normal high-volume trail running program and was only rarely having symptoms. Testing demonstrated improved range of motion and strength, but persistent deficits in the star balance and eccentric step down test, indicating that he still had impaired motor control, and was still at risk for recurrence.

  • After 2 months, all testing was negative, with no differences between the left and right sides. The athlete subjectively reported near complete resolution of symptoms.

Too often, we see athletes with a similar presentation mismanaged by well-intentioned practitioners in two ways:

1) Initial treatment of pain generators is skipped, and rehabilitation jumps right to progressive loading. In this case, pain can often persist.

Or, 2) The athlete is not placed on a long-term program to improve muscle activation, control, balance, side-to-side symmetry, and strength. In this case, the risk for re-injury remains high. Our approach blends strength and conditioning principles with traditional physical therapy management, but always remains firmly rooted in diagnosis and objective measurement.

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Brian Kinslow