By Dr. Michael Eid
The ankle is the most commonly injured joint in both athletic pursuits and in daily life, and while it is commonly thought to be an easily managed problem re-injury can occur in up to 80% of cases.
Chronic ankle instability can develop in up to 30% of people that have suffered an inversion sprain or in everyday terms, a rolled ankle. Quite often these injuries are thought to just affect just the joint and associated soft tissue, like the ligaments, tendons and muscles.
However, a number of studies recently have shown a synergistic relationship between the muscles that control the ankle and the muscle that controls the hip. Minor postural changes are managed at the foot while major changes are managed at the hip, leading to the school of thought that weak, underactive or inhibited muscles of the hip complex can be not only a predictor of ankle sprains but also a modifiable risk factor (De Ridder et al., 2016). “After lower limb ligamentous injuries, dynamic postural stability of the lumbopelvic complex decreases” (Lentell et al., 1995).
So, which is the proposed mechanism that results in failure to correct after overbalancing and essentially leading to an ankle injury, the hip or the ankle?
Here is the science bit… (stay with us)
“…research has introduced the role of proximal stabilising musculature in the occurrence of distal injury based on kinetic chain theories. These theories postulate that impaired proximal function increases the likelihood of uncontrolled joint displacements or unsolicited accessory movements throughout the lower kinetic chain, which may contribute to the occurrence of injuries. Hip muscle weakness has been identified as a predictor of lower extremity overuse injuries such as exertional medial tibial pain.
Adults sustaining an ankle sprain and subsequently suffering from chronic ankle instability also have impaired proximal hip function compared with ankle sprain copers. Furthermore, Friel et al found decreases in hip abduction strength in individuals with ankle sprains, whereas neuro-muscular deficits in the tensor fascia latae and gluteus maximus muscles were associated with chronic ankle instability. Although these findings suggest a relationship between impaired proximal hip function and ankle injury, to our knowledge, no prospective study to date has investigated the relationship between intrinsic proximal and modifiable risk factors such as hip muscle strength…” De Ridder et al. 2016
So what does this all mean and what can we do about it?
Chronically unstable ankles have demonstrated a change in activation patterns and change in neuromuscular control of joints of the lower limb, taking a global approach to addressing these changes should create the best long-term outcomes.
By focusing on how the whole kinetic chain is working, as well as activating stabilising musculature we can regain functional independence and reduce the risk of recurrence.
How can getting checked help?
From a Chiropractic perspective, we would address the ankle from a full body perspective, taking into account the nervous system and the rest of the kinetic chain from the ankle to knee to hip to Pelvis and lumbar spine.
There are a number of neurologic mechanisms that come into play in addressing proximal muscle weakness, for example if sacroiliac joint movement is restricted it will affect activation and contraction of musculature of the lumboplevic hip complex (Webster & Gribble, 2013). Joint position sense is also important to consider, as literature demonstrates that Chiropractic care has a positive impact on elbow position sense after adjusting the neck (Haavik & Murphy, 2011), the same neurologic mechanisms would likely create a similar response in the lower limb after adjusting the lumbopelvis.
Postural stability is also important to look into, when addressing a patient for ankle sprains, we take a global view and not only address the joint affected but look along the whole kinetic chain to ensure that forces are distributed evenly and muscles are activated in the correct fashion.
Strength and endurance of gluteal complex is important and is required to help to stabilise the pelvis to not only provide a solid stabile platform for the spine to function properly but also to distribute and absorb mechanical loading from movement.
It has also been demonstrated that after an adjustment, activation of important stabilising and the gluteal complex (Motealleh et al., 2016) and the quadriceps group (Motealleh et al., 2016, Suter et. al. 1999) increases leading to better control of the lower limb.
What can you do at home?
Incorporate a strengthening exercise program at home on a daily basis to increase activation of the gluteal complex. The clam (side lying isometric exercise) completed daily will achieve best results. You can start with as little as 8-10 reps on each side and work your way up.
It’s important to ensure you progress at the right rate for you. At The Chiropractic Works, we can tailor an individualised program for you that will focus on increasing glut strength and building strength around the hip joints.
Take home points:
- The ankle is the most commonly sprained joint in the body and is frequently reinjured
- Glut muscle weakness can be attributed to the cause of inversion sprains due to the failure of musculature of the hip to correct for lateral sway and may result in ankle injury.
- Hip strength is a modifiable risk factor and shown to reduce the frequency or recurrence of ankle injuries.
- Hip-focused stability training could be effective in improving dynamic hip control. Which in turn takes stress of the knee and ankle
- De Ridder, R., Witvrouw, E., Dolphens, M., Roosen, P., & Van Ginckel, A. (2016). Hip Strength as an Intrinsic Risk Factor for Lateral Ankle Sprains in Youth Soccer Players: A 3-Season Prospective Study American Journal of Sports Medicine 45(2):410-416. doi: 10.1177/0363546516672650
- K Friel, N., McLean, C., Myers., & M, Caceres. (2006). Ipsilateral Hip Abductor Weakness After Inversion Ankle Sprain. Journal of Athletic Training, 41(1):74– 78.
- Lentell, G., Baas, B., Lopez, D., McGuire, L., Sarrels, M., & Snyder, P. (1995). The contributions of proprioceptive deficits, muscle function, and anatomic laxity to functional instability of the ankle. Journal of Orthopaedic Sport Physical Therapy. 21:206–215.
- Haavik, H., & Murphy, B. (2011) Subclinical neck pain and the effects of cervical manipulation on elbow joint position sense. Journal of Manipulative and Physiological Therapeutics, 34(2):88-97. doi: 10.1016/j.jmpt.2010.12.009.
- McHugh, M., P., Tyler, T., F., Tetro, D., T., Mullaney, M., J., & Nicholas, S., J.(2006). Risk factors for noncontact ankle sprains in high school athletes: the role of hip strength and balance ability. American Journal of Sports Medicine. 34:464-470.
- Motealleh, A., Gheysari, E., Shokri, E., & Sobhani, S. (2016). The immediate effect of lumbopelvic manipulation on EMG of vasti and gluteus medius in athletes with patellofemoral pain syndrome: A randomized controlled trial. Manual Therapy, 22:16-21 doi: 10.1016/j.math.2016.02.002
- Suter, E., McMorland, G., Herzog, W., & Bray, R. (1999) Decrease in quadriceps inhibition after sacroiliac joint manipulation in patients with anterior knee pain. Journal of Manipulative and Physiological Therapeutics, 22(3):149-53
- Webster, K., A., & Gribble, P., A. (2013). A comparison of electromyography of gluteus medius and maximus in subjects with and without chronic ankle instability during two functional exercises Physical Therapy in Sport, 14:17-22 doi: 10.1016/j.ptsp.2012.02.002.