Ankle sprains affect everyone, but predominantly athletes and older adults. It doesn’t matter if you’re doing dynamic moves like jumping or simply walking down the stairs; an ankle sprain can hit anyone with a weakened ankle musculature. It’s easy to fall into the tried and true, comfortable rehabilitation method of strength-building exercises like four-way ankle exercises. However, Phil Page PhD, PT, ATC, CSCS, FACSM, LAT warns that, based on his many years of research, this traditional approach isn’t the answer.
What’s the Missing Element in Ankle Sprain Injury Management?
“Strength really isn’t the problem in these chronic ankle sprains,” said Dr. Page. “In an acute ankle sprain, you’ll obviously have swelling and damage to the tissue and we do need to address some limitations in strength. But strengthening can only bring you so far.”
If building strength isn’t the main component, then what is? Turns out, it’s joint stability. Because joint stability depends on sensory input from peripheral receptors, balance is function of joint stability. The ankle is a main component to the body’s base of support, making the joint an even bigger component to regulating the body’s balance. This makes balance training top priority. If athletes and everyday people are lacking the ability to stabilize their balance by means of their ankles, injuries are bound to ensue.
In his article covering balance and joint stability, Dr. Blackburn noted, “Maintaining balance is a function of a number of sensory inputs to the central nervous system, including visual, vestibular, and somatosensory components. Postural sway is compensated for by the neuromuscular control mechanism by way of reactive neural-feedback loops between the central nervous system and the musculoskeletal system; as well as feed-forward mechanisms compiled from previous motor experience. Thus, proprioception and muscular strength play essential roles in regulating balance by way of neuromuscular control. Research has substantiated the theory that injuries to the ankle joint not only result in damage to anatomical structures such as ligamentous supports, contractile units and the joint capsule, but also that they often include a deficit in proprioception because of alterations in the ability of mechanoreceptors within these structures to relay appropriate information to the central nervous system. In addition, balance deficits have been observed after lateral ankle sprains. Functional ankle instability can result from alterations in proprioceptive sense: allowing for increased deviation of the center of gravity outside the base of support. Chronic symptoms including dysfunction of various types have been reported in as many as 15% to 50% of individuals who sustain acute damage to the lateral ligaments of the ankle, with the most common residual symptom being functional instability” (Blackburn JT et al 2000).
Research has proven time and time again that adding dynamic challenges to the muscles and working them in a more functional fashion will better target the stabilizing principles than traditional strength training would. However, half the battle is creating an effective, comprehensive balance training program. Let’s see what research data has to say about that.
How to Prescribe and Progress Balance Exercises Correctly
As you build a balance-focused ankle sprain injury rehabilitation program, there are three exercise progression factors to consider: exercise type, surface and vision.
1. Balance Exercise Type Progression
“Sensorimotor training” includes balance exercises that progressively retrain neuromuscular mechanisms. Balance, or “postural stability,” is based on the interaction of the base of support and the center of gravity. The sensorimotor training progression moves from static, to dynamic and functional exercises by challenging the base of support and center of gravity:
- Static: Maintain balance and center of gravity on firm and unstable surfaces
- Dynamic: Add extremity movement while maintaining the center of gravity within the base of support on firm and unstable surfaces
- Functional: Perform functional movements (walking, squatting, etc.) while on firm and unstable surfaces
2. Balance Exercise Surface Progression
As your patients begin to master a stage of sensorimotor training, challenge them further by switching out the surface before moving on to the next. Multiple studies have highlighted the effectiveness of using unstable surfaces for balance training:
- A progressive balance training program utilizing TheraBand Stability Trainers resulted in significantly improved function and postural control in chronic ankle sprain patients (McKeon et al. 2008).
- Patients with chronic ankle instability reported improvements in gait kinematics, specifically the coupling of rearfoot and lower leg motion during walking after a balance training program on unstable surfaces (McKeon et al. 2009).
- A balance program including static and dynamic balance exercises using wobble boards resulted in improved proprioception and a 50% reduction in injury (Kynsburg et al. 2010).
Interchanging balance exercise surfaces can be accomplished through the utilization of foam pads, balance boards and inflatable discs. Worth noting, research shows that there is no significant difference in EMG activation of the ankle between rigid balance boards and air-filled balance devices (Harput et al. 2013).
3. Balance Exercise Vision Progression
As previously noted, visual, vestibular and somatosensory are the three sensory systems involved in balance. Changing the visual environment of the individual undergoing balance training adds another element of progression to training:
- Balance training with eyes open
- Balance training with eyes shut
Put ‘em Together and What Have You Got? An Evidence-Based Balance Progression Protocol
All of this information, solidified with this prescriptive study, give us enough concrete evidence to identify the proper progression of balance exercise. Here is the protocol based on the data from Rogers et al. (2006):
- Firm surface (floor) - eyes open
- Firm surface (floor) - eyes closed
- Foam surface (TheraBand Stability Trainer Green) - eyes open
- Foam surface (TheraBand Stability Trainer Blue) - eyes open
- Air-filled textured surface (TheraBand Stability Trainer Black - side 1) - eyes open
- Air-filled smooth surface (TheraBand Stability Trainer Black - side 2) - eyes open
- Wobble board surface (TheraBand Wobble Board) - eyes open
- Foam surface (TheraBand Stability Trainer Green) - eyes closed
- Foam surface (TheraBand Stability Trainer Blue) - eyes closed
- Air-filled textured surface (TheraBand Stability Trainer Black - side 1) - eyes closed
- Air-filled smooth surface (TheraBand Stability Trainer Black - side 2) - eyes closed
- Wobble board surface (TheraBand Wobble Board) - eyes closed
Ankle Sprain Rehabilitation Exercises You Don’t Want to Miss
While there are many exercises you can use to train balance, it would be wise to follow the guidance of Dr. Page, who has spent years researching and perfecting balance exercises for ankle injuries. In this continuation of the Injury Management Series, check out Dr. Page’s top five ankle sprain rehabilitation exercises and implement them into your stability training protocol today!
Save and use this PDF to incorporate them into your practice for patients of all ages!
Sources:
Blackburn JT et al 2000. Balance and joint stability: the relative contributions of proprioception and muscular strength. J Sport Rehabil 9:315-328
Harput G et al. 2013. Activation of selected ankle muscles during exercises performed on rigid and compliant balance platforms. J Orthop Sports Phys Ther. Aug;43(8):555-9. doi: 10.2519/jospt.2013.4456. Epub Jun 11.
Kynsburg A et al. 2010. Long-term neuromuscular training and ankle joint position sense. Acta Physiol Hung. Jun;97(2):183-91.
McKeon PO, et al. 2008. Balance training improves function and postural control in those with chronic ankle instability. Med Sci Sports Exerc. 40(10):1810-9.
McKeon PO, et al. 2009 Effects of balance training on gait parameters in patients with chronic ankle instability: a randomized controlled trial. Clin Rehabil.Jul;23(7):609-21. Epub 2009 May 15.
Rogers N et al. 2006. Quantification of a sensorimotor training progression: A pilot study (Abstract). J Orthop Sports Phys Ther. 36(1):A53-54
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