ANKLE SPRAIN - How the Thoracic Spine and Hip Can Contribute

Recovering from an ankle sprain appears to be pretty straight forward, however there are other factors which can hinder recovery. The two areas we will focus on are the hip and thoracic spine (upper back). Daily activities in the sitting position, such as computer use, reading and driving, etc., results in an increase stiffness in our hips and thoracic spine.
The tissue surrounding the gluteals become stagnant from prolong sitting making it difficult to generate force and absorb energy. At the same time, the hip flexors in the front of our pelvis shorten from sitting.
The thoracic spine is another region which is affected from prolonged sitting. The muscles of the thoracic spine work to fight gravity which pulls our trunk forward. Most daily activities which are performed in front of our body also contributes to increase pull forward.  To make matters worse, the thoracic spine is a difficult area to stretch due to the bony anatomy and rib cage.
Limited mobility of the hip and thoracic spine changes our biomechanics which can impair the body's ability to recover from a lateral ankle sprain.

HIP

Hip Mobility

When the heel hits the ground, the bony anatomy of the ankle generates a rotational force up the lower leg and into the thigh. At the same time, the body weight shifts from the back leg to the lead leg which produces a lateral motion of the hip and pelvic junction.

If there is a limitation of frontal plane motion of the hip, the movement will find another path. A common pathway is the ankle.  As the body shifts laterally to the front leg with a limited hip motion, the lateral movement will be forced at the ankle causing a lateral ankle sprain.

Hip Mobility Assessment

Stand with your legs hip width apart. Bring your arms up next to your head. Reach to the side as far as you can, then to the other side. Feel for any difference in motion in your hips from side to side. You may need to stand in front of a mirror or have a friend to give you feedback.

The above pictures show less mobility on the left hip (picture on the right). The larger hip/pelvis angle reveals there less motion occurring at that joint. Side note: I roll my left ankle during this run.

Hip mobility Treatment

Lateral hip stretch -

To stretch the side of the hip, stand next to a low bench or step. Place the leg across body onto the step with the knee bent. Allow the body to move over the stance hip until you feel a stretch. Use your pelvis to drive forward, sideways and twist. Please refer to the video above.


***Bonus lateral hip stretch - Instead of crossing the leg in the front, cross my leg behind my body.  Make sure the back leg does not twist the body away from the stance leg. Shift toward the stance leg. Then use the pelvis to drive the body in the sagittal plane, frontal plane and transverse plane. Please refer to the video below.

Gluteal Stretch -

Place one leg on a table ( at home I use the end of my couch, kitchen or bathroom counter) at about mid thigh to hip height depending on flexibility. The knee should be bent to 90 degrees and thigh perpendicular to body. From there, hinge forward in the sagittal plane, reach away sideways in the frontal plane and rotate towards in the transverse plane to the stretch leg. These motions create length at the hip and pelvic junction. Perform about 10 repetitions per plane of motion or until you feel improvement in flexibility.
Refer to the video above for planes of motion.
*** Hinge at the hip NOT the lumbar spine.

THORACIC SPINE

Thoracic Spine Mobility

When one leg is swinging forward, the same side arm is swinging back. The swinging of the arm backwards drives rotation of the upper back. For example, as the right leg swings forward the right arm swings backwards. A rotational motion is created at the core since the opposite leg is behind the body. This position helps to load the abdominals in a rotatory fashion, similar to a spring.
If the thoracic spine is tight, the rotation will bypass the region and the motion in transferred elsewhere. Occasionally, this force causes a shearing motion in the back. Other times, the force goes into the ankle.

Thoracic Spine Assessment

Place one leg in front of the other with the knee slightly bent. Bring your arms in front of your body at chest level. Turn as far as you can towards the front leg then towards the back leg. Switch so the other leg is forward. Feel for the rotation in the thoracic or have a friend watch for you.
Watch the video below.

 

Thoracic spine treatment

Rotation T/S stretches- These stretches improve the rotation of the spine.

To improve rotation of the thoracic spine while the arm is swinging forward - Take a step forward with L leg and L arm next to head, bring R arm in front of body and reach forward. 
To improve rotation of the thoracic spine when the arm is swinging backwards - With L leg in front and R arm next to head, swing L arm behind the body.
Refer to the video below.

To maximize the effects of the stretches, follow up with strengthening exercises. Performing strengthening exercises after stretching will stimulate sensors in the newly acquired range of motion which may have been dormant for weeks, months or years.

Stay tuned for my next post on strengthening exercises for runners!

ANKLE SPRAINS

Throughout my years of working with athletes, I have come to realize that most runners experience a lateral ankle sprain at some point. Unfortunately, when I ask athletes what they have done to rehab, most say "I ice" or even worse,  "nothing". A lateral ankle sprain occurs when the outside portion of the ankle rolls towards the ground.

While performing my assessments, I have found that an untreated or ill treated ankle sprain is the underlying culprit for most other insidious onset of injuries in the lower extremity. It doesn't seem to make a difference if the ankle sprain happened 1 month ago or 10 years ago. They all have lasting impact on the mechanics of the body.
If you have an injury, ask yourself, " have I EVER had an ankle sprain?" "Do I have an injury on the same side as the ankle sprain?"

WHAT HAPPENS?
The moment you feel your ankle roll, an inflammatory response occurs. This inflammatory response induces chemical reactions which allow an increase of fluid into the injured region. Micro tears occur in the muscles and ligaments of the lateral ankle. When proprioceptors are stretched, the body has an increased difficulty communicating the joint position to the brain. This leads to an increased susceptibility to future ankle sprains.

Change in biomechanics

Swelling takes up joint space, making it difficult to move, and limiting range of motion (ROM).  Over time the impaired motion limits joint mobility resulting increased stiffness of the capsule (tissue around joint). The limited ankle dorsiflexion ROM also contributes to instability since the plantar flexed position is unstable due to bony anatomy. Our body, in its attempt to find the path of least resistance, moves through another joint. This leads to injuries in other regions not meant to take the stress.

How do we rehab from an acute ankle sprain?
Immediately after injury, the first priority is to manage swelling. Minimizing swelling will help decrease pain, maintain good ROM and mechanics. Next, recover proprioception through balance exercises to regain sense of joint position. If joint motion is lost, it must be restored as quickly as possible.

EXERCISES

Mobility

There are several ways to improve ROM of the ankle joint. Here's how to use the swing leg to drive an ankle stretch in all 3 planes of motion. The movements help to engage more muscle fibers then the typical forward stance. There are 2 muscles which make up the calf, gastrocnemus and soleus. The gastrocnemus is stretched when the knee is straight and soleus when the knee is bent.

Tri-plane gastrocnemus stretch: swing leg driver (video below) - Stand with one leg forward with the front knee bent. Shift your body forward until you feel a stretch in the calf of the back leg. Use the forward leg the drive in the sagittal plane, frontal plane and transverse plane.
To stretch the soleus, bend back leg and perform the swing leg driver in 3 planes.

*** Most shoes have more cushion at the heel which makes it difficult to stretch your calf. If you don't feel a stretch, go barefoot, or use a towel, tree root or rock under your forefoot to get a better angle.

Balance training

The proprioceptors need to be retrained after being over stretched after an ankle sprain. Single leg balance activities are the best way to improve function.
 Single Leg Balance - Standing on one leg is the best exercise to improve balance. Since vision contributes to balance, closing your eyes will increase the difficulty. Another way to increase the challenge is to look left and right or up and down. Mimic running by standing on one leg while swinging your arms. 

Balance Reaches (video below) - A balance matrix exercise uses your leg to create instability in different planes on the standing leg. You reach forward (sagittal plane), to the side (frontal plane) and rotate to the back (transverse plane). Initially, you can gently tap the ground to provide stability, then progress to reaching without touching the ground. To make this more challenging reach to toward the stance leg. This encourages lateral motion of the ankle which is the position of an ankle sprain. Balance reaches performed in these positions train the ankle to recover prior to reaching the critical point of a sprain.

Variations on SL balance
1) look over your shoulders
2) hand reach side to side or cross body

                                     

Strength

One way to strengthen the muscles around the ankles is to perform a tri-plane heel raise.
Heel raises (3D style) - Most people know how to perform a heel raise. Performing the exercise with different foot positions changes the emphasis of the muscles being used. There are seven basic foot positions: normal, narrow, wide, toe out, toe in, right forward and left forward. The exercise can be changed to fit the needs of each individual. An example is instead of raising straight up, perform a twist in all the foot positions. This promotes the transverse plane.

                                       
*** Perform these exercises to your comfort level and in a pain-free range. These are general exercises demonstrating the use of 3 planes of motion to get your body moving after an ankle sprain. Visit a movement specialist for exercises specific to your biomechanics presentation.


OTHER CULPRITS

When the ankle hits the ground a simultaneous chain of events begins. As the foot strikes the ground a reaction occurs up the lower extremity, while at the same time being driven by top down motion of the arms swinging.

Limited hip motion

As body weight is transferred to the lead leg, a frontal plane motion is generated. If hip adduction is limited, the ankle will try to compensate for the lack of side to side motion.  This will cause the ankle to roll to the side, resulting in increased susceptibility to injury.

Thoracic mobility

As the arm swings, a rotational motion in transmitted to the spine. However, if thoracic spine motion is limited, the rotatory force is transferred through the hip and to the ankle causing an lateral sprain. The force can be magnified if the hip is also tight.

Stay tuned for part 2 of ankle sprains to assess and treat other culprits!

What is 3 dimensional?

Our body functions in 3 basic planes of motion- sagittal, frontal and transverse. Sagittal plane is characterized by forward and backward motion, frontal plane is side to side motion and transverse is twisting motion. Our everyday motions are typically composed of one predominate plane with the 2 other planes used in the supporting roles. An example of this is walking. When we move forward we primarily use the sagittal plane, however the frontal and transverse planes are vital to allowing the proper mechanics necessary to achieve the movement of walking. Without the frontal and transverse planes of motion, more stress is created in the sagittal plane, ultimately leading to injury. Lack of training in the other planes of motion leads to limited endurance and causes premature fatigue.

Visualize the way football players, baseball players, soccer players, etc, move during a game. They step to the side, they step and rotate with every pivot, they twist and turn, all in reaction to the game they play.
Next time you participate in activities such as throwing a baseball or gardening take notice of how our body moves throughout all planes of motion. 

So if our body functions in 3-D, why don't we train in 3-D? 

Examples of 3-D "Jumping Jacks"

The key to minimizing injury and improving performance is to find the exercises which facilitate motion in all 3 planes which is specific to your sport.

Below are videos to show "jumping jacks" performed in the 3 planes of motion demonstrating different variations arm and leg patterns.

Did you think there is only one way to perform "jumping jacks"?