"I think I tore something, " groaned the middle aged man named Jim lying on the floor grasping his right ankle. "Oh, man it hurts. I don't think I can walk."
A minute earlier he was running the basketball court when he tripped over one of his teammates twisting his right ankle. This was not the first time Jim had sprained his ankle but it was definitely the worst. Two of his friends helped him to his feet. He dangled the right foot off the ground and gingerly set it down. He tried to step on his leg but a nauseating wave of pain galloped up his leg. He couldn't walk. Carried on the arms of his friends, Jim hopped off the court.
His friends took him to the ER just in case he had broken something. He could no longer see his ankle and his foot was fat. A bluish hue was creeping over the outer part of his ankle and foot. "This can't be good," he thought.
The doctor X-rayed his foot. No broken bones but he would have to use crutches for a couple of weeks. The ER tech wrapped his foot and ankle in an elastic bandage, gave him a pair of crutches and said, "Use these for about two weeks or so and keep your foot elevated. You'll be fine after that," and left the room.
Three months later, Jim was not fine. While he could walk, sort of, he could not run, jump or cut. His ankle hurt. All he could do on a basketball court was shoot free throws. He had been back to his family doctor a couple of times but always heard the same brief advice, "Wait. You'll get better. You just have to wait."
Jim had been diligently following the instructions issued by his doctor. He stretched his ankle several times a day and "spelled the alphabet" with his foot in the air. He strapped an elastic band to his foot and pulled his foot up, down and to the side trying to strengthen it. He tried to jog every few days but was met with the same frustrating response. He began to wonder if he would ever run again.
Jim's problem, a sprain of the outer or lateral ligament complex of the ankle, is the most common injury in sports comprising approximately 20% of all sports injuries. A ligament sprain is a stretch injury of the ligament. Since ligaments are generally inflexible and tend to resist stretching, a sprain is really a tearing of the ligament. The question is how badly is it torn. Ligament sprains are subdivided into three classes: Grade 1, Grade 2 and Grade 3. Each grade represents an increasing amount of damage with Grade 3 being a complete rupture of the ligament.
Chronic ankle instability often follows a Grade 2 or Grade 3 injury. Instability refers to the inability of the body to maintain control of the joint. All joints of the body move around an axis of rotation. When the axis remains relatively fixed, motion appears smooth, graceful and is pain free. When the axis drifts or slides, as in the case of an instable ankle, normal movements hurt (Imagine the wheel of your car as it turns. The center of the wheel is the axis of rotation. When the wheel is "out of alignment", the ride is rough. When the wheel is balanced, the motion is smooth).
Jim cannot make his ankle do what it should no matter how hard he tries. His ankle is controlled by regions of the brain not under his conscious control mainly the motor cortex and the cerebellum. His treatments, moving his foot around spelling the alphabet, stretching and using an elastic band, are all voluntary motions. He can do those. What he cannot do requires subconscious control.
Joints possess something very cool called Joint Position Sense (JPS). Tiny sensors in the joint relay information to the brain about where the joint is in space. The brain then coordinates an orchestra of output firing muscles at the appropriate time. Brilliant. This is how you can walk and not constantly stub your foot. Your foot only needs 5 mm of clearance from the floor. Your JPS does the job for you. Imagine how difficult it would be if with every step you had to think about how much to pull up your foot to clear the floor. I suspect you would not walk very much. Too much work.
People with chronic ankle instability (CAI), have ankles that are lost in space*. The ankle joint sends information but it is incorrect. So, the brain, using the data to develop the motor plan, sends the sequence of muscle contractions, which of course are incorrect too. The result is delayed contractions, slip sliding of the axis and pain.
To retrain the JPS, you have to train on your foot. Something as simple as standing on one leg (which you should be able to do for 30 seconds without arms flailing and body teetering). If you cannot stand on one leg with control, how will you ever control something as dynamic as running?
Our approach with clients with CAI is this:
1. Master balancing drills with the goal of 30 seconds on one leg.
a. single leg, no additional perturbation, no other movements
b. single leg, with perturbation such as an unstable base of support
c. single leg with perturbation and with other limb movements such as playing catch or light saber fighting with a PVC pipe
2. Jump, run, hop at loads which are not painful but are challenging and difficult to perform (see the View "When Can I Run Again" for details on tools and tests).
For Jim to run, play basketball and enjoy life again, he must retrain his JPS. Sitting down, stretching and spelling the alphabet might be a good start (well, I never have understood stretching something that is torn so strike the stretching), but eventually Jim must train himself by doing the very things he cannot do. He can only do that by adjusting the load due to gravity. When he weighs less, everything is easier and his body learns faster. He will no longer be lost in space.
Make today count.
Doug Kelsey
Reference: *Konradsen L. Factors Contributing to Chronic Ankle Instability: Kinesthesia and Joint Position Sense J Athl Train, Dec 2002, 37(4) p381-385.
