The term Achilles heel is often used to describe weakness or vulnerability. It is derived from the Greek mythology legend of Achilles, who was dipped into the river Styx by his mother to make him invincible.
The ankle is a prime spot for this weakness. How many of your patients have suffered ankle sprains in their lifetime? Prior ankle injuries create compensation chaos and dysfunctional movement patterns, which manifest as pain or energy leaks in other areas. A chain is only as strong as its weakest link. The system of interconnecting human movement chains must function at optimum levels to prevent injury and pain. These chains are susceptible to injury when there is dysfunction between the intricate yin / yang balance of mobility and stability.
The body craves stability and will sacrifice functional mobility to obtain it. Unique movement compensations develop for each person based on their history. The body is hardwired to avoid potential threat and takes the path of least resistance to ensure safety. Its objective is to use minimal energy and effort to accomplish a given task.
One of the primary "safety net" systems the body uses for self-protection is stiffness, aka tissue extensibility dysfunction. The brain increases neurological input to muscles, ligaments and joints, facilitating stiffness in an unconscious effort to protect. Think of how the body reacts when walking on ice. Everything stiffens to prevent falling. The majority of your patients will be moving like they are walking on ice, perpetually stiff.
How prepared to you think the body will be for efficient movement if it is locked in stiffness 24/7? Optimal performance in activities of daily living are sure to become compromised.
To avoid ligament injuries and compensation chaos in the kinetic chain, it is critical for patients to gain stability and strengthen the ankle. The foundation for all stability and efficient movement sequencing begins in the reactive core. There are three effective movements your patients can perform that increase ankle mobility and lock in stability. If you find that manual ankle mobilization is indicated, these exercises help patients become involved by taking an active role in therapy. For purposes of maximizing stability, focus on a few major players of deep inner core function during the exercises; specifically the diaphragm and transverse abdominus.
The Ankle Mobility Drill
A key concept to the ankle mobility drill is realizing that it's a mobility exercise, not a flexibility / stretching one. You want to rock the ankle back and forth in the sagittal plane with controlled dynamic movement, not a static hold. It is essential that the heel remain in contact with the floor. Most people who have ankle mobility restrictions will immediately lift the heel. You may need to hold the heel down for beginners so they can feel the movement. Exercise should be performed in bare feet for maximum benefit.
- Get into a half-kneeling position and maintain the downward knee centered below the extended hip.
- Use a stick or pole and position it on the outside of the front foot near the "little toe." Prior to initiating the movement, press the downward knee into the floor to activate the gluteus muscles (make sure there is a pad underneath the knee). The purpose is to teach glute activation prior to hip extension for proper hip stability.
- Grasp the pole with both hands and press into the ground, activating the inner unit reactive TVA core muscles. While maintaining an upright "tall spine" position (not flexing forward at the waist), lunge forward, ensuring that the forward knee goes to the outside of the pole. This will prevent the foot from falling into a dysfunctional compensatory pronation pattern to obtain more motion at the joint.
- Do not hold breath. Inhale through the nose into the diaphragm and exhale via the mouth.
- Keep hips squared and straight ahead with no rotation. Return to starting position and repeat 10 times. Maintain pressure on the downward knee and pole at all times. It is normal to feel a stretching sensation in the back of the calf. Be observant of a "cheat" in the hip whereby patients will rock forward into flexion of the hip to gain stability from the psoas.
Ankle Inversion With Variable Resistance
Adding resistance bands to this movement is an effective way to isolate precision and control of the ankle mortise while strengthening the tibialis anterior and tibialis posterior. Use a variable resistance band that is not too strenuous and wraps easily around the ankle.
- Once band is wrapped, maintain a diagonal line of pull to approximately 15 degrees.
- Maintain even pressure on the band during the motion.
- Precision and control are the goal. Be careful not to let speed enter into the movement.
- Perform 15-20 repetitions.
Ankle Eversion With Variable Resistance
Balance of antagonistic muscles must be achieved for ankle strengthening and stability. Eversion motion will work the peroneus tertius, peroneus longus and peroneus brevis. Since the majority of ankle sprains are inversion types, the everters are often compromised with inhibition.
- You may need to add or decrease band strength depending on the individual.
- Maintain a diagonal line of pull on the band approximately 30 degrees.
- Do not let your knee move.
- Try to confine all the movement and work to your ankles.
- Perform 15-20 repetitions.
Variable-resistance band strengthening exercises help promote eccentric strength and proprioception in the open-chain environment. When ankles are strong, your patients will be much better at maintaining balance under awkward conditions. Think about it: The intrinsic muscles of the ankle are constantly firing to maintain balance. If they lose reaction time, people are more prone to slip-and-fall injuries. And here's one more huge benefit to strong and stable ankles – you can make them practically injury-proof!
Click here for more information about Perry Nickelston, DC, FMS, SFMA.