Proprioception defines our awareness and perception of where our body is positioned in relation to space. This is fed from our visual and vestibular systems, which play an integral role in balance and stabilisation. As a multi-directional, weight bearing joint, ankle sprains are one of the most prevalent injuries to occur in athletes and non-athletes alike.
There are many factors that we can improve to help prevent ankle sprains. These include strengthening of the muscles, tendons and ligaments around the ankle joint, and ankle proprioception exercises to improve our proprioception and balance.
What is proprioceptive training?
Proprioceptive training is shown to decrease the incidence of an ankle injury in both active and non-active populations. This type of training involves training special types of receptors called proprioceptors in the body, that respond to touch, pressure and vibration, in order to improve our proprioception. This is done through the means of completing tasks that challenge our proprioceptive sense, and hence tasks that focus on ankle strength, balance, and muscular control will be a target area for this.
To see how proprioception can attribute directly to ankle sprains, let’s use the example of an athlete landing from a jump. As the athlete lands, if their foot lands on an angle, it may begin to roll inwards. This will create stress of the muscle spindle and lateral ankle ligaments, including the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL). If the athlete has poor proprioception, they may not be able to recognise where their ankle is in relation to space, and these ligaments will be strained or torn as they continue to roll in and stretch, resulting in a sprained ankle.
We can decrease the risk of this happening on both the dominant and opposite leg by completing proprioception training. By improving our proprioception, this athlete in the same scenario will be able to recognise that his ankle is beginning to roll inwards, and start to move his ankle back outwards to prevent it from rolling, hence preventing an ankle sprain.
What are proprioceptive and balance exercises for ankle stability?
A proprioception training program can be created which will include balance, postural stability and proprioceptive exercises aim to improve the body’s ability to recognise where the body sits in relation to space. Some common ways to increase proprioception include, but are not limited to the following:
Tandem Walking: Tandem walking, or tight-rope walking, is a great dynamic balance activity which involves walking forward, heel to toe, in a straight line. This narrows your base of support, and as a result decreases your ability to balance. As you improve at this, this exercise can be progressed by completing it with your eyes closed, which will take away the visual systems ability to help you. Your proprioception and dynamic balance ability will be tested here, as without a visual aspect, it will be harder for your body to recognise where you are in space. This activity can be further progressed by holding your arms across your chest, and rotating your head as you walk forward.
Single Leg Stance/Wobble Board: The single leg stance is a classic static balance and proprioception exercise as it can be progressed and regressed so easily. To begin, simply stand on one leg, keeping your eyes locked forward. This can be progressed by closing your eyes, and moving your head around just like the above exercise. Additionally, you can change the surface you are attempting to balance on. By implementing an unstable surface such as a wobble board or balance board, your ankle joint position will begin to move. This will require an increased effort of your proprioceptors to relay messages to the brain that tell you if the ankle is beginning to move outside its stable limits, and needs correcting.
Single Leg Squats: The Single Leg Squat is a great exercise that can help with postural control, as it begins to incorporate not just the muscles around the ankle, but also those in the upper leg, including the glutes, quads and hamstrings. This is completed just like a normal squat, but using one leg. This activity can be progressed by completing it eyes closed, as well as changing the surface by standing on a foam mat, wobble board, or even on an upside down bosu ball.
Hopping: Hopping is another great ankle exercise to help improve your dynamic proprioception ability. This is often completed through the single leg triple hop, in which the patient must hop three times directly forward and cease momentum without falling. The cross-over hop is a variation of the triple hop in which the patient hops three times forwards, 10cm either side of a straight line. The side-to-side hop is another variation where the patient hops side-to-side 40cm each way. These exercises are good, as they can be accurately used as patient specific outcome measures when tracking strength, balance and proprioception, looking at stability on landing, distance hopped, and number of times able to hop in 30seconds.
Hopping onto Balance Mat: A good end-stage activity is hopping onto and off a balance mat, in various directions. This requires a high level of ankle proprioception to stay balanced and protect the ankle joint, as the stability of the surface will change. It also mimics common scenarios where people may endure ankle sprains, such as landing in a ditch on an oval or another uneven surface.
Star-Excursion Balance: Star-excursion balance requires maintaining single leg balance whilst the other leg reaches out as far as possible in an 8-point star formation. This test is perfect for improving balance and proprioception, as it can also be used as an outcome measure, by measuring how far the patient is able to reach their leg, whilst maintaining single leg balance.
Ankle Sprain Recovery Exercises
Following an ankle sprain, it is important that we complete ankle rehab exercises to prevent further ankle injuries occurring. Once an ankle sprain has occurred, the injured ankle is more likely to roll, due to the damage that can occur to the ligaments and structures around the ankle joint, which will decrease joint stability, balance, and proprioception.
It is important that we start with strengthening exercises to increase the strength of the structures around the ankle joint. A good place to start this is through different variations of single leg calf raises, resisted inversion and eversion exercises, and resisted ankle rotation. These are all great exercises to strengthen the different muscles that help create stability alongside the ankle ligament, including the calf, peroneals, and tib ant/tib post muscles.
Additional to specific muscle strength training, it is important to include a vast range of proprioceptive and balance exercises to improve functional ankle stability following an ankle sprain. Your physiotherapist can help to guide you through these exercises, selecting low level stages of these and slowly progressing them, to improve your proprioceptive sense and decrease the risk of further damage to your ankle in the future.
Whilst ankle sprains are a common injury, through strength, balance, and proprioception training focusing on the ankle joint, we can decrease the risk of these injuries in both healthy patients, or those with acute or chronic ankle instability.
