Ankle Instability Treatment in New York

Structures that Stabilize the Ankles

The ankle is a hinged synovial joint that works in concert with the subtalar joints to plantar flex and dorsiflex the foot. Tough ligaments made of Type 1 collagen are the primary stabilizing structures of the ankle, while musculotendinous tissues work to produce, absorb and control forces. The ankle is stabilized laterally by three separate ligaments, the anterior and posterior talofibular ligaments, and the calcaneofibular ligament. The ligaments attach the lateral malleolus to the bones below the ankle joint, helping to resist stress from foot inversion and internal rotation.

The structures of the ankle are highly adaptable to the specific types of demands placed on them. For example, a hockey player’s ankles adapt to training differently than a basketball player’s ankles. Strengthening exercises that specifically target the feet and ankles can help prevent sprains and preserve ankle stability.

Unilateral Ankle Instability Alters Muscle Activation Patterns

When an ankle becomes unstable, it can affect muscle activation patterns along the entire kinetic chain, in both the injured and non-injured sides of the body. One recent study used surface EMG (SEMG) to compare muscle activation in participants with unilateral chronic ankle instability (CAI) and an uninjured control group. They monitored the participants on a split-belt treadmill, with and without random left- and right-sided perturbations.

Research results found that:

• Participants with CAI showed increased muscle activity on the non-injured side of the rectus abdominis
• The gluteus maximus on the injured side had shorter latency – the time between muscle stimulus and contraction – compared to the non-injured side
• Activation of the leg muscles in the CAI group, including the rectus femoris, biceps femoris, and gluteus medius, activated earlier and less bilaterally
• Muscles of the trunk in the CAI group – the bilateral rectus abdominis and the erector spinae on the non-injured side – were activated earlier and with greater intensity than in the non-injured control group

The research team concluded that unilateral CAI alters bilateral motor control strategies around proximal joints. Altered muscle activation patterns reduce movement efficiency, increase injury risk and lower physical performance. Over time, unilateral CAI can cause postural issues that contribute to joint pain and other issues.

Common Causes of Ankle Instability

In physically active and athletic populations, chronic ankle instability often manifests after a lateral ankle sprain, a common injury that involves the foot and ankle rolling inward at a high velocity during sports or exercise. Lateral ankle sprains account for about 30% of all injuries, with a 73% chance of re-injury. Of those injured, as many as 40% will develop CAI.

Symptoms of CAI include:

• Residual ankle pain
• A sensation of the ankle “giving way”
• Limited ankle range of motion
• Local muscle weakness
• Reduced functional performance
• Ankle joint osteoarthritis

Injury to the ankle ligaments can cause damage to the proprioceptors that signal the central nervous system to influence neuromuscular control, not only of the ankle joint, but also control of the proximal joints.

Factors that affect ankle stability include:

• Traumatic injuries, especially lateral ankle sprains
• Weak intrinsic foot core muscles
• Inefficient muscle coordination patterns
• Decreased ankle range of motion
• Balance deficits
• Repetitive stress from sports and exercise, with insufficient recovery
• Obesity and physical deconditioning
• Joint hypermobility due to lax ligaments
• Bony deformities
• Proprioceptive deficits
• Weak peroneal muscles
• Muscle weakness and joint misalignment farther up the kinetic chain
• Failure to fully rehabilitate an ankle injury
• Premature return to sports after an ankle injury

CAI rehabilitation is geared toward muscle strengthening, range-of-motion exercises, regenerative therapy to repair and rearrange joint cartilage, neuromuscular feedback training, postural realignment, and eradication of compensation patterns.

Testing for Ankle Instability

There are a number of clinical tests for CAI, some of which require the patient to jump and land. But in the early stages of ankle injury, patients are often incapable of jumping, and attempting to land on an injured ankle can make things worse. Thankfully, new technologies are changing the game for CAI assessment.

1. Dynamic High-Resolution Ultrasonography

Advanced diagnostic ultrasound imaging takes the guesswork out of ankle instability assessment, providing a window into the structures that affect ankle function. Ultrasound is useful for comparing the injured and uninjured ankles, visualizing how the ankle structures interact, identifying facial densification and myofascial trigger points, and guiding therapeutic procedures. Capabilities for Superb Microvascular Imaging (SMI) and sonoelastography provide invaluable tools for monitoring the rehabilitation process.

2. Star Excursion Balance Test

The Star Excursion Balance Test (SEBT) is a dynamic test that measures strength, flexibility, and proprioception. It is widely used to measure dynamic postural control, and it is extensively used to test for chronic ankle instability. NYDNRehab has customized the SEBT for 3D motion analysis.

SEBT at NYDNRehab

3. 3D Running Gait Analysis

A high-tech gait analysis using sophisticated equipment and customized software can reveal quantitative details about ankle instability, and its effects on functional performance. When combined with a wearable dynamic ultrasound device, 3D running gait analysis provides data on functional performance that can be used for rehabilitation and athletic performance enhancement.

Running Analysis innovation

4. Myolux Medik E-Volution

The Myolux system was developed in France to assess and rehabilitate foot and ankle functional deficits. MyoLux is used to test and assess ankle proprioception. Its envelope of function measures the upper and lower thresholds of load that the ankle can tolerate. Myolux also serves as a re-education device to promote and restore ankle stability.

5. Rehabilitation-Oriented ASsessmenT (ROAST)

ROAST is a clinical assessment for mechanical and sensorimotor impairments in acute ankle sprains. ROAST is used to establish the mechanism of injury, assess ligaments and bones, and screen for previous ankle injuries. ROAST helps clinicians to identify the risk of developing CAI in the early stages of injury.

Holistic Ankle Instability Rehab

Because ligaments have limited vascularity, it was previously thought that once a ligament had been stretched and torn, surgery was the only hope for restoring ankle stability. But new technologies and advancements in research are debunking that notion, offering alternative approaches to treating CAI.

Tissues like ligaments and tendons have less blood flow – and hence receive less oxygen and fewer nutrients – so they heal more slowly than other soft tissues. The ankle tendons are supplied with blood by the anterior tibial, posterior tibial, and peroneal arteries, and respond well to regenerative interventions. Although severe cases may require surgery, most ankle instability can be successfully treated conservatively.

Treatment options for CAI include:

• Prolotherapy, an orthobiologic injection therapy that irritates damaged tissues, promoting a healing response from the immune system. Prolotherapy is most successful when the injections are guided by high-resolution ultrasound for precise targeting of damaged tissues.
• Strengthening of the intrinsic foot core muscles that support the foot arch. A recent Korean study found significant improvements in dynamic stability after test subjects received 8 weeks of foot core training, with four 15-minute sessions per week.
• Neuralign is a new technology that addresses neuromuscular adaptations after an injury. Adaptations may include increased activity in the sensorimotor network that alters muscle activation patterns. Neuralign is a wearable device with a kinematic sensor, activated by movement. The patient dynamically interacts with the device to stimulate efficient muscle recruitment patterns, enhance movement quality, and restore optimal muscle balance during rehabilitation.
• Ultrasound-guided neuromodulation aims to regulate neural activity that affects muscle firing patterns in the foot and ankle. By calming hypersensitized nerves and stimulating underactive nerves, neuromodulation helps to restore synergy in the neuromuscular system.
• Neuromodulation with MyoLux and HEIT combines proprioception retraining with high-intensity magnetic pulses to stimulate neuroplasticity.
• TECAR therapy with INDIBA helps to restore the ionic charge of damaged cells, for faster injury healing and rehabilitation.
• Fascial manipulation combined with ankle mobilization helps to revitalize function of densified fascia tissue and restore ankle range of motion.
• Ultrasound-guided dry needling eliminates myofascial trigger points that undermine muscle function.
• Extracorporeal shockwave therapy targets damaged tendons and stimulates collagen repair.
• Customized physical therapy provides personalized functional mobility training based on the individual patient’s profile.

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Preventing Ankle Instability

There are a number of things you can do to minimize your risk of developing CAI:

• Choose comfortable footwear that provides support, stability and shock absorption
• Frequently replace worn athletic footwear
• Allow for ample recovery time between training sessions
• Maintain a healthy body weight
• Exercise regularly to maintain muscle strength and balance
• Get a biomechanical analysis to identify motor deficits that increase your risk of ankle injury
• Fully rehabilitate an ankle injury before returning to physical activity
• Rehabilitate old injuries that were never properly treated

Get Cutting-Edge Ankle Rehabilitation in NYC

Ankle instability can dramatically affect your performance and increase your risk of injury, both now and in the future. As you age, chronic ankle instability can increase your risk of falls and contribute to joint and muscle pain. Early treatment after an ankle injury and full-spectrum rehabilitation are your best bets for enjoying a lifetime of physical activity and functional pain-free movement.

To get the most advanced and comprehensive CAI treatment in NYC, contact NYDNRehab today!

Treatment of Foot and Ankle at NYDNRehab