This is the final part in our start-to-finish injury journey. As I said in parts one, two, and three, an ideal injury's lifespan goes from the Why meeeeeeeee? moment all the way to forgetting it ever happened. We looked at instantaneous injury response, then how to begin using a damaged joint again, and most recently, that weird place where the pain is gone but your joint is clearly not well yet. (As with part three, I'm continuing with sprained ankles because that's where we started. But most of this info can be extrapolated to include many injuries.)
Today, we're answering the question, "Is it going to happen again?" Getting hurt sucks so badly that the fear of re-injury can drive someone permanently away from athletics. We're terrified that our ankles are gonna be like Lucy with the football. The road will be all sweetly beckoning us and then WHAM! flat on our backs again.
This is because everyone you've ever known with a medical degree from the New York Times has offered this common wisdom when you get hurt: Be careful! Once you sprain your ankle/dislocate your shoulder/break your wrist, you're more and more likely to keep doing it!
I feel the need to go big or go home here.
For the vast majority of injuries, it is not preordained that you'll do it again.
The recurrence of injuries does not happen because you've exploded yourself, like USC admissions, and you'll never recover, like Lori Loughlin.
The recurrence of injuries happens when the first injury was ignored instead of being paid attention to, like her shitty daughter Olivia.
That's all. You are not destined to repeat the past just because it happened at all.
Yes, some injuries recur. However, most people get hurt a second time because like Humpty Dumpty, their joint was never put back together again. Ligament laxity can become a problem after multiple similar injuries. But this usually happens when you re-injure an un-healed leg. Not a properly healed leg. This is a huge difference.
It is possible for shitty joints to become unshitty.
A look at this study suggests similar. Hundreds of athletes up to age 70 participated in an eight week rehab program at home, while the controlled half did not receive any program.
34% of the people in the control group had a recurring ankle sprain in the first year.
Only 20% in the rehab group had the same. Although it's Mia Science, I'd wager that if the rehab had been done under a professional eye, the recurrence would have been even lower than that.
Rehab works. So why are people still getting hurt?
There are two main reasons. The first is that physical therapy compliance rates are super low, with some research suggesting a 70% non-compliance rate. There are a ton of factors that contribute to non-compliance, from pain to depression to low self-esteem. But the bottom line remains that without legitimate rehab, you cannot expect a joint to return to form. If physical therapy is a money or time or annoyance constraint, you can do this at home. You just need to be consistent and vigilant, like a meerkat watching for predators.
The second reason you might re-injure yourself is that no matter what kind of program you choose, physical therapy is designed to get you from non-functional to back-on-your-feet again. It is not designed to get you from non-functional to Usain-Bolt-again. There is a chasm between successfully pointing and flexing your foot with a Thera-band and running a competitive 10k race. You don't graduate from physical therapy ready to set personal records. You graduate from physical therapy ready to begin training.
The good news is that this post-injury rehab can happen any time. So if you hurt your shoulder four years ago and it still sucks, you can still start putting it back together now. The longer a joint has been shitty, the longer you can expect it to take to become unshitty, but you CAN expect it to become unshitty.
Physical therapy gets you back into your life. So what is supposed to happen after that? Two things. Improve the range of motion, then improve the strength of your new range of motion. Then you've got a joint you can train with. Here's how to do it.
Improve Range of Motion
Range of motion changes depending on how your joint feels about you moving it. When it feels safe, it will move fast and easily, like the roadrunner trying to evade the coyote. When it does not feel safe, it will move slowly and poorly, like Maria Sharapova trying to evade Serena Williams.
Your first question to ask yourself is "Can I move the joint in any way without pain?"
Old injuries will often move just fine when you don't have any weight on them. Stick your foot up in the air and see how far you can point, flex, invert, and evert. If this is painful, you will need to do your range of motion work while sitting or lying down until the pain reduces. If it's not painful, move on to the next one.
Stand on two feet and try the same tests (rise up on toes, bend your knees towards a crouch, then roll side to side like you are skiing). Note which ones are more difficult, painful, or don't go at all. If you can do this in front of a mirror, it's easy to see whether the two ankles move differently.
If that test was fine, do it all on one leg. If you don't notice any mobility or strength problems here, you don't need this blog, put your computer away and go do some sprints, it's beautiful outside.
Your second question is, "Can I move the joint, with weight, all the way, in all directions, without pain?"
If you can crouch all the way without a problem but cannot rise up on your toes at all, you need to learn how to rise up on your toes (plantarflexion). If you can Misty Copeland your shit all day but can't crouch to save your life, then you need to learn how to flex deep into that ankle without searing pain across the front (dorsiflexion).
How?
Start moving into those difficult ranges of motion as slowly as is humanly possible. This is where you can start differentiating between discomfort and pain. Just like you know when salting your food has become oversalting your food, you'll know when discomfort switches into pain. Discomfort I'm fine with if you are gentle with it. Pain is no good. Sharp pain is really no good.
Mike Reinold, a fantastic PT, has a well-done piece about improving ankle dorsiflexion. Read it here. I am especially a fan of the Mulligan mobilizations that you can find at the end. Don't forget to be a patient little meerkat. Don't do all these things one time and then rage that your ankle still sucks. You'll get eaten by a snake.
After you can move all the way in all directions, you'll need to...
Improve Strength in the New Ranges of Motion
What if you can flex fine but you can't rise up on your toes? Use as much assist as you need in order to get all the way up on your toes. (This can be done on two feet for an easier version, or one foot for a harder version.) You can sit and rise up on your toes. You can slump over a table and rise up on your toes. You can piggyback somebody else and rise up on your toes. Do whatever you need to do to get up higher than you can get when you're unassisted.
Once you get there, stay.
Good boy.
Stay...
OK!!! You can come down! Good boy!!!
Just holding steady is the first part. As that gets easier over time, you'll add in the negative. The negative part of an exercise is the part that moves with gravity. Rise up as high as possible (it's fine if this is still assisted), and then lower yourself down excruciatingly slowly. EXCRUCIATINGLY. Like ten seconds per descent. If your ankle is shaking, chattering, wobbling, skipping, or soulja boy'ing, those are good signs that your nerves are responding to the stress. For the love of god, don't rush these.
Most common mistake: rising up over the pinky toes instead of over the big toes. When you're on tippy toes, you should feel your weight resting in between the piggy that went to market and the piggy that stayed home. The difference is this:
If I practice pushing off from that sideways position, I'll teach my ankle to push from that sideways position. Kills your power, speed, and ligaments. Always reassess your rehab positions.
Once the negative is good, you add the positive. Start on flat feet and practice rising up to the very top. In a perfect world (this may take many months), you will eventually get to the point where you can stand on one foot, without holding on, and rise straight up onto your tip toes and then stay there.
OK, you don't have to quite do it this way. If you aren't doing ballet or gymnastics, you don't need to look like you're ready for pointe work. You can aim for doing it this way:
The range of motion on top is pretty end range. The one on the bottom needs more. If you can get yourself in between them, you'll be good. In a related story, doing ankle rehab will immediately give you respect for ballet.
OK, I hear you asking, what happens once I can rise up and crouch down and move all around? Can I set personal records?
No.
After you learn how to move slowly, you learn how to move fastly. Running, jumping, single leg hopping, agility work, lightning feet over hurdles, learning how to push all the way through the ankle when you're taking off and how to land all the way through the ankle when you're coming down. It should look like this:
Look how much force comes down into your foot when you land just from a few inches in the air. Now here's a second rep that I did:
I landed this one just a tiny bit off kilter, which you can see in the landing heel bounce. If this had happened on the balance beam I wouldn't have even wobbled (who am I kidding I wobble on the beam if I fart). But even being off just that tiny amount leads to a big difference in the landing—you can see my shin, knee, toes, and Achilles instantly flex to keep up with the force changes. Now imagine you've got an undertrained ankle and then it turns sideways on a rock. If it can't absorb and adjust to rapidly changing forces, your foot and ankle won't stand a chance.
So before you go setting PRs, you need to move without pain, then be strong in your movement, then be fast in your movement. You do those things well, you're gonna have a good time.
If you skip the slow boring parts and dive right into the fast fun parts, it's like doing pizza when you want to french fry. You're gonna have a bad time.
When you play the long game, you'll get better as you go.
All of this takes work. And time. It might take you a year, two years, more than that. I train someone who has been improving his back mobility with me for nearly ten years now. But he had spent the twenty years before that hunched badly over a computer. These things take time to undo. His body looks completely different now than it did when we started. It's still not perfect, but he's running seven minute miles at age 48. Over half marathon distance. His back mobility is the definition of Progress Not Perfection.
I'm not saying it's going to be ten years before you run again. You're gonna be running in no time. What I'm saying is that when you play the long game, not only will you be running again, but you'll be getting better as you go. Ten years from now, with great ankles, and your great ass, you're going to be running fast as fuck AND not rolling your ankle over tree roots. You'll have achieved the dream: to forget you ever had that shitty ankle. Remember, the goal is to forget the pain, forget the feelings of instability, forget tripping and falling onto a couch and ending up making out with the guy who was already sitting there (I see you, Christina).
This kind of mobility and strength work is all about building confidence. You want to know that your ankle is ready for whatever game your three year old wants you to play on the floor/your drunk roommate wants you to play in the next bar. (Hey, I don't know what stage of life you're at, representation matters.)
Whatever improvements your make, remember to maintain them over time. Otherwise, they'll just disappear again, like your parents' hopes that you would ever become a doctor.
Speaking of, Mia, when do I give up and get surgery?
OK, fine. Surgery is a resort. It's the last resort, but it is a resort.
Just remember that ANY surgery is trauma. Your body hates trauma. Try everything possible first.
Surgery is the last option. I spent three years rehabbing a snowboarding ankle injury. I was basically pain-free in flat shoes. But I still couldn't wear high heels without sharp, unrelenting pain. This is true: I had ankle surgery so I could wear high heels again. I am vain about shoes. I cannot live without high heels. My shoe closet is to die for and I am not willing to let go of my solemates. So I finally gave in and discovered a two inch hole in my ankle cartilage. There's no exercise on the planet that can fill a two inch hole in cartilage. So I had surgery, and it must have had heeling powers because now I can't remember which ankle I had surgery on. BUT MOST IMPORTANTLY I CAN WEAR THE AWESOME SHOES THAT OPEN THIS ARTICLE. It seems superficial to voluntarily undergo surgery just to wear a certain type of shoe again but hey, everyone has their thing. Some people like wine. I like shoes. Also I like wine. Everyone has their couple of things.
Finally, what happens for those who are like goddammit, I didn't ever do rehab and I do have ligamentous laxity in a joint because I hurt it ten thousand times and is there any way I can still improve it? Answer: hell yes.
A physical therapist (or any qualified set of eyes) will be helpful in evaluating your starting point. Everything written in this article is gonna be your plan, but just requires extra vigilance to make sure your pieces are moving in the proper directions. Take heart! This review showed that improving balance and proprioception (your body's understanding of where it is in space) after injury could be better attributed to neurological learning than to muscle strength. In other words, when your brain better understands what the hell is going on down there, you'll start improving, even if your muscles haven't had a chance to grow yet.
Above all, be patient with your body when it's hurt. Pain isn't a vengeance against you, it's just your body asking for help. Take care of it long-term and you'll be prepared for any unexpected twists.
If you liked this series on ankle health, please share it! Let's help heal all the ankles.