Chronic ankle sprains: why trail runners need hip and core strength

You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. Hey everyone, this is Dr. Mandy with the Restoring Human Movement podcast. I am your handy running person, so thank you for joining the movement movement. Today we're going to be talking about everybody's favorite condition, chronic ankle sprains. So trail runners, this is specifically for you, but those of you who have chronic ankle sprains and you've never wanted to try trail running in your entire life, you are going to find some information in here that should be helpful for y'all as well.

Now, if you are somebody who suffers from chronic ankle sprains, probably the first thing you looked up was rehab for chronic ankle sprains or strength work for chronic ankle sprains. And there is a ton of information out there. Lots of it is good and lots of it is bad. So we're going to go over specifically strength for chronic ankle sprains and my take on what's useful and what's not. So what do I mean by chronic ankle sprains? This can be one of two situations. Number one being you had a big ankle sprain at some point. Maybe you had bruising and swelling. Maybe you actually ruptured a ligament.

And then since then, even though that initial ankle sprain has recovered, you're finding that you sprain your ankle either moderately or mildly over and over again. It may or may not swell again, but you notice that you're going to get that roll feeling more often than you would on the other side. The other boat is folks who just mildly sprain their ankle over and over again. This can be one-sided or both sides. And for trail runners, this will most commonly pop up when you're running technical trails or making tight turns. I was taught by a practitioner once, and I can't remember who this was, so if you know, shoot us an email.

And they said that knees are dumb joints. And what they meant is knees are dumb in the sense that they just kind of go back and forth. They hinge forward and backwards, flexion extension. They don't have a lot of meaty musculature around it. And what the context that they were giving for the knee is that most knee problems actually respond better to working in a different area other than the knee itself. Ankles are similar, so they're not as dumb. They do more than flexion extension. In the foot, we call that plantar flexion and dorsiflexion. They also pronate and supinate. They can rotate a little bit.

They do more than the knee. So I would say they're slightly less dumb, but they are still kind of dumb in the sense that they don't have a lot of meaty musculature around it. And a lot of ankle problems stem from either higher or lower. There's not much lower, but in the kinetic chain. So our big question with people who experience chronic ankle sprains is, how do we protect the ankle from being sprained over and over again? And what's missing from our program that has allowed it to be sprained over and over again? Herein lies my favorite bias, strength work. But I went ahead and searched up chronic ankle sprain rehab just to see what Dr. Google is telling y'all and what you can find easily online.

And the little Google AI tool is telling me this includes strengthening exercises, balance training, and gradual return to activity. And this is great and useful and evidence-based information when you have an acute, so a short-term, just-happened ankle sprain, particularly if it's moderate to severe. So if you have a lot of swelling, your ankle looks like a basketball or you have bruising. This includes if you ruptured a ligament and the surgeon does not feel that surgery is warranted. But this has little to do with chronic ankle sprains, except for the fact that if you are in that first scenario, like I mentioned earlier, where you had one bad ankle sprain and then you've been chronically spraining it over and over, you do need a foundation of balance work and range of motion training to get over the acute part.

And then you have a foundation to build off of for the chronic part. If your acute ankle sprain was like two years ago, congratulations, you have done a lot of balance work by virtue of walking or running, especially trail runners who have gone back to trail running and you're hitting the technical trails again. That's balance work. And you've done some strength, again, by those same mechanisms, and you've done some range of motion by those same mechanisms. There is sometimes a deficit in range of motion in those scenarios where, say you didn't do any dedicated rehab when the bad one happened, you don't necessarily expose the ankle to ranges that it wouldn't necessarily otherwise expose to.

So that can be contributory to chronic ankle sprains because if you step on a rock and your ankle goes into a range of motion that it never restored, it can kind of fall out, so to speak. A lot of that initial early rehab for acute ankle sprains has a lot more to do with signals rather than true strength. So think about it. You probably have never seen anyone with like beefy hypertrophied angles in the sense of like, you see gym goer with really beefy biceps because those muscles are quite small. So you're not necessarily going to get a ton of strength or hypertrophy gains in the ankles. Even the world's best trail runners like Courtney DeWalter does not have huge, beefy ankles.

And truthfully, I don't know if she sprains her ankles a lot or not, but she races enough that I would venture to guess she doesn't. But calling the four-way band exercises and the spell the alphabet with your foot strength work is pretty limited view, in my opinion. And I think that it's more a signal work of let's turn on all the stuff down there that was previously protective. So for example, your posterior tibialis muscle, some people call this the shin splint muscle, it runs along the inside of your shin and it helps your foot go out in the same mechanism that most ankle sprains are shown.

So when you sprain your ankle, muscles like that or on the other side, your peroneal or fibularis muscles tend to turn off, which is an oversimplification. But they turn off because they don't want your ankle to go in that range anymore because you just twisted it. And sometimes they can become very stiff. Now, when you're rehabbing an acute ankle sprain, that signal to protect it gradually goes away as the body realizes, hey, this is not a dangerous range anymore. We are building it back up again. Those signals tend to go away rather than calling those exercises a true strength protocol, which is that the muscles are getting stronger over time.

Now, for chronic ankle sprains, we do need actual, true, legit strength work. But it often doesn't come in the ankle. So if you have a foundation, you have full range of motion, your ankle moves okay, in life it feels fine, but you keep spraining your ankle, you need to look higher up. And remember, knees are dumb joints, so we're not really looking at the knees much. Even if your knees move weird, they're dumb joints. That weird movement is not coming from the knee most of the time. It's coming up the chain. Usually we're talking hip work, glutes are the fountain of youth, sometimes core work in the torso for positioning your body such that you're not, you know, tipping over your body when going down switchbacks.

And occasionally we're talking about quad work, but that's much less common. What this looks like in practice is movement variability under load, specifically under load. This is important. Now, again, you can build up that foundation with movement variability by going out and hitting the technical trails, hitting the switchbacks, all that good stuff. But until you put it under load, you're not going to know what your body responds to under load in a non-controlled scenario. So greatest example is you're 65 miles into 100 miler. The load doesn't necessarily change unless you're like stuffing lots of water into your pack for some reason.

But your fatigue levels do change. So at that point in the race, what you rely on is your strength. And yes, mental strength, we can get into that. But your physical strength is what carries you in the latter half of these longer races. So if you lack strength there and you're fatigued and you find a rock on the trail with your foot, maybe it's dark outside, you just twist your ankle a little bit, but that can turn harder to recover from if you don't have the strength foundation and it may happen more and more frequently. I think I can relate to a lot of you guys who late in the race, you're fatigued, you're kind of over it, maybe you're in a low and you start twisting your ankles.

And not only does that suck on a body kind of perspective, but it sucks mentally. So ideally, we're protecting, yes, the ankle. But for those of you who are really going for high performance in long races, this is also relevant for the mental side of it. So for movement variability under load, we are talking more traditional strength training in that you should be using weights and they should be difficult. So this is not, let me take some five pound dumbbells and like do a hundred curls. That's all fine and good. But if you are a lower body athlete, like a runner, you're going to need more load than that because your legs and your hips and your core are already strong.

And there's this fallacy out there that you only do strength training because you're weak in some area. But if you're running up a mountain, you're doing thousands of feet of vert in a day. You're not weak in anywhere in your lower body. But again, that load is different. So fatigue starts to play a role and strength, again, later in these long runs starts to play a role. And again, it's not because you're weak. You just are under utilizing your body's ability to keep stable or keep that strength going throughout this long run. When I talk about movement variability or variance under load, I'm talking side lunges.

I'm talking plyometrics potentially, although that load is different. The dynamicness of it changes the load by virtue of gravity. And I'm talking weird stuff that you would not normally see people doing in the gym. So your goal is basically to do stuff with weights that the folks in the gym should look at you like you're a crazy person. In order to be somebody who's well-rounded in all planes of motion, you need to do the frontal plane. So that's side to side motion, like as if you're bending towards the left and bending towards the right. You need rotational stability. So again, rotating to the left or the right.

You need stability in the kind of front and back plane, which you should be probably pretty good at already by virtue of running that is in a front and back plane of motion. And ideally, you need some hinge stability. And this is not a standard plane of motion, but it's hinging from the hips rather than anywhere else, because that does play a role in torso biomechanics and how well you can keep your center of gravity when your legs are maybe not. I cannot stress enough how crucial that this is for chronic ankle sprains. And for those of you who have chronic ankle sprains, there is risk with not dealing with this, in part because your body's signals just get whacked out after a while.

Like I had a patient who they had a big ankle sprain a while back. They actually ruptured a ligament and surgeon said, no, we don't need to do surgery. You can rehab it. She rehabbed it fine. Did the standard, you know, banded four-way exercises, write the alphabet, all the good stuff that creates a decent foundation. But she didn't do any of the strength training. And she was a runner and a soccer player. So she had some more demands in terms of like planes of motion because she was running fast and cutting in soccer and doing single leg plants to kick the ball. And she just kept spraying her ankle over and over again.

And they were never as bad as the first one. But the first few times it swelled up, kind of similar to the first one, but not as bad. And then after like sprain four or five, it just stops swelling. And at that point, that gets more dangerous because you don't actually know how much damage you are potentially doing to your ankle because those signals aren't there anymore. So, yes, strength training is important to avoid the chronic ankle sprains, but also you need to avoid it because at some point your body's not going to tell you it's really dangerous or not. And then you can get in a really bad cycle where, again, say you're halfway into a race, you kind of roll your ankle a little bit and you keep going because you don't think it's that bad.

When in reality, you've done more damage, that signal didn't work to tell you to stop. And then you run another 50 miles and then you're super screwed after the race and you have to go through way, way, way longer of a recovery process or even surgery if it's bad enough. So to wrap this all up, for chronic ankle sprains, if you are only focusing on strength and balance work in the ankle, you're doing yourself a disservice. You need higher load, you need movement variance, and you need it to focus somewhere stronger and beefier, more able to handle load than the ankle. So the ankle, again, it's a dumb joint.

There's not that many big muscles around it. You move up the chain. Look at the knee. It's a dumb joint, arguably even dumber than the ankle. It has a little more musculature around it, but really our money spot is in the hips, it's in the core, and sometimes in the quads as well. Put these things under load, pick up some heavy weights, do it safely. Obviously, I recommend working with a coach who works with trail runners specifically. Even changes in, say, a 400-meter runner versus a 3200 or 5K runner are important. Again, just a reminder, I'm a real person. I'm not just a podcaster. I treat and work with runners, any distance runner type, especially ultra and trail athletes.

So hit us up. Information's in the description if you need help. But you do need somebody who's specific to the demands of your sport. If they are, they're going to know what planes of motion you need to be stable in and how much. You probably shouldn't be hitting the gym five times a week if trail running is specifically your performance goal. But on the same token, you shouldn't be hitting it zero times a week. So there is a balance there. And if you're somebody who's prone to chronic ankle sprains, you need to be doing stuff that's non-standard. And again, people should be looking at you weird in the gym.

So pick up heavy weights, move weird, move in ways that make people look at you like you're crazy. And you're going to set yourself up well as long as you do it safely. Work in the hips, work in the core, sometimes in the quads. We have a ton of podcasts on all sorts of topics. There's more running podcasts coming out soon, but there's some prior to this one. If ankle sprains aren't your thing, or they are even, we have other podcasts on that and a whole host of other injuries. And of course, if you need one-on-one help, it is way simpler to do things one-on-one than searching the internet for answers that may or may not be true, depending on your source.

If you want one-on-one help and you're sick of searching through the internet, hit us up. Our stuff is in the description below. If nothing else, send us an email, tell us what's up, and we can get you moving in the right direction, even if it's not with us. So hope you guys get in contact, and we'll talk soon.