Ankle injuries are extremely common, especially ankle sprains, and part of the rehab process for ankle injuries is helping to prevent future ankle injuries from occurring.
While ankle injuries are sometimes unavoidable, many of the cases I see in the clinic could have been prevented if certain risk factors were identified and addressed early on.
This article will discuss some simple ways to give yourself the best chance to avoid ankle injuries, with a larger focus on ankle sprains, as sprains are the most common ankle injuries. The three main sections of this article will include:
1. Risk factors for ankle injuries
2. Exercises to help reduce these risk factors
3. Other things you can do to reduce the risk of ankle injuries
Risk Factors for Ankle Injuries
In the clinical world, risk factors are often broken down into two categories: modifiable and unmodifiable.
Modifiable risk factors are those that you can actually work on reducing, while unmodifiable risk factors are those that are much more difficult to do anything about.
We will focus on the main modifiable risk factors in this article.
Reduced Active and Passive Ankle Range of Motion
Reduced ankle mobility, or in other words, a stiff ankle, can be a risk factor for sustaining ankle injuries or developing overuse conditions like Achilles tendinopathy.
Dorsiflexion range of motion is particularly important for the ankle. This is the motion of bringing your toes up towards your nose, or “letting off the gas pedal”.
This motion is functionally important, as it will accommodate some very functional movement patterns. For example, those who lack normal dorsiflexion range of motion may find it difficult to walk downstairs normally, as the ankle can’t bend enough when the other leg is reaching for the next step.
Additionally, if you consider motions like squats, lunges, or landing from a jump, a stiff ankle will require more demand on the knees and hips to make up for the rest of movement.
Not only can this lead to problems higher up in the body, but the ankle may be expected to accommodate a lot of force, especially when landing from jumping, and some studies have demonstrated that if the ankle can’t move enough to accommodate this loading, then you may be at more risk of sustaining an injury (Hadzic et al, 2009).
Reduced Strength of the Hip, Knee, Ankle, and Foot Muscles
Given that many ankle injuries, especially sprains, are a result of the joint being forced into extreme positions, adequate muscle strength is the first line of defence to help resist these forces that are trying to create an extreme amount of motion at the ankle.
For example, if we consider the classic lateral ankle sprain, which results when the ankle is forced into excessive inversion, strengthening the muscles that perform the opposite motion can help defend against this mechanism of injury (Willems et al, 2002).
In this case, the peroneal muscles, which are found on the outside of the leg and ankle, are often targeted as a go-to muscle to strengthen for both treatment and prevention of ankle injuries, specifically inversion sprains.
All other muscles that cross the ankle are also important to keep strong, as sprains and other injuries like fractures can occur when the joint is forced into any extreme position.
In addition to the peroneal muscles, studies have shown that poor strength and strength imbalance in other ankle muscle groups can be a risk factor for ankle injuries (Fousekis et al, 2012).
In terms of the knee and hip muscles, it can be helpful to consider landing from a jump. In this case, deceleration and control when landing from a jump requires flexion at all lower body joints, which means the glutes, quads, and calf muscles all have to work eccentrically.
If one of those muscle groups is lagging behind, then there is much more demand placed on the other muscle groups, creating an imbalance that can make you a little more vulnerable to injuries.
Lastly, when you consider that the foot is ultimately your connection between the ground and the rest of your body, it’s important that the smaller muscles of the foot, as well as the deeper muscles in the lower leg that attach to the foot, are adequately strong. You can consider the foot as the foundation, and a good foundation will be necessary for structural strength.
Chronic Ankle Instability
While you can’t change the past, or in this case, a history of ankle sprains or medical conditions that lead to hyper-mobile joints and chronic ankle instability, you can address this with appropriate strength and stability training.
This basically fits in with our discussion above regarding strength, so we won’t touch on it too much. We just wanted to reassure you that chronic ankle stability is something that can be improved with exercise-based activity, which we will touch on in our next session.
Body Mass Index (BMI)
Body mass index (BMI) is an indicator of body composition and is often used to classify levels of being weight and obesity. Body mass index is calculated by taking a person’s weight and dividing that by the square of their height. This calculation is usually done in the metric system, meaning kg/m2.
A recent study summarizing some risk factors for lateral ankle sprains identified in previous literature pointed out that BMI is a significant risk factor for lateral ankle sprains among soccer players and American football players (Delahunt and Remus, 2019).
Extrapolating from this data, as well as exploring data from studies not involving athletes, one can be fairly confident that being overweight is a risk factor for ankle injuries (Vuurberg et al, 2019). This is rather intuitive, as increased weight will mean increased force through the ankle joint, and this can be a problem when the joint is forced into unsafe positions.
The only caveat to mention about BMI is that someone who has a high proportion of muscle mass may be considered overweight if using BMI alone, as muscle mass is more dense than fat tissue.
For example, a short jacked guy may have a higher BMI relative to someone of the same height and a higher proportion of fat mass. As such, it’s important to be careful when interpreting BMI in relation to general health.
Poor Footwear
Poor footwear can also lead to increased risk of ankle sprains. The proper footwear may be different across individuals, but in general, poor fitting shoes, shoes without good support, and shoes that have worn soles and become slippery, can all lead to increased risk of ankle sprains.
Exercises to Help Avoid Ankle Injuries
Considering these risk factors, we will highlight some easy ways to improve your ankle mobility, strength, and stability, all within the context of preventing ankle injuries.
It’s important to note that these exercises are simply a small fraction of exercises that may be effective, and that they won’t completely eliminate any risk of ankle injuries.
However, these do represent good bang-for-your-buck exercises to help address the aforementioned risk factors, and can often be easily incorporated into workouts.
Ankle Mobility
In a previous article, we discussed a good amount of ankle mobility exercises that can be used in different contexts and to improve all directions of ankle range of motion. If we target ankle dorsiflexion specifically, the following exercises can be quite effective.
Ankle Dorsiflexion Passive Range of Motion
Given that reduced ankle dorsiflexion specifically has been identified as a risk factors for ankle injuries, when in doubt, this is probably the most important motion to work on.
In this case, you can comfortably perform passive range of motion exercises like the one shown below, which will target the ankle joint and soleus muscle. I like this one because the half kneel position offers good control, it’s a bit more comfortable, and I find it easier to ensure that the heel stays on the ground.
There is no predetermined dose for this exercise, but as a starting point, I would recommend 2 sets of 15 repetitions. If this feels too uncomfortable, simply reduce the dose. If you find it really helpful, simply perform this exercise more often.
Gastrocnemius and Soleus Stretches
Stiff calf muscles can also limit ankle dorsiflexion, and as such, it’s a good idea to keep these muscles as loose as possible. Plus, calf stretches just tend to feel good as well.
To stretch the gastrocnemius muscle, it’s important to keep the knee straight, as this muscle also crossed the knee. If the knee is bent, the gastrocnemius will go on slack and you will no longer be stretching it.
Conversely, to target the soleus muscle with a stretch, you can bend the knee to “knock out” the gastrocnemius muscle, and thus, focus more purely on the soleus muscle.
When it comes to stretching, I usually aim for 2 minutes total per muscle. This can be broken up into a few reps, for example, 4 reps of 30s holds.
To get more out of stretching, it’s not so much about how long you’re holding it for, but rather, keeping up a daily routine and maximizing the frequency at which you stretch.
Ankle Strength
There are tons of exercises to help build ankle strength. In this case, we will focus on inversion and eversion strength, as this is crucial in preventing low ankle sprains, which are the most common form of ankle injury.
Resisted Ankle Eversion
Admittedly super boring and tedious, this is one of the most common exercises to improve ankle eversion strength. It’s safe, allows you to target the peroneal muscle group specifically, and is something you can either do within a workout, or sitting in front of the TV.
Essentially all you’re trying to do is pull your ankle towards the outside against a resistance band, which is the opposite motion of rolling your ankle.
Higher resistance and lower reps will offer a greater focus on strength, whereas lower resistance and higher reps will offer a greater focus on endurance. To get a bit of both, I like starting with 3 sets of 12 reps, with a resistance that is tough but tolerable.
Resisted Ankle Inversion
Also boring and tedious, this is basically the same exercise as above, just going the other direction, to help strengthen ankle inversion. This can be useful for preventing and treating medial ankle sprains and other ankle injuries, as well as conditions linked to excessive foot pronation.
As mentioned above, higher resistance and lower reps will offer a greater focus on strength, whereas lower resistance and higher reps will offer a greater focus on endurance. To get a bit of both, I like starting with 3 sets of 12 reps, with a resistance that is tough but tolerable.
Resisted Ankle Dorsiflexion
Dorsiflexion strength is often ignored, but by strengthening the tibialis anterior muscle specifically, you can improve your overall ankle strength and stability, while also improving medial arch stability by way of where the tibialis anterior tendon inserts (medial cuneiform bone and base of first metatarsal bone).
While this is an easy one to do while sitting in a chair, I personally prefer doing this in a long-sit position with the band tied off to something in front of me. This doesn’t necessarily mean it’s the best way, I just like feeling a little more constrained and I don’t have to worry about holding the band in my hand.
To perform this exercise, pull your foot upwards towards against a resistance band, ensuring that you are moving the ankle joint itself, not just your toes.
As mentioned above, higher resistance and lower reps will offer a greater focus on strength, whereas lower resistance and higher reps will offer a greater focus on endurance. To get a bit of both, I like starting with 3 sets of 12 reps, with a resistance that is tough but tolerable.
Calf Raises
The calf raise, also known as heel raise, is an extremely popular exercise for general strength of the calf muscles.
When placing an emphasis on controlled movement, particularly on the way down, which is the eccentric phase, this can also be very useful for improving ankle strength, stability, and control, thus helping to avoid ankle injuries.
Not only will this have a role in preventing injuries like sprains, but these are also useful exercises for preventing and treating Achilles tendinopathy.
To get started, you can try this in a double leg fashion, then progress to single leg when you really want to challenge your ankle strength and control.
Additionally, performing this exercise with the front half of your foot on a step and the back half floating off the edge of the step, you can work through a larger range of motion, which will help emphasize the eccentric component, which is highly valuable in injury prevention.
Single Leg Balance and Ankle Proprioception
Working on single leg stability and ankle proprioception represents a more functional way to help minimize the risk of ankle injuries.
This can be done in a static and dynamic fashion, with static usually being a little easier, and dynamic being a little more advance and can often be more sport-specific.
Single Leg Balance With Eyes Closed
Your balance relies on three main things:
1) Your vision (what you’re seeing around you)
2) your vestibular system or inner ear (which tells you where your head is in relation to gravity)
3) your proprioception (joint position awareness with many receptors located in muscles and joints).
By performing single leg balance exercises with your eyes closed, your brain is forced to focus on the feedback you’re getting from you ankle joint and surrounding muscles. This will create an additional level of challenge, but will also help train up your ankle proprioception, which is highly valuable for injury prevention.
Keep in mind that this needs to be done somewhere safe with good support nearby in case you lose your balance.
Again, there is no determined dose, so I usually start off by recommending 5 reps of 30s holds allowing for the occasional correction.
Single Leg Balance on an Unstable Surface
Similarly, introducing an unstable surface to single leg balance exercises will challenge the ankle joint and surrounding muscles more than a flat surface.
This can actually feel quite fatiguing, as the ankle muscles have to work hard to maintain balance, and as such, this also represents a reasonable ankle strength exercise.
Definitely start by keeping your eyes open with this one. Similar to other balance exercises, I usually start with 5 reps of 30s holds if possible.
Y-Balance Squat
The Y-Balance squat represent a way to increase the challenge of a standard single leg squat. By reaching in the three different directions with the opposite leg, you are displacing your centre of mass, and your entire lower body has to work to maintain proper control.
One study showed that a poorer performance on the Y-Balance Test was associated with a greater risk of sustaining an ankle sprain injury (Hartley et al, 2018).
The key here is to go slow and ensure proper knee control as well, usually meaning not letting the knee collapse inwards (knee valgus) and not letting the femur roll inwards (femoral internal rotation).
This is a great exercise to work on more functional ankle stability, global lower body strength, and is fairly convenient given you don’t need any equipment.
I usually recommend aiming for 2 sets of 5 reps to begin with, whereby 1 rep = all three different directions. This doesn’t sound like much, but really, it amounts to 30 reps total of a single leg squat motion.
Jumping Control
Jumping is usually reserved for the more advanced phases of rehab, but should also be a portion of ankle injury prevention, especially if you often participate in faster-paced exercises like HIIT workouts.
The focus with jumping isn’t so much the jump itself (although that is very important for general strength, power, and performance), but more so the landing, as this is when the ankle is typically injured.
Trying to create a soft and quite landing with good ankle, knee, and hip control is the goal. This ensures proper decelaration, as opposed to a sudden impact when the ankle may be rapidly forced into an unsafe position.
This will require good eccentric strength from the ankle muscles (especially the calf muscles), knee muscles (especially the quadriceps), and hip muscles (especially the glutes and hamstrings).
Start with double leg exercises to get the feel, and eventually, when confident, you can move onto single leg jumping exercises.
It’s virtually impossible to assign sets and reps to jumping exercises without looking at the person perform them, as that will rely on multiple variables including strength of all lower body muscles and current ability to maintain control.
In general, ensure you feel safe and confident, and always inquire with a physical therapist to ensure proper technique.
Here are a couple examples of jumping exercises that can help improve ankle strength and stability.
What else can you do to avoid ankle injuries?
While specific exercise represents an effective means to avoid ankle injuries, other methods can assist as well. This can include proper footwear, as well as ankle braces.
Lace-up Ankle Braces
Lace-up ankle braces are highly effective at providing an increased amount of external support for the ankle joint. While they won’t prevent injuries altogether, and shouldn’t be completely relied upon, they do represent an effective way to improve ankle stability while engaging in high-risk activities.
For example, a volleyball player with a history of ankle injuries may wear an ankle brace during practices or games to help prevent ankle injuries, but will still work on improving ankle strength and stability off the court.
Similarly, your average joe who sprained their ankle while hiking may also benefit from an ankle brace when they get back to hiking, or even back to day-to-day walking while they are still rehabbing an ankle injury.
In both of these cases, it’s important to recognize that the ankle brace is used to help minimize risk of injury during activity, but regarded as a complete solution or substitute for exercise-based rehab.
Summary
This article described risk factors for ankle injuries and methods to help avoid ankle injuries. The information in this article is intended to provide you with some exercise ideas for your workouts and education as to how these exercises can minimize risk of injury, but at the same time acknowledging that there are many different ways to achieve the same goal of reducing injury.
For more personalized advice, and to ensure safety, we always recommend consulting with your local physical therapist to develop a safe and effective injury prevention program.
References
Fousekis, K., Tsepis, E., & Vagenas, G. (2012). Intrinsic risk factors of noncontact ankle sprains in soccer: a prospective study on 100 professional players. The American journal of sports medicine, 40(8), 1842-1850.
Hadzic, V., Sattler, T., Topole, E., Jarnovic, Z., Burger, H., & Dervisevic, E. (2009). Risk factors for ankle sprain in volleyball players: a preliminary analysis. Isokinetics and Exercise Science, 17(3), 155-160.
Hartley, E. M., Hoch, M. C., & Boling, M. C. (2018). Y-balance test performance and BMI are associated with ankle sprain injury in collegiate male athletes. Journal of science and medicine in sport, 21(7), 676-680.
Delahunt, E., & Remus, A. (2019). Risk factors for lateral ankle sprains and chronic ankle instability. Journal of athletic training, 54(6), 611-616.
Vuurberg, G., Altink, N., Rajai, M., Blankevoort, L., & Kerkhoffs, G. M. (2019). Weight, BMI and stability are risk factors associated with lateral ankle sprains and chronic ankle instability: a meta-analysis. Journal of ISAKOS, 4(6), 313-327.
Willems, T., Witvrouw, E., Verstuyft, J., Vaes, P., & De Clercq, D. (2002). Proprioception and muscle strength in subjects with a history of ankle sprains and chronic instability. Journal of athletic training, 37(4), 487.
Disclaimer:
The content here is designed for information & education purposes only and is not intended for medical advice.
