What is an inverted ankle?
An inverted ankle is often used by the general population to describe an inversion ankle sprain, also known as a lateral ankle sprain. Inversion is the motion that places the lateral ankle ligaments on stretch, and if this inversion is motion occurs in an excessive or rapid fashion, it may exceed the ligaments’ ability to withstand this force, resulting in an inversion ankle sprain.
Therefore, this term can be a little misleading, as the ankle isn’t “stuck” in an inverted position, but rather, temporarily moves into an amount of inversion it cannot safely withstand. After an inversion ankle sprain occurs, the ankle will not be stuck in an inverted position unless there is major bony deformity that would require extensive emergency ankle surgery.
What causes an inversion ankle sprain?
We have previously published an article discussing the pathology and treatment of lateral ankle sprains, which are the same thing as inversion ankle sprains, but we will discuss this injury a little bit more differently in this article, placing a focus on the inversion movement itself.
Inversion mainly occurs at the subtalar joint of the ankle, which is the joint formed by the talus and calcaneus, which sits below the talocrural joint of the ankle. The talocrural joint of the ankle is the joint formed between the tibia, fibula, and talus, and this joint is more responsible for ankle plantarflexion and dorsiflexion (moving the ankle up and down).
For a real life example you can safely try on your own, think of moving the inside of your foot and ankle towards midline. For example, if you are sitting in a chair, think about keeping your right heel on the floor and sweeping your right foot towards the left, all while keeping the pinky side of your foot in contact with the floor. This should place your ankle in a predominantly inverted position, whereby the ligaments, muscles, and tendons on the outside of your ankle are stretched, hence the term lateral ankle sprain.
“Rolling the ankle” is the classic mechanism of injury described by patients with inversion ankle sprains, and it’s one of the most common ways that people sustain damage to the ligaments on the outside of the ankle. Here is a list of examples where people can sustain inversion ankle sprains, but keep in mind this list is certainly not exhaustive and that this type of ankle sprain injury can occur in many different ways:
– Running on uneven terrain. If you are running outdoors and land on a bump or ledge and not are expecting it, the ankle may roll such that you stretch the outside of it.
– Slipping off a curb. The outside of the ankle may slip off a curb or ledge and experience rapid stretch in the outside.
– Landing from a jump on something irregular. Inversion ankle sprains are common in jumping sports. For example, if you think about jumping for a rebound in basketball and landing on someone else’s foot, the ankle may roll to the outside causing an inversion ankle sprain.
– Rapid change of direction, for example, plant and cut. Take a soccer player in this case. If the soccer player is running full speed and they attempt to plant the right foot to cut towards the left, there may be some risk of rolling the ankle, particularly if the cleats stick more than expected, the player has a history of ankle instability, or they did not anticipate having to perform this maneuver and were not ready to engage the muscles that surround the ankle appropriately.
While this is certainly not an exhaustive list of the different ways you can sustain an inversion ankle sprain, we hope this helps provide more understanding to the types of functional movements that can excessively invert an ankle.
What structures can be injured by an inverted ankle?
The most commonly injured ligament in an inversion ankle sprain is the anterior talofibular ligament, also known more simply as the ATFL. This ligament is highly stressed with excessive inversion, but can also be placed under stress with plantarflexion. The combination of those two movements often occurs when rolling the ankle during functional activities, which is why this ligament is commonly injured in an inversion ankle sprain and can be associated with other ankle injuries as well.
Other commonly injured ligaments include the calcaneofibular ligament (CFL) and the posterior talofibular ligament (PTFL), and inversion ankle sprains can create isolated or combined injuries to these ligaments. In fact, the calcaneofibular ligament is the primary stabilizing structure that resists pure ankle inversion (Li et al, 2019), but is less stressed when the ankle is also positioned into plantarflexion.
In addition to ligaments, muscles and tendons can also become damaged. In the case of an inversion ankle sprain, the peroneal muscles, also known as the fibular muscles given their anatomical location, can be stretched as well. These muscles are located on the outside, or lateral aspect, of the shin, and their associated tendons cross the outside of the ankle to attach to the outside and bottom of the foot.
The primary action of the peroneal muscles is ankle eversion, and as such, they resist excessive ankle inversion and are considered crucial for ankle stability. It is fairly common to see these muscles/tendons injured in combination with the lateral ankle ligaments, especially in severe ankle sprains.
Additionally, there can be injury to the bones of the ankle when excessive inversion occurs. For example, rather than tearing in their mid-substance, the ligaments and/or tendons can sometimes pull off of the bones they attach to, bring a small piece of the bone with them. This is formally termed an “avulsion fracture” and is commonly associated with ankle sprains. Additionally, compaction fractures can occur with an inversion ankle sprain, and this would usually happen on the inside of the ankle where joints are being compressed.
How do you treat an inverted ankle?
Assuming the inverted ankle you are wondering about refers to an inversion ankle sprain, treatment will vary depending on the extent of injury. At the end of the day, the main goal is to allow symptoms to settle, structures to heal, and to improve functional mobility, strength, and overall stability of the ankle.
It is equally as important to focus on the advanced stages of rehab as it is the early stages, as ignoring any of the areas mentioned above may lead to chronic lateral ligament injuries, as well as other foot an ankle injuries (Delahunt and Remus, 2019).
This means that treatment for a sprained ankle will likely include some period of rest in the very early stages of the injury to allow for an optimal healing environment of the injured ligaments, but will soon transition into restoration of ankle range of motion, whereby safe movement exercised may be prescribed by a physical therapist.
Once symptoms settle and range of motion is largely restored, the next step will be to strengthen the ankle, particularly the muscles on the outside of the ankle joint (e.g. the peroneal muscles), as well as the muscles of the foot, which will all help to resist inversion, and thus protect the ankle from future injury.
This strengthening will be particularly crucial in moderate to severe inversion ankle sprains, as damaged ligaments may become a little more loose, and the ankle will now be a little more unstable than it used to be. Therefore, the muscles around the ankle joint and up the chain into the knees and hips become increasingly important for performance and injury prevention, particularly in the sense of preventing future foot and ankle injuries.
Ultimately, all of this is combined into more functional strength and stability training, whereby the ankle joint is being highly challenged to maintain stability. This will often come in the form of balance exercises, which are really working on a special type of sensation in the body called proprioception, which is crucial part of treating an ankle sprain, and as such, is a large component of physical therapy. Proprioception refers to joint position awareness and is very important in allowing the body to react to the environment that it is moving in.
Examples of advanced exercises may include single leg exercises on a bosu ball, single leg jumping exercises, agility drills in confined spaces, plant and cut practice, and dynamic reactive training. This is extremely important to focus on even after the ankle joint is feeling better, as many people who recover from an inversion ankle sprain still have proprioception deficits and are at a higher risk of re-injury (Xue et al, 2021)
Lastly, while inversion ankle sprains are extremely common, there are still a wide variety of presentations, meaning that these injuries shouldn’t be treated the exact same for every patient. As such, it’s highly recommended that you seek a physical therapy consult if you have suffered from a sprained ankle, as the physical therapist will be able to identify the best course of treatment to ensure smooth recovery, and they can also ensure that nothing else needs to be investigated, such as an ankle fracture, before it becomes a bigger problem.
What else could inverted ankle mean?
The term inverted ankle would suggest that the ankle is staying or stuck in this inverted position. One common mix-up that people make is confusing inverted ankles with being pigeon toed. While it may look look like the ankles are inverted, and in some cases there may be an element of inversion, it’s technically due to one or a combination of other factors.
What does it mean to be pigeon toed?
Pigeon toes, also known as “in-toeing”, is a structural anomaly that is often present from birth and result in the feet or toes pointing inwards towards midline. This can be a result from the fetus being in a particular position in the uterus and can involve the toes, mid-foot, ankle, or a combination.
If in-toeing occurs during childhood, this is often due to internal tibial rotation, meaning the shin bone is rotated inwards, as opposed to the ankle being inverted, which is the key distinction from an inverted ankle.
How do you correct or treat in-toeing?
In-toeing often resolves on its own over time, and even if it does not fully correct, doctors will often deem the positioning to still be functional enough that it’s not worth the risk of referring for surgery. Generally speaking, surgical options are deferred until later in life unless the in-toeing is so severe that it is disrupting the child’s normal function.
Other less invasive forms of treatment such as specialized foot wear or casting for repositioning may be indicated, but again, the pros and cons of these interventions must be weighed and decided upon in the context of the patient’s goals.
Either way, if you suspect your child has an issue with pigeon toes, it is highly recommended to check in with a doctor or physical therapist regardless. Recent evidence has shown that being pigeon toed can lead to altered stress distribution on the foot and ankle joints, and over time, this can lead to the development of degenerative joint disease (Karimi, 2023).
As such, conservative treatment, such as physical therapy, is becoming increasingly recommended; however, there is no defined treatment algorithm to automatically indicate the best form of conservative treatment. That said, it is our personal opinion that improving the functional strength, mobility, and balance of the foot and ankle to may be beneficial, an opinion that is extrapolated from recent evidence in the literature correlating ankle osteoarthritis with functional outcome measures (Smith et al, 2021), as well as clinical experience.
An inverted ankle typically refers to an inversion ankle sprain, also known as a lateral ankle sprain. This is one of the most common ankle injuries of the lower body, and occurs when the ankle is forced into excessive inversion beyond which the ligaments and muscles on the outside of the ankle can resist.
While many people understandably confuse pigeon toes, also known as in-toeing, with inverted ankles, this position can often be a result of changes at other joints in the foot and lower body, and usually does not involve pure ankle inversion.
Delahunt, E., & Remus, A. (2019). Risk factors for lateral ankle sprains and chronic ankle instability. Journal of athletic training, 54(6), 611-616.
Karimi, M. T. (2023). Toe-in Gait, Associated Complications, and Available Conservative Treatments: A Systematic Review of Literature. Journal of Korean Foot and Ankle Society, 27(1), 17-23.
Li, L., Gollhofer, A., Lohrer, H., Dorn-Lange, N., Bonsignore, G., & Gehring, D. (2019). Function of ankle ligaments for subtalar and talocrural joint stability during an inversion movement–an in vitro study. Journal of foot and ankle research, 12, 1-8.
Smith, M. D., Rhodes, J., Al Mahrouqi, M., MacDonald, D. A., & Vicenzino, B. (2021). Balance is impaired in symptomatic ankle osteoarthritis: A cross-sectional study. Gait & Posture, 90, 61-66.
Xue, X., Ma, T., Li, Q., Song, Y., & Hua, Y. (2021). Chronic ankle instability is associated with proprioception deficits: a systematic review and meta-analysis. Journal of sport and health science, 10(2), 182-191.
The content here is designed for information & education purposes only and is not intended for medical advice.