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Your ankle hurts because your back doesn’t work…and vice versa

Imagine this: you have a long history of ankle pain. It’s hurt on and off ever since you sprained it in an intramural softball game during your sophomore year of college. You stretched a single into a double, your team won but … it’s just never quite been the same.

And boy are you sick of that darn BOSU ball. Physical Therapy’s helped in the past, but it’s never really gotten back to 100 percent and the thought of going back for more rehab is a little annoying.

You’ve been able to get back to running, did a half-marathon last year(!), yoga is just fine, but once every hiking season your ankle just goes out from under you. Suddenly you’re working from home for a week until you can make that mile-long hobble to the bus stop without Advil.

We actually see this quite a bit. And often, even though the initial injury is to the ankle ligaments, the best way to address persistent ankle pain is to work on your lower back and hip.

When you sprain an ankle ligament, that ligament can regenerate, somewhat, if the right treatment is applied promptly. However, often that’s not the case and you’re left with a deficit in the structure of the ligament which is replaced with scar tissue. As a result, the structural integrity of the ligament actually doesn’t return to 100% and the next time your foot/ankle encounters terrain that it needs 100% of that structural integrity to cope with, the muscles surrounding the ankle then take on some of the responsibility of keeping you upright and uninjured.

That’s easier said than done, though. The initial ligament tear generates a ton of sensory information that’s transmitted to the spinal cord for processing. Most of the time, that volume of information simply overloads that particular region of the spinal cord and everything associated with that region is affected. This means local core muscles, the almighty gluteals and the muscles of the ankle and foot (this is called Segmental Facilitation) are all inhibited, or, in effect, turned down and it’s harder for them to do their job.

When an area of spinal cord is facilitated, muscles with nerve supply coming from that area (for example, the ankle muscles get their supply from the L5 area of the spinal cord) can fatigue more quickly, fire/twitch more slowly, and generally not work the way they need to. If the core muscles at the lower back aren’t working well, spinal joints often move awkwardly causing a perpetuation of poor core recruitment and continued facilitation – over time, this means it becomes harder and harder for you to recruit your foot and ankle musculature (and your gluteals) and therefore it gets harder and harder for you to balance.

We bring up gluteals (don’t we always, as PTs?) because they’re actually rather important. The way the body is wired, muscles closer to the trunk/torso fire before muscles farther away. So when you are put in a situation demanding balance, your core and gluteal muscles fire first to decrease the amount the ankle muscles have to work. This makes biological sense: torso-proximal muscles are bigger and can generate force for longer. When the core and gluteals don’t pull their weight (both literally and figuratively), more is demanded of muscles of the ankle and foot – which are smaller and, in the case of facilitation, already compromised and easily fatigable. Suddenly you’ve got a muscle which is overtaxed and/or fails. More damage, more sensory inflow to the spinal cord, more facilitation. The result is a vicious cycle.

If you have persistent ankle sprains, it’s almost certain that you have core and gluteal muscle weakness which are possibly caused by, and certainly contributing to, these difficulties. Let your MTI Physical Therapist know that you have persistent ankle pain. We can help, and we have quite a few more tools than BAPs boards and BOSU balls.

Deep dive reading:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1421486/
https://www.ncbi.nlm.nih.gov/pubmed/31937576
https://www.ncbi.nlm.nih.gov/pubmed/28887759
https://www.ncbi.nlm.nih.gov/pubmed/29116830
https://www.ncbi.nlm.nih.gov/pubmed/7822072


Matthew Wood, PT, DPT, has been practicing osteopathy since 2002 and Physical Therapy since 2015. He is a Fellow of the American Academy of Orthopedic Manual Physical Therapist, and takes a special interest in working with athletes (particularly basketball players) and with patients who have experienced failed manual or physical therapy. He works at MTI Physical Therapy’s First Hill clinic, and now sports an excellent beard.