What is Proprioception / Balance of the Ankle?

What is Proprioception / Balance of the Ankle?

Proprioception is also known as the Joint Position System (JPS).  JPS is a system that allows the joints to send a continuous stream of information to the brain about muscle use, joint position and movement.  This allows us to know subconsciously where our limbs are in space without looking and it’s also the sense that produces sudden reflex actions when we sense danger.

For example, close your eyes….. do you know exactly how your hands are placed? Of course you do! That’s your proprioception at work.


JPS is very important for co-ordinating all our movements and in terms of sports, where good co-ordination is crucial. Following injury to ankle joints and ligaments, the joint position receptors located within them can be damaged. This interferes with the joint position information that’s usually sent to the brain, and the messages are conveyed much slower. As a result, the joint feels unstable and odd in the sense that “you don’t completely trust it not to give way”.


Once you’ve damaged the proprioception or JPS, it can cause you to move awkwardly with decreased co-ordination in ordinary activities and in sports. Loss of JPS also affects balance and this interferes with the ability to avoid injury by quick and co-ordinated movements.

Fortunately, physiotherapists are able to re-train the JPS system with special exercises.   In some cases, injured athletes have gained a heightened JPS sense after physio treatment for an arm or leg injury and improved their performance!


Following an ankle injury the doctor may need to immobilize it in a plaster cast to ensure the bones heal in the correct alignment.  When the plaster comes off and the doctor is satisfied that the bones are healing well, the physiotherapist takes over.

If a cast hasn’t been necessary, the physiotherapy exercises should be started as soon as possible after the injury.  This is important because the early scar tissue is still soft and can be broken down by the physiotherapist.  If you don’t get physiotherapy early on, the scar tissue becomes rigid and causes permanent restriction in the flexing and rotating movements.

Proprioception exercises

Massage, heat treatment, joint manipulation and stretching are the best way to get an injured joint back to normal mobility.  Muscle exercises fortify the muscles that control the joints and special proprioception exercises, like balancing and ankle disk training restore the nerve-muscle control.

Physiotherapy reduces your vulnerability to the same injury in the future and speeds up recovery – so you can return to your daily activities and sports in good form!

Are Ankle Braces Useful?

Are Ankle Braces Useful?

There is a lot of misinformation being circulated about ankle braces and their effect on the body and athletic performance.

Why Use a Brace or Support?

A support brace helps you by:

  • Relieving your pain
  • Resting the injured tissues by taking some of the stressful loads
  • Protecting the injured structures from further injury
  • Allowing for initial tissue healing
  • Preventing future injury by support or joint stabilisation.


A hinged style ankle brace that allows full up and down ankle range of motion will not weaken the joint because the brace is allowing unrestricted natural ankle motion. Hinged style ankle braces move with the ankle joint, and not against it, to protect the ankle from twisting and turning while still allowing for full natural range of motion.

A lace-up style ankle brace restricts all ankle range of motion, even up and down movements. This up and down natural ankle range of motion is not a cause of ankle injuries so there is no need to restrict it. One could argue that by restricting normal ankle range of motion you could potentially weaken the ankle, so it’s important to compare different ankle braces and choose the one that is best for your specific situation.

Wearing an ankle braces for an extended period of time will not weaken the ankle. There are no clinical studies available that support the notion that wearing ankle braces weaken the ankle.

Lace -up style ankle supports do hurt athletic performance. A recent study by the University of South Alabama concluded that wearing a lace-up ankle brace negatively affective ankle joint motion and muscle function. In other words, wearing a lace-up ankle brace reduced ankle range of motion and muscle strength in athletes thus reducing the level at which they could effectively perform.

Aren’t You Only Supposed to Wear an Ankle Brace After an Injury?

Athletes that play sports with a high incidence of ankle injuries like volleyball and basketball should wear preventative ankle bracing since there are many situations during a game where ankle injuries cannot be prevented regardless of ankle strength or athletic ability. With these sports it’s not “if” the injury will occur but “when” it will occur – think coming down on another player’s foot after jumping for a block or a rebound.

However, in other sports with less ankle injuries it’s not absolutely necessary to wear preventative ankle bracing. In those cases, it would be important to look into ankle bracing after an injury since 70% of athletes who sprain their ankle end up re-spraining that same ankle causing further damage to ankle ligaments.



  1. When should I see a Physio?The first reason to see a physio is to be evaluated for a fracture. Signs of a fracture include the inability to bear weight following the injury or if there is tenderness over the bony protrusions of the ankle or foot. In these situations X-rays should be performed to assess for a fracture. Another reason to seek medical advice is to reduce the risk of recurrent or chronic ankle problems. The most important risk factor for ankle sprains is a previous ankle sprain. Therefore, individuals should seek medical guidance and possibly formal rehabilitation to prevent recurrent and chronic ankle issues.
  2. How long does it usually take to get back to my activity?
    Most ankle sprains require two to six weeks to recover, but the length of time required is dependent on the severity of the injury and the activities required of the individual. Treatment involves three phases. Initially controlling inflammation, next regaining full range of motion and strength and finally regaining the muscular control and endurance required for one’s activities.
  3. What is involved in controlling inflammation?
    Initially controlling inflammation will decrease pain and swelling, and involves the following:
    – Icing (usually 10- 20 min, with at least 30 minutes in between sessions to avoid frostbite)
    – Compression (using an elastic bandage)
    – Elevation
    – Relative rest.

Depending on the severity of the injury, rest may involve a short term use of crutches or walking boot. However, it is important to note that early mobilization improves time to recovery, long-term stability and decreases swelling. Therefore one should begin protected and full weight bearing activities as soon as tolerated. Completing all phases of rehabilitation allows one to confidently return to sport and lessens the likelihood of chronic ankle issues.  In particular, rehabilitation should involve exercises to improve strength, balance and functional rehab exercises to guide one back to sport and exercise.

  1. Does wearing braces help prevent sprains?
    Wearing braces, specifically an air stirrup brace or lace-up support can be used to aid in early mobilization and to protect against re-injury following return to sport. Unfortunately, braces must be worn during all high risk activities for at least one year to have this benefit. In addition, braces do not stimulate healing or retrain one’s muscles, ligaments and reflexes to react to the stresses placed on them.
  2. How do I know when I am ready to play again?
    In general, once the individual has full movement and strength, in addition to being able to perform all sports specific activities required without pain they can return to play. One rule of thumb is the “rule of 20s” where the athlete is able to run20 yards, cut 20 times, hop on the leg 20 times, and balance with eyes closed for 20 seconds on the effected ankle without problems. However, it’s important to note that the risk of re-injury persists for up to 12 months, even after full rehabilitation. External ankle support and neuromuscular training can reduce this risk and are an important aspect of returning to play safely.
Foot Mechanics: There’s more to keep in mind than just what your feet are doing. 

Foot Mechanics: There’s more to keep in mind than just what your feet are doing. 

Running mechanics have been a hot topic of discussion – from the barefoot crazy to custom-made orthotics, it is possible to find someone who swears by ‘their’ style of running. Many running stores have treadmills with recording equipment set up to help find “the right shoe for your mechanics”.

So what is different when you have your gait analysed by a physical therapist?

A comprehensive analysis performed by a physical therapist looks at the foot mechanics in several ways — a non-weight bearing state, standing, walking, running at pace (i.e. endurance vs. sprint) and after fatigue. It is also considers more than the foot — a physical therapist will look at the knee, pelvis and low back. Arm swing may also be analyzed to tease out upper body compensations for lower body weaknesses. Let’s look at a few of these in a little more depth.

Biomechanics in a non-weight bearing foot boils down to the functionality of the multiple joints of the foot and how they interact, particularly in a dynamic state. Is your foot rigid, flexible, flat or high-arched? Does your big toe have the motion it needs for push-off? Is the main ankle joint moving correctly? What changes when the foot bears weight in standing, walking or running?

At a shoe store, runners are often evaluated while standing, walking, or jogging. Many are told they are ‘pronators.’ Pronation is a normal part of weight bearing in static and dynamic conditions. In very general terms, as a limb strikes the ground the foot must go through a phase of pronation to absorb and distribute the forces of the body. As we move through a gait cycle, the typical foot will then go through the opposite motion and supinate to act as a spring which helps propel us forward. Pronation is neither an entirely bad thing nor a single action, and pronation during walking may look different when jogging or running or when fatigued.

In part, this is where experimentation with barefoot running or transitioning to minimalist running shoes have gained popularity.  Motion control shoes are seeking in part to prevent ‘excessive’ pronation during the gait cycle. Part of the concept of barefoot running centers around what part of the foot strikes the ground first – toe, mid-foot, or heel. The common argument is that if runners move to a mid-foot strike they will be more efficient and can avoid using motion control shoes. I take a slightly different stand. Rather than forcing a mid-foot strike, runners should focus on increasing cadence (number of foot falls) and speed. As these two things increase naturally, most runners will move into a mid-foot striking pattern. I do agree that if the majority of running is done on the mid-foot, the need for motion control decreases, but is not eliminated, as most of the motion control in a shoe is toward the heel. The second consideration to keep in mind is the assumption that running is only efficient if you strike at your mid-foot, when in reality many factors determine efficiency.
When running, foot strike location in relation to the body position is a major factor in efficiency. If foot contact with the ground is made in front of the line of the body, regardless of where on the foot the contact happens, the foot will act as a break in motion. Ideal foot contact would be under the body to allow forward momentum to continue unimpeded.

Q: What does this mean for the average runner?

A:Think more about where your foot is landing and less about which part of your foot lands first.

Efficiency is also affected by hip strength and mobility, core strength, and arm swing. Runners with a mid-foot strike that translate much of that energy into up and down motion – rather than forward motion — will be less efficient than a heel striker who sends all the energy forward.

All of this is should be considered before we change the shoe platform. From a physical therapist’s perspective, no one solution exists for every foot type, body type or runner. Changing mechanics and footwear is possible and may be beneficial, however, slow and steady changes are more effective for the long term health of your body.

What is a high ankle sprain?

What is a high ankle sprain?


Unlike other ankle sprains, this injury is sustained to the tissue (ligaments) that connect the tibia and the fibula.  These are the bones that make up the lower leg (the inner bone being the tibia or shin and the outer being the fibula).

With common ankle sprains “low ankle sprains” the ligaments that are most often injured are the ones on the outside of the ankle.  These help to connect the fibula to the foot.  These ligaments are injured when someone “rolls” their ankle over.

In the high ankle sprain, there are several structures potentially damaged.  These include ligaments that connect the tibia to the fibula known as the tibfib ligaments, as well as a tissue called the interosseous membrane.  The severity of this injury often depends on how many of these structures are damaged.  The recovery time frame varies from 8 weeks to 6 months and this is why the high ankle sprain is so dreaded.

What are the symptoms of a high ankle sprain?

With a high ankle sprain there is often a minimum degree of swelling but unfortunately there tends to be more and longer lasting pain.  The pain that occurs with this type of sprain will usually occur when the ankle is turned outward and will be noticed above the ankle.  This tendency and the fact that the ligaments are above the ankle lead to the term “high ankle sprain.”  Most athletes are diagnosed with these injuries when their ankle sprain takes longer to recover than usual.  Clinical diagnosis is based on pain location, palpation, observation and a test known as the “squeeze test.”

How does one get a high ankle sprain?

The common mechanism of injury is sport and most often they occur during forceful twisting outward of the ankle.  This injury is more common in football, hockey, wrestling and soccer.  In these sports the opportunity to become tangled under another person is increased. The outward twisting motion of the ankle will cause the two bones to pull away from one another and tear the ligaments that connect them.

Another way to injure these ligaments is via hyperdorsiflexion – which means that the toes are forced toward the shin beyond their normal range.  This will occur when an athlete has his foot planted and falls or is pushed forward.  In either event the splaying (pulling apart) of the two bones causes the ligaments to tear.

How is a high ankle sprain treated?

  • When identified early a stable high ankle sprain is treated with a boot for the first 6 weeks.  Once the boot is removed, the real tough part of the recovery begins.  At this point, due to the immobilization, the joints from the ankle to the toes are very stiff.  The physiotherapy is key to restore the lost motion, strength, balance and of course to teach the athlete how to walk and run properly again.
  • If missed, the immobilization is usually absent and the ankle sprain is treated very similar to other sprains, but with a lot more patience, plenty of rehabilitation and there is often a need  for more caution on return to sport.  This caution is necessary because of the possibility of ongoing instability.
  • If the sprain is determined to be unstable, the bones of the lower leg require surgical stabilization usually via a screw.

Final thoughts on ankle sprains in general:

In my practice I hear from people that they “always sprain their ankle” or that it’s “just a sprain.”  I must make a point that the time to deal with any ankle injury is immediately!   There are many degrees of ankle sprain and as you have now read, many different types of ankle sprain.

Determining the injury type and severity will go a long way to ensure that your ankle recovers properly.  As well, just because the swelling is going away and the pain decreases, this does not imply that the ankle has healed properly.  Loss of range of motion, scar tissue and persistent instability are all complications of ankle sprains – even minor ones.

Strengthening the ankle joint!!

Strengthening the ankle joint!!

The ankle is a complex hinge joint that is primarily defined by the shin bone (tibia) and its meeting with the talus bone on top of the foot. There are several other bones that surround this meeting, as well as all the muscles, ligaments and tendons that make these bones moveable in several directions.
Let’s focus on how to prevent ankle pain and injury by improving the joint’s overall function.
Running and sports that involve agility are usually the cause of most ankle injuries, and these usually stem from the joint and tissues that surround it not being strong, mobile or stable enough to control the joint when asked to perform a task.
These exercises for the ankle and foot will help strengthen the joint by creating stability and mobility in the surrounding regions.
The peroneals are a group of muscles that run down the side of the lower leg and attach between the knee and the ankle. Their respective ligaments run around the foot and ankle and can cause pain and undo tension when these muscles are tight. Using a foam roller to perform self-myofascial release therapy will help muscle release tension and, as a result, relieve the stress being placed on the attachment points in and around the foot and ankle.
Because the hamstrings and calf (and soleus) are the major muscles in the posterior aspect of the leg, they are primarily responsible for plantar flexion of the foot and can become tight when there is an issue of mobility in the ankle.
A weak foundation is often to blame for other areas of the body becoming injured, so a good place to begin training is improving the support system. Strengthening the arches in the feet will help provide additional support to the ankle.
By including dynamic movement patterns, especially when barefoot, the muscles that support the foot and ankle movement will be engaged to further improve stability of the joint.

How Do I know If I’ve Rolled My Ankle?

How Do I know If I’ve Rolled My Ankle?

An ankle sprain is a common injury. Inversion ankle sprains are the most common, making up 85% of all ankle sprains. It is know that the incidence of lateral ligament injuries is the most common amongst the sporting population and the consequence of not rehabilitating after an initial injury increases the chances of recurrence.
• Presents with history of inversion injury or forceful eversion injury to the ankle. May have previous history of ankle injuries or instability.
• May be unable to weight-bear through the limb.
• Potential description of a cold foot or parathesia
• Tenderness, swelling and bruising on the lateral side of the ankle.
• Bony tenderness, deformity or crepitus present.
• Passive inversion or plantar flexion + inversion should replicate symptoms for a lateral ligament sprain, passive eversion should replicate symptoms for a medial ligament sprain.
• Special Tests: +ve Anterior Draw, Talar Tilt or Squeeze Test
If this sounds like you have any f these symptoms please book in to see one of our physios today

Ankle Sprains

Ankle Sprains

Lateral ankle sprains (LAS) are one of the most common sports injuries. As a result they have a high economic burden with direct and indirect costs associated with the injury.


From a clinical point of view, the problem with LAS is that there is a very high recurrence rate and 20% of the general population and 30-50% of the athletic population will go on to suffer from chronic ankle symptoms (pain, swelling and instability); also known as chronic ankle instability (Gribble et al., 2016, Attenborough et al., 2015 & Tanen et al., 2014). It is believed that contributing factors to the development of chronic ankle instability are:


1) Very few will seek medical attention for primary LAS

2) Most people prematurely return to sport; when their pain is absent.


The good news is that a recent systematic review and meta-anaylsis showed that there are 2 very simple things that can be done to reduce the chances of a primary LAS developing into chronic ankle instability (Doherty et al., 2016). These are:


1) Exercise Therapy: Exercise therapy when performed in high doses (>900mins) significantly reduced the chances of recurrent LAS by 42%. Furthermore, exercise therapy significantly improved function following primary LAS.

– 900mins sounds like a lot, but when broken down is very achievable:

– 5x30mins per week = 150mins per week

– 150mins per week x 6 weeks = 900mins


2) Bracing/Taping: Significantly reduced the risk of recurrent LAS by 62%. It is currently recommended that a brace be worn on the injured ankle, or that it is taped for every game or training session for at least 6 months following the initial LAS.


Take home messages:


1) Ankle sprains are not so simple, and they need to be respected.

2) The absence of pain does not mean that you’re ready to return to sport. The subtle losses of strength, ROM, proprioception and balance do not magically re-appear once your pain has gone.

3) Make sure you COMPLETE your rehab; 6 weeks of regular strength, balance, stretching, plyometrics and agility should be considered a non-negotiable part of the rehab plan.

4) Ensure that you brace or tape your ankle for training and games for at least 6 months following your sprain.

5) Like every injury, the decision to return to sport following a LAS should be based on performance criteria such as strength, balance and hop tests rather than time-alone or the absence of pain.

Patellar Tendon Pain

Patellar Tendon Pain

Patellar Tendinopathy is most commonly characterised by pain localised to the inferior pole of the knee cap and load related pain which increases the demand on the knee extensors.

Risk factors include being 15-30 years old, males are affected more than females, involvement in jump/lunging sports and training loads.

Pathology occurs because there is an ↑ tenocyte numbers, ↑ ground substance, swelling, matrix degeneration and neovascular growth.

Presentation is generally pain localised to the inferior pole of the patella, load related pain (knee extensors). Regional findings sometimes present with wasting of quads, foot issues, ↓ hamstring/ quad flexibility and ↓ dorsi flexion.

Imaging generally doesn’t confirm patellar tendon pain but can exclude other diagnosis’ such as bursitis or fat pad irritation for example.

Management of Patellar Tendinopathy

  • Eccentric Exercises may be too aggressive when there is high irritability, and there is little data that leads to better outcomes.
  • Heavy slow resistance exercises demonstrated similar improvements to eccentric exercises in pain and function, with the benefit of higher patient satisfaction scores.
  • The focus of treatment is to develop tolerance of the tendon, muscle and kinetic chain. progressive criteria is based on pain, strength and function.
  • Initial load modifications aims at reducing pain with a focus on ↓ high load energy storage tasks. Modify : Volume and frequency
  • Progress loading based on pain monitoring with a 5/10 during exercise.

**********24 hour response test **********

At the same time each day the client does a single leg squat to 90 degrees and compares the pain to baseline scores. If pain is higher than the previous days it means the previous days load has not been tolerated well.

Bottom line ……..

1) Calm it down and build it back up

2) Some pain is acceptable during exercise but symptoms should resolve quickly after exercise and should not progressively worsen over the course of the rehab program.

Do’s And Dont’s of OA Knee Pain

Do’s And Dont’s of OA Knee Pain

Do: Choose Low-Impact Exercises
Low-impact aerobic exercises such as walking, biking, and swimming are considered joint-friendly. They help build strength around the affected joints and keep them aligned and functioning properly.

Don’t: Engage in Repetitive, High-Impact Exercises
Joint-pounding exercises such as running and tennis can tax your already damaged knees. You stop using your muscle because it hurts, you lose strength, and then your alignment isn’t good either

Do: Incorporate Strength and Flexibility Training
A fitness plan for osteoarthritis should include strength and flexibility training along with aerobic exercise. Strengthening exercises help support the muscles around the joint, while stretching can maintain and sometimes improve flexibility around the knee.

Do: Warm Up and Cool Down
Don’t jump right into your workouts if you have knee osteoarthritis. In general, a warm-up lubricates your joints so that you’re less stiff and it’s easier to move, which lowers the risk of sustaining any injury during your workout. Cooling down helps you reset after exercise
Do: Maintain a Healthy Weight
Excess weight puts greater pressure or stress on your already damaged knees. If you’re overweight, losing weight can relieve knee pain and improve function

Do: Wear Comfortable Supportive Shoes
There are a fair number of studies that suggest shoe choice matters if you have knee osteoarthritis,. In fact, flat, flexible shoes that mimic the foot’s natural mobility can decrease the force placed upon the knee during daily activities.

Don’t: Be Afraid to Use Assistive Devices
Canes and knee braces can play a role in decreasing knee osteoarthritis pain and improving function.

Do: Take Medications as Prescribed
Over-the-counter or prescription-strength non-steroidal anti-inflammatory drugs (NSAIDs) are among the mainstays of knee osteoarthritis treatment. While effective, they do come with their share of side effects. Other treatments are also available to help relieve knee pain, stiffness, and swelling, including analgesics, corticosteroids, and hyaluronic acid.

Don’t: Ignore New or Worsening Symptoms
Knee osteoarthritis is a chronic condition, which means that pain is always possible. However, if pain grows more severe and occurs at rest instead of after periods of activity, or if it awakens you from sleep, it could mean that your knee osteoarthritis is progressing. Other symptoms such as swelling, a locked knee, or one that just gives way are concerning.