In this blog post we are going to look at the most common ankle injuries that can arise from both MMA training and competition.
The foot is an incredibly complex mechanism, too complex in fact to discuss here so we’ll just cover the basic anatomy and try to highlight the structures that will cause the most problems. Supporting the 26 bones and 30 joints of the foot are a network of muscles, tendons and ligaments (soft tissues) which give the foot its shape by holding the bones in position. Although our feet take 1 million steps a year, walk a hundred thousand miles in a lifetime and can absorb 500 pounds of impact (road running) they are extremely structurally delicate which is why we have so many foot and ankle problems.
As with all other joints discussed in this series, ankle injuries may be divided into 3 categories:
· Single-event (acute) trauma
· Acute-on-chronic injury
· Multiple-repetition (or chronic) injuries.
Single-Event (Acute) Trauma Ankle Injuries
The stability of your ankle joint is dependent upon the ability of the tibia and fibula (shin bones) to keep the talus (ankle bone) in place whilst the ankle moves back and forth. The ankle is more stable when your foot is flat on the floor or pulled back towards you (dorsiflexed) as the talus is more rigidly held in place by the tibia and fibula. However, when you point your toes (plantarflex) during a round kick (or when your foot becomes secured in an ankle lock) your ankle becomes unstable because the distance between the tibia and fibula becomes larger. This causes your ankle to rely on the ligaments to maintain the stability of the ankle. Since soft tissues are “softer” than bone, you are more vulnerable to a sprain when you are pointing your toes.
When your ankle is twisted during an ankle lock attempt the toes are usually pointing down which makes the ankle mechanically unstable placing the ligaments at risk of injury, that’s when you’re supposed to tap! The most commonly injured structure of the ankle is the Anterior Talo-Fibular Ligament (ATFL) which can account for approximately 85% of all ankle injuries. The ATFL may become sprained (damaged) in ankle submissions, during poor kicking technique and “going over” on the ankle.
All these movements have one thing in common, the foot is pointed down and turned in under force, this is technically known as an “inversion injury” and it occurs as the ankle is placed into a position of weakness. However sometimes during an inversion injury the ATFL will remain intact but the fibula can break or in extreme cases both ATFL and Fibula can break! Although this can be incredibly painful and will stop most of us, some fighters will continue to fight on with adrenalin driving them through the pain (pray you never meet this guy in competition)!
ATFL injuries can be graded by severity:
Grade 1 is an overstretching of the ligament
Grade 2 is a partial tear
Grade 3 involves a complete rupture
Treatment of Ankle Ligament Injuries
In the first 48-72 hours following an uncomplicated Grade 1 ligament injury it is important to follow the PRICE approach.
Protection, Rest, Ice, Compression and Elevation should be applied by the individual. Ice packs can be applied for a period of twenty minutes every couple of hours and may help with the pain but pain-relieving medication may also be necessary.
The pain should subside over a few days allowing a gentle return to training without any restriction. However, if your pain is extreme and continues for over 48 hours, you should see your GP or Chartered Physiotherapist as you may have a Grade 2 sprain.
In the case of a Grade 2 sprain, crutches should be used to protect the injured ankle and full weight bearing avoided. However, it is important not to be on the crutches for longer than necessary and as soon as the pain allows you should begin to gently put your weight through the ankle by walking. In the early stages of the injury, ultrasound treatment is effective in encouraging the healing process and the formation of scar tissue to repair the ligament. Once you are able walk on the ankle, more active rehabilitation can be started.
A Grade 3 injury will require some sort of immobilisation (cast) and/or bracing to protect the area whilst healing, particularly if there has been an avulsion fracture (ligament ruptures and breaks a piece off bone with it!). When the bones around your ankle break, they can cause gross instability and this may result in a subluxation or even worse a dislocation.
If you think you have fractured, subluxed or dislocated your ankle; get to A&E; and get it X-rayed, assessed and dealt with ASAP! In the case of a dislocation, arteries may become damaged and cut off the blood supply to the foot, so if it looks discoloured and deformed it needs attention NOW! A loss of circulation may cause permanent damage to the foot so if even if you’re in doubt of the severity of the injury, get it seen to! Once it has been reduced (put back in place) and other injuries have been checked for, you should seek advice regarding your future rehabilitation from a Chartered Physiotherapist.
Basic rehabilitation principles and exercises
would be the same for this injury as in a Grade 2 tear but would obviously progress much slower over a greater period of time.
Ankle Instability Post Injury If the stability of the ankle has been affected then strapping or bracing can be employed to reduce the risk of any further injury whilst undergoing your rehabilitation programme. Bracing provides pain relief by stimulating your nerve fibres which make you feel that your foot is more stable and secure whilst compressing your surrounding tissue making it actually feel better. Strapping the ankle can temporarily improve the stability of the ankle and be gradually reduced over time to allow a full return of function whilst building confidence for a return to full training. Each approach has its own part to play in the rehab process.
Acute-on-Chronic Injury After an initial inversion injury the ATFL may become prone to reinjury if not rehabilitated fully. Following recurrent inversion injuries instability (giving way) may occur.
Ankle instability may suggest that you have torn some ligaments in your ankle and foot. The instability may worsen when you try to walk on uneven surfaces such or when you change direction suddenly during training. Some instability however is normal after a minor sprain, especially in the early phases of recovery. Persistent instability in the ankle is a sign that professional treatment is required. If you have “weak ankles” you should focus on proprioception, which is the ability to know where a body part is in space without looking at it. When proprioception is impaired following a ligament injury the joint may feel unstable which may increase the risk of re-injury.
Proprioception training re-educates your body to control the position of an injured joint. It is best performed standing on the injured leg with the eyes closed and measure the amount of time you can remain stable. As you improve make it more difficult by standing on an unstable surface (eg. wobble board or trampette). Better proprioception will improve your kicks, throws, takedowns and counters and overall balance. Tip: Even if you are not injured train this aspect of your game; as I’ve stated before, I’ve never worked with an athlete whose proprioception was too good!
Prevention of Ankle Ligament Injuries
The most effective method of preventing ankle sprains is by improving the muscular support around the ankle and the proprioception in that area. The muscular support in that area can be effectively improved through plyometric training. Plyometric exercises combine speed of movement with strength. The effect of the exercises is to improve the reaction time of the nervous system thus increasing muscle reaction times. As it is the muscles that control the placement and stability of the ankle and foot improving their reaction times enables the muscles to contract quicker to correct a twisted ankle before an injury occurs. However, these exercises can be very strenuous and put an injured area under a great deal of physiological stress so it is important that these exercises are approached with caution and they should be started very gently.
Multiple-Repetition (or Chronic) Injuries
One of the most common forms of chronic foot pain that occurs during training usually involves the heel (Calcaneus). The heel is the largest bone of your foot and it is connected to the Achilles tendon and the Plantar Fascia.
The Plantar Fascia helps keep the arch of your foot supported and may become inflamed (plantar fasciitis) when the foot becomes overstressed or the biomechanics of the foot become altered. Sometimes a bony heel spur will form at the tip of the calcaneus although these generally do not cause pain. Plantar fasciitis is usually sharp and occurs during your first few steps after sleeping or resting. This is because your foot and heel tissue (fascia) contract when you rest and the tight tissue is then stretched during full weight bearing, creating pain.
However, once the fascia has been stretched, the pain diminishes after a few steps but may return when overstressed. Although the initial pain from this condition is not debilitating the continued pain that is causes may go on the affect training, particularly roadwork, skipping and boxing training (due to the spring loaded position of the foot in the boxing stance). The onset of this condition is usually slow and insidious with no initial trauma.
The problem may originate from poor biomechanics and an increase in physiological stress associated with road running or inappropriate footwear. Treatment is usually aimed at stretching the plantar fascia, taping to unload the area and orthotics (shaped gel insoles) to absorb shock and improve the biomechanics of the foot. If professional advice is taken and followed treatment is usually successful, if left alone however, symptoms can persist for months to years! Other common injuries that may also occur in the lower leg include Achilles’ Tendonitis and Shin Splints. Both these conditions tend to be associated with biomechanical dysfunctions on the foot and can usually be dealt with in a similar way using stretching, strengthening exercises and orthotics (shaped gel insoles) to absorb shock and improve the biomechanics of the foot.
Note: If you are suffering chronic long term problems with your feet or ankles you should seek the advice of a State Registered Chiropodist or Podiatrist that specialises in biomechanical dysfunction. These specialists will be able to advise you on specific exercises to improve your feet and also should be able to make a cast your feet to make insoles to improve your lower limb biomechanics.
Rehabilitation of Chronic Ankle Injuries
One of the major goals of rehabilitation is to maintain your cardiovascular fitness levels, so for instance when you suffer a lower limb injury instead of roadwork, try aqua jogging with a flotation belt (running upright in a swimming pool without your feet touching the bottom of the pool). You, your coach/trainer and your physio should work together at devising alternative training programmes as soon as possible particularly if you are a competitive fighter. In addition to cardiovascular fitness, you may use the injury period as an opportunity to strengthen weaker areas whether they be physical, mental, technical or tactical. Your physical rehab plan should include exercises to restore normal strength using progressive resistance exercises that should involve the calves and lower leg muscles as well as the entire lower limb.
In addition in the later stages rehab should include eccentric as well as concentric exercise and plyometric (explosive movements) training followed by combat-specific drills (with an emphasis on proper technique), agility and proprioceptive training. Strapping and bracing may also be used as appropriate in the earlier stages of rehab. As I have stated in previous articles if you are bracing or strapping (with the exception of hand wraps) a joint you should not be full contact training or considering stepping into the competitive arena. It must also be appreciated that the power, speed and angles which occur during competition may far exceed the criteria for successful completion of rehabilitation exercise. To be ready for competition you must perform over and above what you are required to do in competition.
Return to Training/Competition After a Chronic Injury
Depending on the severity of the injury, it may take several months of physical therapy for you return to full training or competition. The differing grades of ankle or foot injury makes for a wide range of recovery and rehab times. Ligament injuries often take months to rehabilitate and a fracture dislocation may continue to prevent return to full MMA competition even after six months of rehabilitation. For return to full training /competition two principal factors must be considered, firstly the risk of re-injury and secondly the ability to fight/perform at a satisfactory level. These factors are often intertwined.
When there is a risk of re-injury, the potential for further or permanent damage must also be considered. The criteria for return to competition after an ankle injury include restoration of normal strength, endurance, flexibility and proprioception. With repetitive injuries it is important to identify the specific activity that caused the initial injury so that activity can be avoided or training modified. Avoidance steps may include changing technique, training habits, and equipment, and the use of orthotic insoles or modified footwear during training and bracing/strapping in the early stages of rehab.
This is just a brief outline of the foot and ankle injuries you may incur during MMA training and competition and a rough guide to treatment and rehabilitation principles. If you have any specific foot or ankle problems you will need to seek first hand advice and treatment from an experienced sports injuries Chartered Physiotherapist.
This post is for the purpose of information only and it is not intended to diagnose or treat medical conditions and is not considered to be a substitute for individual medical assessment and advice.