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EDS, Hypermobility and Ankle Sprains

A woman sitting on and exam table having her ankle evaluated by a doctor.

Ankle sprains are a common injury. They're so common that many people, especially kids, don't even seek treatment from a medical provider. Most people sprain their ankle and recover within a few weeks or months. They go on with life, and a few of them are lucky enough to never do it again.

Unfortunately, however, this isn't the norm. Studies show that up to 75% of people who sprain an ankle, will sprain that ankle again. (1) This is especially true if they don't do a proprioceptive rehabilitation program, like one prescribed by a physical therapist.

People who already have "laxity" or loose ligaments in their ankle may be at an increased risk for ankle sprains in the future. This can occur due to a prior ankle sprain, or a genetic condition like Ehlers Danlos Syndrome. To understand why, let's look at how an ankle sprain happens.

A person standing on a red track wearing a white shoes that is rolling their left ankle.

The vast majority of ankle sprains are "lateral ankle sprains" where the ligaments that are injured are on the outside of the ankle. A person "rolls their ankle" into what a physical therapist would call "inversion". This puts a significant stretch on the ligaments that help hold the ankle stable. When the stretch becomes too great, the ligament may develop small tears, or in extreme cases, the ligament can rupture and tear completely. That is why it is usually best to go and see a physical therapist or a sports medicine doctor after an ankle sprain to determine how severe the injury is. (Coming soon, Ankle Sprains: When To See A Doctor)

Ligaments function a lot like rubber bands. If you stretch them too far, they don't quite go back the same way. Fortunately, the human body has the ability to heal unlike a rubber band. So why do so many people sprain their ankle again?

The answer lies in our nervous system. There are nerves called proprioceptors that sense the position of our bodies in space. If you were to sit with your eyes closed and raised your hand in the air, you would be able to feel where it is in space without looking at it. That is because your proprioceptive nerves tell the brain that your arm is now up in the air rather than down by your side.

Most of your proprioceptive nerves live inside your ligaments. When the ligament becomes stretched out, the nerves don't sense tension as quickly as they did before. This can delay your reaction time. When your ankle begins to shift into an unstable position in the future, you may not realize it until it is too late for your muscles to help you correct course. This can increase the risk of you to spraining your ankle again and again. As a result, the ligament doesn't ever get a chance to fully heal and return to its' normal length.

That is a problem for our brains. The second reason our nervous system is to blame for the tendency to sprain an ankle repeatedly is that the brain relies on expectation. Our brains develop certain plans for how we move. When a child first learns to walk, they often wobble and have to catch their balance. As they walk more and more, they get more stable and coordinated over time. The brain develops a certain plan for walking. It knows how much force each muscle needs to produce and at what time in order to create a smooth movement.

When we sprain an ankle, the plans for how to move our ankles that our brains have developed for years all of a sudden don't work anymore. The old plans relied on the ligament to provide a certain amount of stability in the joint. Once the ligament is stretched out, it doesn't hold the same amount of tension to support the joint that it did before.

Fortunately, the body has a back-up stability system. When the ligament changes, the muscles have to learn to adapt to work differently to stabilize the joint. If you had adequate strength in your muscles before, they don't necessarily have to get stronger in order to do the job of supporting your joint. They just have to learn how to coordinate their movement and strength in a new way.

Developing new plans takes time and intentional repeated movement for the brain to build new habits. This is where physical therapists come in. The design targeted exercise plans to help you re-learn how to use your ankle again. They look for coordination problems and prescribe exercise programs to address them.

For example, a physical therapist might ask you to go up on your tip toes during your evaluation. After an ankle sprain, frequently, the ankle you sprained will bow out to the side or "invert" without you even realizing it. This is a position that can put you at risk to sprain your ankle again.

To correct this, the therapist might give you exercises to practice that encourage your muscles to hold your ankle in neutral, such as squeezing a tennis ball between your ankles while you rise up on your tip toes.

For a person who is otherwise healthy before spraining their ankle, the recovery process is fairly quick. With the right physical therapy for a few weeks, your muscles support the joint well and your ligaments can heal. Repeated ankle sprains don't have to be a part of your life.

Ehlers Danlos and Hypermobility

For people with a Hypermobility Spectrum Disorder (HSD), the most commonly know of which is Ehlers Danlos (EDS), recovery can be a bit more complicated. The baseline level of flexibility of the ankle ligaments isn't the only factor. People with hypermobility disorders may also have loose ligaments in the joints in the foot, as well as the knee.

Your physical therapist should look at the mobility in your feet and your knees. They may give you exercises for those muscles and joints in addition to your ankle. Temporarily, they may also encourage different footwear or braces. Bracing is not the best option for everyone, and the type of brace is important. (See: To Brace or Not to Brace). It's best to work with your therapist in finding a brace rather than simply buying one at the local drug store.

It may even be necessary to evaluate your hips and pelvis. Many people with hypermobility struggle with hip and pelvic pain. Unfortunately, due to the more intimate location of those symptoms, they are often never discussed with a doctor. When it comes to the nervous system however, they are intimately related. In fact, the part of the brain that processes information for the foot and ankle is right next to the part that processes information for the pelvis. If you are experiencing persistent foot and ankle pain, despite doing all the orthopedic rehab your PT has recommended, it may be time to see a pelvic PT especially if you also have problems with urinary incontinence, bowel problems, or pain with penetration like using tampons or during intercourse or gynecology examinations.

People with EDS that impacts the vascular system can also have problems with blood flow. Even for hypermobility patients who don't have vascular EDS, they also commonly have problems with Raynaud's phenomenon, or dysautonomia related conditions like POTS which can impact their circulation and delay healing.

In general, our bodies heal themselves naturally by sending nutrient rich blood to supply the tissues in repairing themselves. Most people who sprain their ankle notice swelling on the outside of their ankle that makes it stiff and sore.

The ankle is far from the heart, and typically is lower than the heart for most of our day. As a result, getting good blood flow to our feet and ankles is challenging, and it may take longer for the swelling to go down in your ankle than it would if you had swelling in your shoulder.

For people with hypermobility who also have circulatory issues, the body may need some extra help to get good blood flow to the ankle to help it heal. Elevating the ankle when you're sitting, using compression socks, and ice packs may be needed to manage the swelling. If this still isn't enough, a physical therapist certified in dry needling may need to help facilitate blood flow using dry needling to direct the circulatory system.

For people with hypermobility disorders, delayed healing is common. The ligaments may not tighten back up easily, even if the muscles do hold the ankle in a good position and circulation is well managed. Balance and coordination training exercises may need to be a regular part of life for people with hypermobility.

The healthcare system and insurance companies have traditionally seen physical therapy as a reactive treatment in response to an injury. People with hypermobility may need a different approach to consider physical therapy as a preventative part of their regular treatment plan. It is generally recommended to get an annual physical with your primary care doctor, and regular cleanings/exams at the dentist.

For people with hypermobility, a preventative care screening appointment with a physical therapist may help prevent injuries before they happen. The best defense against long and inconvenient healing times is to prevent the injury in the first place. This is especially true for kids and adults who want to participate in sports.

Disclaimers: This article is intended for educational purposes and is not a replacement for individual medical advice from a licensed healthcare provider. If you are interested in personalized recommendations for your unique situation, click to book online and schedule an evaluation appointment with a physical therapist.


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