No pain does not mean a healed ankle sprain

During a form shooting drill my my u20 team last night, I walked over to a player and asked about his ankle.

“When did you hurt your ankle?
“It’s fine,” he answered.
“When did you hurt it?”
“Last year, but it’s fine now,” he reassured me.
“It’s affecting your performance,” I said. 

When he bends to shoot, his left heel comes of the floor. You often see this with individuals when they learn to squat: they cannot keep their heels flat on the ground. This can be a sign of tightness somewhere in the chain – hip flexors or calves usually – but with basketball players, it is often a sign of a past ankle sprain.

When players sprain an ankle, they tend to pay attention to pain. They limit activity and the range of motion of the ankle – they limp. When it does not hurt, they resume normal activities. However, the absence of pain does not mean that the ankle has returned to 100%.

This is the mistake that athletes make. In May, I listened to Dr. Adrian Luow’s presentation titled “A Neuroscience Approach to Low Back Pain” at the Boston Sports Medicine and Performance Group conference. He said that pain is a construct of the brain and is a perception of threat. He added that when you roll your ankle, your ankle (proprioceptors and nerves) tell your brain danger, not pain.

If pain is a construct of the brain, the absence of pain would have nothing to do with the health of the ankle. He added that thinking about pain creates more pain. Once the initial threat has subsided, the feelings of pain diminish. Once the feelings of pain subside, the athlete is willing to put pressure on the foot and start to walk. When he walks on the foot, and there is no pain – the danger has been removed – he feels like he is 100%, and he begins to resume normal activities.

Unfortunately, between the trauma of the injury and the immobilization during the recovery — whether explicit (brace, boot) or implicit (limping) — the athlete returns with an ankle that is less than 100%. Stability has been reduced due to the trauma, and range of motion has been decreased due to the immobilization and any residual scarring from the injury and recovery. Returning to training may or may not improve stability and range of motion — a lot depends on the type of training. To be certain of a 100% return, the athlete should engage in some ankle rehabilitation exercises.

This video shows some basic exercises to use:

For those without resistance bands or a lacrosse ball (though I recommend all of my players to have a lacrosse ball or at the very least a tennis ball), I use the old standby: stand on one foot and draw the alphabet with the other foot. Standing on one foot is the stabilization/strengthening aspect, and drawing the alphabet (exaggerate the size of the letters) is the range of motion component. Start with eyes open and hands on hips; progress to eyes open and hands on head; finally, progress to eyes closed and hands on head. Once an athlete can hold his or her balance through the alphabet with his or her eyes closed, the ankle’s stability likely has returned to 100+% of pre-injury. To check for range of motion, do full squats. If the athlete can do a full squat with his or her toes pointed forward, there is likely sufficient range of motion.

The final concern, however, especially with an athlete like mine who has gone a year since his injury with reduced range of motion, is to redevelop the correct motor pattern. Due to the injury, he has adapted a motor pattern with a reduced range of motion. Once he recaptures a full range of motion, he has to incorporate that full range of motion into his skill. Right now, when he bends, his left heel lifts off the ground. Once he has the range of motion, he has to practice shooting without this lift – as he bends for a free throw, his feet should stay relatively flat on the ground (dorsiflexed ankles), so that he has the full ankle extension to power his shot. This is the same re-learning as if I wanted him to change his hand placement on the ball or concentrate on not thumbing the ball with his off-hand. He has to re-learn his motor pattern and re-adapt to the more optimal movement once he has the ability to move through a full range of motion.

By Brian McCormick, PhD
Director of Coaching, Playmakers Basketball Development League
Author, The 21st Century Basketball Practice


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