Preventing Ankle Injuries for Trail Runners

The Low-Down on Ankles

We’ve all been there…blissfully barreling down an inviting single-track trail, reveling in all of the surrounding beauty, when a root decides to ruin the status quo and send you into the thought spiral of “how long will it take for me to recover from this injury,” “will I recover in time for my 50k next week?”, “yikes, did I break it?!”.  According to a research study conducted in 2022, ankle sprains are the most common acute injury in trail runners, which makes sense considering the terrain that trail runners traverse on a regular basis.  In addition to acute injuries, runners are also very prone to developing overuse injuries, with over 70% of trail running musculoskeletal injuries being due to overuse.  Despite the fast speeds, high impacts, and uneven foot strikes, overuse injuries can certainly be mitigated with effective prehabilitation and rehabilitation programs.  While the jury’s still out as to whether first-time acute ankle sprains can be prevented with effective strengthening programs, it is well-studied that these programs can decrease repeat acute ankle injuries.

“Root-proofing” your Ankle

When we talk about injuries, we have to take multiple structures into consideration.  Injuries can occur to bony structures, ligaments, tendons, muscles, and everything in between.  Injuries can occur due to poor body mechanics leading to stresses being placed on structures that are not developed to handle them; they can occur from limited proprioceptive awareness, leading to the inability to quickly react to unexpected uneven foot placement, fast speeds, and unexpected turns can cause high-impact activity that overpowers a structures tensile strength…ultimately there are many different ways injuries can occur in our bodies, and there are many different ways we can train our bodies to adapt to decrease our risk of injury.  When it comes to the ankle, research shows that balance, strength/stability, plyometric, and proprioceptive training can all decrease the risk of injury while running. Oftentimes, recurrent ankle sprains occur because some of the structures that provide support in our ankles get overstretched from the injury. They can’t sense and respond to small ankle movements like they used to, and many of these exercises are targeted at regaining that 6^th sense if you will. Injury prevention as a general philosophy does need to encompass the entire body and mind, and ultimately is a lifestyle that should be adapted by all athletes, however in this article I will focus on the small but mighty ankle and foot strength and proprioceptive exercises that from research and personal experience I find to be the most effective in mitigating and preventing injury on trails.

Strength and Stability

For strengthening, I like to focus on the lateral ankle muscles and foot muscles.  And don’t worry, these exercises won’t give you Hulk toes, but they will help to improve your overall running form and your lower body’s ability to better handle uneven terrain.  In general, muscle volume has been shown to increase at an average of 8 weeks starting implementation of area-specific muscle training.

Pro-Tec Athletics Resistance Bands | REI Co-op $14.95

Resisted ankle eversion: in a seated position, wrap a resistance band around your foot.  Turn the ankle outward and slowly return to neutral in a sliding motion; it is important to keep the ball of the toe and heel on the ground.

Standing anti-rotation band press: standing with a resistance band secured at chest height, engaging leg musculature, keeping the heel and great toe planted, press band away, and slowly back toward the chest.

Toe curls: seated or standing, use toes to crunch up a towel.

Arch lifts: seated or standing, try to make a “C” shape with your foot, raising the arch into a dome. It is important to try and keep toes uncurled.

Balance and Proprioception

I am tying these two together because, in short, proprioception is essentially the Robin to balance’s Batman.  Balance is achieved through visual, vestibular (think inner ear), and proprioceptive inputs, with proprioception being essentially our body’s ability to understand where it is in space.  With musculoskeletal injury, proprioception is significantly hindered; therefore, it is important to work toward building and re-building these adaptations.  Below are my three favorite proprioception exercises to incorporate into my routine. You don’t have to have a BOSU ball; anything with an unstable surface can work, or you can start on stable ground and progress to uneven surfaces! For an added challenge, you can increase weight, close your eyes, or toss a ball back and forth with a partner.

SLS BOSU dumbbell press: slowly press the weight away from you and then return to the starting position, ensuring to keep your core and glutes engaged as well.

SLS BOSU underleg weight pass: standing on one leg with the other in front, pass the weight under and over the elevated leg

Living the Injury Prevention Lifestyle

While it would be a dream to be able to live and breathe everything running-related, the majority of us are busy with life, so finding time to incorporate all of this into weekly schedules is hard.  As a general rule of thumb, I try to target lower body injury prevention tools like those mentioned in this article once a week and lower body and core strengthening twice per week.  I alternate when I perform my ankle/foot exercises; sometimes I do them fresh, sometimes I wait until I feel like I can’t lift a *toe*, and then make myself do them- performing these activities in a fatigued state helps to replicate conditions we face when out on the trails.  These exercises are designed to target our muscles in more controlled and less controlled conditions and focus on all planes of movement (which, again, is basically the definition of running on uneven terrain!).  All in all, we all just want to be able to enjoy the trees, the scenery, the mountains, the scents, the wind…, and all the beautiful glory our trails have to offer, and hopefully, these exercises will help you to continue forest bathing indefinitely!

**These exercises are intended for runners who are healthy and have not sustained recent injury.  Please seek clearance from your provider if you’re unsure of whether it would be safe to start these.  If you have questions on exercise progressions, what level you should start at, or if you have an acute or chronic injury, find a local physical therapist to help you achieve your goals!

References

-The Prehab Guys

-Dejong AF, Koldenhoven RM, Hertel J. Proximal Adaptations in Chronic Ankle Instability: Systematic Review and Meta-analysis. Med Sci Sports Exerc. 2020 Jul;52(7):1563-1575. doi: 10.1249/MSS.0000000000002282. PMID: 31977639.

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-Huang PY, Jankaew A, Lin CF. Effects of Plyometric and Balance Training on Neuromuscular Control of Recreational Athletes with Functional Ankle Instability: A Randomized Controlled Laboratory Study. Int J Environ Res Public Health. 2021 May 15;18(10):5269. doi: 10.3390/ijerph18105269. PMID: 34063454; PMCID: PMC8156931.

-Vincent HK, Brownstein M, Vincent KR. Injury Prevention, Safe Training Techniques, Rehabilitation, and Return to Sport in Trail Runners. Arthrosc Sports Med Rehabil. 2022 Jan 28;4(1):e151-e162. doi: 10.1016/j.asmr.2021.09.032. PMID: 35141547; PMCID: PMC8811510.

Cover photo from Daybreak Racing’s Mt. Hood Meadow’s Relay, photographer James Holk.

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