Three Ways Ankle Sprains Cause Chronic Knee Pain

The ankle sprain is the most common acute injury in competitive athletics, while the knee is the most chronically injured joint. Coincidence – I think not.

The question:

How does an ankle sprain lead to chronic knee pain, such as runner’s knee, jumper’s knee, Osteochondral defects, and/or general patellofemoral pain?

Three simple answers:

1. Anterior positional faults to distal fibula and talus are likely following inversion ankle sprain. (1, 2)

a. Anterior positional faults lead to decreased ankle dorsiflexion. (3)

b. Limited dorsiflexion linked to increased knee valgus movement during functional tasks. (4)

c. Chronic knee valgus movement is primary cause in chronic knee pain syndromes.(5)

2. Individuals with chronic ankle sprains have ipsilateral gluteus medius weakness and decreased hip stability. (6)

a. The gluteus medius controls deceleration of femoral internal rotation and adduction. (7)

b. Femoral internal rotation and femoral adduction yields obligatory knee valgus moments.(7)

c. Chronic knee valgus movement is primary cause in chronic knee pain syndromes.(5)

3. Ankle sprains yield mechanical shortening of lateral gastrocnemius, TFL, and biceps femoris. (8)

a. Through altered reciprocal inhibition, the gluteus medius, medial gastrocnemius and medial hamstrings are weak. (9)

b. The altered neuromuscular firing leads to altered arthrokinematics.(10)

c. Chronic knee valgus movement is primary cause in chronic knee pain syndromes.(5)



Summary:

It is prudent rehabilitation professionals completely restore optimal mechanics following ankle sprains. Subtle changes, like positional faults, muscle inhibition, and mechanical shortening of tissue can easily go undetected. This triggers a myriad of injuries through the kinetic chain. I look forward to your feedback and commentary.

References:

Hubbard TJ, Hertel J. Anterior Positional Fault of the Fibula after Sub-acute lateral Ankle Sprains. Manual Therapy. 2008; 13: 63-67. Mulligan, E.P., Evaluation and management of ankle syndesmosis injuries. Phys Ther Sport, 2011. 12(2): p. 57-69. Landrum, EL, Kelln, BM, et al. Immediate Effects of Anterior-to-Posterior Talocrural Joint Mobilization after Prolonged Ankle Immobilization: A Preliminary Study. J Man Manip Ther. 2008; 16(2): 100–105. Fong, CM, Blackburn, JT, et al. Ankle-dorsiflexion range of motion and landing biomechanics.JAT. 2011; Jan-Feb;46(1):5-10. Lankhorst NE, Bierma-Zeinstra, SMA, and van Middelkoop, M. Factors associated with patellofemoral pain syndrome: a systematic review. Br J Sports Med. 2013;47:193–206. Friel, K, McLean N, Myers, C, and Caceres, M. Ipsilateral Hip Abductor Weakness After Inversion Ankle Sprain. J Athl Train. 2006; 41(1): 74–78. Lloyd, ML, Willson, JD, et al. Hip Strength in Females With and Without Patellofemoral Pain. J Orthop Sports Phys Ther. 2003;33:671-676. Bell, DR, Padua, DA, & Clark, MA. Muscle strength and flexibility characteristics of people displaying excessive medial knee displacement. Arch Phys Med and Rehab. 2008. 89(7):1323-8. Sarhmann, SA. Diagnosis and Treatment of Movement Impairment Syndromes. 2002. St. Louis, Mosby. Bell, DR, Clark, MA, Padua, DA, et al., Two- and 3-Dimensional Knee Valgus Are Reduced After an Exercise Intervention in Young Adults With Demonstrable Valgus During Squatting. Journal of Athletic Training published online first, 2013.