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To what extent does intrinsic foot muscle strengthening enhance

rehabilitation outcomes for ankle sprains?

Chapter · June 2015

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 QUESTION 27

François Fourchet, PT, PhD; Darren James, PhD; and

Patrick O. McKeon, PhD, ATC, CSCS

The primary objective for the health care provider in rehabilitating a patient fol-
lowing a lateral ankle sprain is the restoration of full ankle joint range of motion
and neuromuscular coordination to the preinjury state. It is known that 85% of
all ankle sprains occur in the lateral ligaments of the ankle, and reinjury rates are
known to be as high as 70% in certain sporting populations. Such recurrence is
termed chronic ankle instability and is believed to be a combination of mechanical
and functional factors. A very important consideration for ankle sprains is that no
muscles directly attach to the talus, which means that all the dynamic stability of
both the subtalar and talocrural joints comes from contributions of muscles that
attach or originate in bones above or below these joints. Functional instability of
the ankle joint is defined in sufferers who experience one or more of the follow-
ing: impaired postural control, neuromuscular deficits, proprioceptive deficits, and
strength deficits.
Currently, all foot and ankle exercises prescribed by the American Academy of
Orthopaedic Surgeons (http://orthoinfo.aaos.org/topic.cfm?topic=a00150) during

McKeon PO, Wikstrom EA, eds. Quick Questions in

139 Ankle Sprains: Expert Advice in Sports Medicine (pp 139-142).
© 2015 SLACK Incorporated.
 140 Question 27

phase 2 of rehabilitation from grade 1 and 2 ankle sprains essentially target the
extrinsic foot muscles (EFMs) to help the athlete regain an adequate level of ankle
joint stability. The premise for this rationale is that all of these muscles cross the
ankle joints and therefore may enhance the dynamic control of the ankle. However,
on the basis of the high recurrence rate of ankle sprains, it appears that these
rehabilitation recommendations may be inadequate. A group of muscles that have
received far less attention in the literature on ankle sprain rehabilitation are the
intrinsic foot muscles (IFMs): those muscles that both originate and insert in the
foot. These muscles are much smaller than their EFM counterparts but may play
a much different and necessary role in proper foot function.1 The functional rela-
tionship of the IFMs and EFMs has led to the theory that these muscles function
as a core system, similar to the lumbopelvic core system.1 The IFMs function as
the local stabilizers of the foot, whereas the EFMs function as the global movers.
On the basis of their electromyographic activation profiles, the IFMs function to
stabilize the foot-ankle complex during single-limb stance and propulsion during
walking and running. Because the IFMs are most commonly neglected in the
ankle sprain rehabilitation process, an essential element of foot core stability is not
addressed. The purpose of this chapter is to provide a guide for incorporating foot
core training in ankle sprain rehabilitation.
One of the key exercises in foot core training is the “short foot exercise.”1 In this
exercise, the patient is asked to contract the IFMs in an isolated manner to raise the
medial longitudinal arch. This technique is akin to the abdominal draw-in maneu-
ver during lumbopelvic core training. As the patient learns to activate the IFMs
through the short foot exercise in a seated position, the demands of the exercise
are gradually progressed to more challenging activities in double- and single-limb
standing and landing. Four weeks of short foot exercise training has been shown
to improve both local foot postural control (maintaining an arch during stand-
ing activities) and dynamic single-leg balance. Also, short foot exercise training
has been shown to enhance self-reported function in patients with chronic ankle
instability.2 Training the IFMs appears to be an important component for a foot
and ankle rehabilitation program, but a major challenge for clinicians is getting
patients to understand how to isolate and activate them. Proper instruction in the
short foot exercise technique is essential for its success, but many patients struggle
to isolate these muscles.
A complimentary modality for the short foot exercise is neuromuscular electrical
stimulation (NMES) of the IFM, which appears promising as a tool in rehabilita-
tion. In essence, this approach can be used to educate patients during the initial
stages of rehabilitation by allowing them to understand the precise biomechanics
of foot function with involuntary activation of the IFMs rather than trying to
have them figure out how to activate these muscles voluntarily. NMES has been
To What Extent Does Strengthening Enhance Rehabilitation for Ankle Sprains? 141

Figure 27-1. Localization of the electrodes under the medial longitudinal arch of the foot
(a)4-6 and at the AH level (b).3 (Figure 27-1a from Fourchet F, Kilgallon M, Loepelt H, Millet
GP. Plantar muscles electro-stimulation and navicular drop. Sci Sports. 2009;24:262-264.
Copyright © 2009 Elsevier Masson SAS. All rights reserved.)

reported to increase neural activation, and strengthen human skeletal muscle,

complement voluntary exercise and has been posited as a rehabilitative tool for
pathologies that compromise normal neuromuscular function.3 The incorporation
of an NMES protocol on the IFMs with muscle strengthening over several weeks
of IFM training has been shown to enhance foot postural control and plantar pres-
sure profiles during running.4,5
In both cases, we found promising results confirming that NMES to the medial
longitudinal arch (Figure 27-1) had an effect as it prevented arch collapse and
hyperpronation in dynamic conditions. It is apparent that this type of training
has an impact on the foot core system. Positive results were also observed when
NMES was delivered to a specific IFM, namely the abductor hallucis (AH).3,6 This
muscle’s activation profile is regarded as a surrogate for all medially located IFMs;
moreover, it has the largest cross-sectional area and is the strongest muscle within
the foot.1 After only a 20-minute session of NMES, significant alterations in plan-
tar pressure distribution were observed while subjects maintained a static stance
position.6 These results (greater rear-foot inversion and a higher arch) led Gaillet
et al6 to conclude that enhanced balance control is associated with AH stimulation.
On the basis of these results and those from short foot exercise training, the incor-
poration of NMES with short foot exercises to restore proper foot core strength
should be considered when designing rehabilitation programs after ankle sprain.1 A
logical shift from NMES to voluntary activation of the IFMs during rehabilitation
progression is also recommended.
From the evidence presented in this chapter, it is important to consider foot core
training in ankle sprain rehabilitation. The incorporation of NMES can help to
educate patients about proper activation of the IFMs if they are unfamiliar with
 142 Question 27

the short foot exercise or these muscles have been inhibited due to injury. Central
to its inclusion as a complementary technique is the reported “neural” effect with
use, which is in essence the primary objective in rehabilitation following a lateral
ankle sprain. Restoring the dynamic nature of the foot is critically important for
enhancing the ability to cope with changing environmental and task demands and
may be a missing link in the rehabilitation of ankle injuries.

References
1. McKeon PO, Hertel J, Bramble D, Davis I. The foot core system: a new paradigm for under-
standing intrinsic foot muscle function. Br J Sports Med.
2. Drewes LK. Effects of rehabilitation incorporating short foot exercises on functional out-
comes for chronic ankle instability [doctoral dissertation]. Charlottesville, VA: Human
Services, University of Virginia; 2009.
3. James DC, Chesters T, Sumners DP, et al. Wide-pulse electrical stimulation to an intrinsic foot
muscle induces acute functional changes in forefoot-rearfoot coupling behaviour during
walking. Int J Sports Med. 2013;34:438-443.
4. Fourchet F, Kuitunen S, Girard O, Beard AJ, Millet GP. Effects of combined foot/ankle elec-
tromyostimulation and resistance training on the in-shoe plantar pressure patterns during
sprint in young athletes. J Sports Sci Med. 2011;10:292-300.
5. Fourchet F, Kilgallon M, Loepelt H, Millet GP. Plantar muscles electro-stimulation and navicu-
lar drop. Sci Sports. 2009;24:262-264.
6. Gaillet JC, Biraud JC, Bessou M, Bessou P. Modifications of baropodograms after transcuta-
neous electric stimulation of the abductor hallucis muscle in humans standing erect. Clin
Biomech (Bristol, Avon). 2004;19:1066-1069.

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