Understanding ankle hypermobility

Estimated reading time: 9 minutes Lateral ankle sprains are one of the most common injuries that occur with activities and recreation in the general population (not considering hypermobility). Up to 70% of people that sprain their ankle have recurring ankle sprains and chronic symptoms (1). I find this is a common issue in the hypermobile population and something I often address with my clients.

When I first trained in Pilates back in 2007, the feet weren’t really mentioned. Of course, we learnt the anatomy of the foot – bones, muscles, and ligaments and were given a few foot exercises like scrunching up a scarf with the toes. I could tell you all the bones in the foot but how this actually translated to real moving bodies was a mystery.

In reality, I started to see lots of feet moving in the classes I taught. And everyone moved differently! Some people couldn’t flex their ankles, some people couldn’t stand with their feet facing forward, some people only felt comfortable with their feet and ankles turned out, some people had very flat feet and their ankles rolled inwards and some people really struggled with balance work or exercises like heel raises. Then, add in the complexity of hypermobility and laxity of the ankle joints, and that is another issue to manage.

I wanted to know why I was seeing all these different presentations and foot capabilities in my clients. I had started to see some similarities in my hypermobile clients’ ankles and a large number of ankle strains, sprains, torn ligaments, ankles giving out and rolling over. That’s when I found Gary Ward, author of What The Foot and all-round foot in motion expert. After his training back in 2012, things started to make a lot more sense and I was able to devise really effective strategies for my hypermobile clients with ankle laxity.

I am a huge fan of feet and will always start at the feet and work up. The feet are our foundations. Let’s delve deep into what issues ankle laxity can cause.

Defining ankle hypermobility

Ankle anatomy

The ankle joint is formed at the joining of the tibia and fibula bones of the lower leg with the talus bone of the foot. The ankle is stabilized by several strong ligaments. The anterior talofibular ligament is the weakest of the ligaments on the outer (lateral) side and is the most frequently sprained (2). There are 12 muscles involved in the motion of the foot and ankle that originate within the leg and insert in the foot (3).

OpenStax College, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons

The ankle is more than a simple hinge joint but allows movement in multiple directions (3). The ankle allows the foot to adapt to the surface it is walking on and does this through different types of movements: plantarflexion (pointing the foot down), dorsiflexion (flexing the foot up), inversion (rolling the foot inward), and eversion (rolling the foot outward), and abduction (away from the center body) and adduction (towards the center of the body). Different combinations of these movements together with the foot lead to supination and pronation (3).

When is an ankle hypermobile?

Studies indicate a “typical” range of motion for dorsiflexion to between 10-20 degrees and 40-55 degrees for plantarflexion. This likely varies with geographic range, differences in activities of daily living, and method of assessment (3). The range of motion will also change naturally with age.

Ankle hypermobility occurs when there is movement beyond the normal range of motion. In the ankle, ligament laxity may be assessed by clinicians using the anterior drawer test (4). The anterior drawer test is often used to assess for anterior talocrural ligament laxity following lateral ankle sprain (5). In people without connective tissue disorders, a single lateral ankle sprain can result in injury to the ATFL, leading to increased motion of the joint and localized hypermobility of the ankle (1).

Studies using ultrasound found differences in the ATFL in people with generalized joint hypermobility. Researchers report that in uninjured ATFLs, there is often a loose wavy pattern in the ligament in patients with high Beighton scores (a scoring system used to assess hypermobility in some major joints). They found that the height and length of the ATFL were different at both rest and stress between the hypermobile group (n=20) and the non-hypermobile group (n=24). There was also a correlation with the Beighton score, with those having higher Beighton scores (more hypermobile joints) having stretchier and flatter ATFL (6).

Identifying signs and symptoms of hypermobility

Professor Rodney Grahame, hypermobility expert, states people with joint hypermobility syndrome often have a tendency for ankle sprains, and that ankle instability is one of the signs of hypermobility that is often present in childhood (7). Recurring ankle sprains and rolling the ankle frequently may be an indication that ankles are hypermobile. Some even use recurrent sprain as one sign (though not on its own) of joint hypermobility syndrome (8).

If there is looseness or instability in the ligaments that support the ankle joint, we can assess there is ankle joint laxity. The connective tissues in hypermobility can make it easier for the ankle ligaments to stretch and become injured. The ankle joint is an important weight-bearing joint. If we lose alignment at this joint due to laxity and of course gravity pulling the ankle out of alignment, then the foot will be compromised but so will the knees, hips, and so on up the chain.

This can be assessed by a PT or physio but some symptoms include:

• Excessive range of motion
• Recurrent sprains
• Frequent “ankle rolling”
• Instability
• Pain
• Clicking and Popping

How hypermobility impacts foot mechanics

Foot mechanics will be hugely impacted by hypermobility and EDS. We mentioned the impact of gravity earlier – that is a constant presence that is allowing the foot to collapse into the ground in the presence of hypermobility.

If you listen to my interview with Gary Ward, we talk maybe a little controversially, about the fact that hypermobile feet are not pronated feet, but rather collapsed feet. Pronation is a very specific three-dimensional action that is part of healthy foot mechanics, but the feet I see in the clinic do not present as pronated or overpronated. They present as sliding into the midline and collapsing.

I teach my hypermobile clients how to pronate their feet in a healthy way and introduce supination of the foot to them, often for the very first time. Once we can do that, gait and foot mechanics start to become easier.

With poor foot mechanics due to hypermobility, you may experience foot and ankle pain. We have three arches in the foot and these can often flatten in hypermobility. The three arches are the Medial Longitudinal Arch, the Lateral Longitudinal Arch, and the Anterior Transverse Arch. If you have pain in the front of your foot when walking barefoot, take a look at the transverse arch – it is often troublesome in hypermobile feet.  Without good arches, the foot then lacks bounce and the ability to absorb the force of walking. It is estimated the foot bears the force of about 5 times the body weight during normal walking (3)!

You may also experience recurrent ankle sprains, with inflammation and swelling. I often see very tight calf muscles in my hypermobile clients, largely due to poor foot mechanics.  Stretching the calves is not the only answer!

With ankle instability, balance can be challenging and scary for many people. But this is why balance is the fifth principle in my Integral Movement Method (IMM) – walking itself is an act of balance. I focus on helping people feel safe so that they feel able to walk more comfortably.

Risks and complications of ankle hypermobility

We need to be aware of a few risks associated with ankle instability”

• Frequent ankle sprains: this is so common. The loose ligaments make it easier for the ankle to roll over.
• Pain and swelling: this may happen not just because of injury but also because of daily activities. When the foot and ankle are not aligned well, we could be overworking or collapsing into these joints. There could be excessive joint motion and irritation of the soft tissues.
• Tendinitis and overuse: inflammation is common when the tissues are under constant stress and misuse. I always check the alignment of my client’s Achilles Tendons – it tells me so much about what is going on.
• Early onset osteoarthritis: the cartilage can wear down with repeated sprains. Posttraumatic arthritis after injury is more common in the ankle than the hip and knee (3).
• Balance issues and lack of proprioception: sometimes we are not aware of where our ankles are in space or how they should be aligned. This is something we can work on.
• Morton’s Neuroma: I see these quite frequently in clinic. This affects the ball of the foot and involves the thickening of the nerve leading to the toes. It is often caused by irritation and excess pressure.

Muscle weakness and fatigue

Muscle weakness and fatigue can accompany ankle instability, especially if there has been a history of ankle sprains. Understandably, people will want to avoid loading or weight bearing on an ankle joint that has ‘given way’ on them many times before. This can lead to compensatory patterns in how we stand and walk. This could mean some muscles are going to be overworking and they will fatigue. Other muscles may not be working enough, and may also complain as they start to decondition.

The muscles around the ankle will be particularly impacted. Peroneal muscles, calf muscles, and tibialis anterior have to stabilize the joint. They could become overworked and fatigued. Remember a fatigued muscle will pretty much always let us down at some point.

If you’ve had repetitive injuries, and many hypermobile people will have, this may lead to muscle weakening and the muscles being unable to give the necessary support to the ankle joint.

This could all result in slower reaction times – like tripping up or slipping on a curb quickly. Uneven surfaces could become more problematic as the foot and ankle need to deal with a challenging walking surface. This is why addressing ankle instability is really key to hypermobility management.

Managing ankle hypermobility effectively

To manage ankle hypermobility we need to work on alignment, stabilization, and strength.

• Physical therapy can be helpful if you are recovering from an injury and need help with that rehab with some manual therapy. They can also help with taping and support for the ankle.
• Exercises are going to be key for effective long term management. We can’t neglect our exercises once PT is finished, especially if you have a history of ankle injuries. I list some exercises below plus links to my foot classes on YouTube.
• Balance training: in people with hypermobility was also shown to lead to fewer ankle sprains and improved muscle strength (9).
• Supportive footwear and orthotics may be needed to help protect and support the ankle.
• Gait analysis is beneficial: how we walk may lead to inefficient loading of one side of the body. Learning to walk in a balanced way can help prevent further injuries.
• Bracing and taping: Research has shown in people with a history of lateral ankle sprain, bracing and taping leads to a lower incidence of recurrent sprains. It is hypothesized to be a result of either mechanical support or improved proprioception (1).
• Some people may need surgery for a ligament repair if all other options have not worked.
• Be consistent: try to be mindful of how you stand, and keep up with the exercises to maintain stability and strength. We have a number of classes in The Zebra Club focusing on gait, standing, and the lower limb.

Choosing proper footwear and orthotic support

Podiatrist Sophie Roberts and Dr. Alan Hakim write that in hypermobility, orthotics help improve proprioception, help with ankle stability and recurrent sprains, and help with issues further up the kinetic chain (like the knees, hips, and back) (10). Working with a podiatrist or orthotist to get custom orthotics can help support stability in the foot and ankle. Supportive footwear is also a great idea.

Sophie Roberts joined us for a member meet-up in The Zebra Club to discuss the role of podiatry in hypermobility and provided useful information on both orthotics and footwear. Members can find this presentation in the Presentations folder in the Resources Section of the app

Exercises to improve strength and stability

I always prescribe foot and ankle exercises for my hypermobile clients – even if they haven’t had recurrent injuries. Stability of the foot and lower limb are so important to stability further up the chain.  Gary Ward says “when the foot hits the ground, a whole body reaction occurs” and I agree with that. A good connection and a stable, yet mobile connection with the ground is so important.

• I love a simple Rock and Sway exercise in standing to help people find their centre when upright. This can really help with alignment and balance.
• Heel raises and holding a tennis ball between the ankle joints can be really helpful for control and strength.
• I love using resistance bands and loop bands for the feet – we have a whole set of classes for the feet in The Zebra Club.
• Balance exercises when ready – starting with standing on one leg, progressing to hedgehogs and sitfits.
• It is really important to learn how to load the joint safely and how to decelerate the movements to avoid injury. Take a look at my live foot class for more foot ideas on loading the tissue.

Here is quick 5 minute video focused on foot and ankle stability.

FAQ

How do you know if your ankles are hypermobile?

Hypermobile ankles often present with frequent sprains. There are specific assessments that can be done by a PT to test the range of motion in the ankle joint. Excessive range, instability, pain, clicking and popping sounds could all be signs of instability.

How do you fix hypermobility in the ankle?

Fixing may not be the correct word – it is more a case of managing hypermobility in the ankles. There are strategies to support hypermobile ankles like bracing and orthotics. There are exercises we can do to support ankles by working on proprioception, balance, and strength.

How to strengthen hypermobile ankles?

Working on alignment, proprioception, awareness, and exercises that target balance, stability, and strength are key to building strength in the ankle joints.

Literature review by Catherine Nation, MSc, PhD

Works Cited

1. Hubbard & Wikstrom (2010) Ankle sprain: pathophysiology, predisposing factors, and management strategies. Open Access Journal of Sports Medicine.
2. Manganero & Alsayouri (2023). Anatomy, Bony Pelvis and Lower Limb: Ankle Joint. National Library of Medicine, NCBI, StatPearls.
3. Brockett & Chapman (2016). Biomechanics of the ankle. Orthopaedics and Truama 30:3.
4. Nicholson, et al. (2022). International Perspectives on Joint Hypermobility A Synthesis of Current Science to Guide Clinical and Research Directions. Journal of Clinical Rheumatology.
5. Croy, et al. (2013) Anterior Talocrural Joint Laxity: Diagnostic Accuracy of the Anterior Drawer Test of the Ankle. Journal of Orthopeadic and Sports Physical Therapy.
6. Song, et al. (2020). Evaluation of the uninjured anterior talofibular ligament by ultrasound for assessing generalized joint hypermobility. Foot and Ankle Surgery.
7. Grahame, R. (2009). Joint Hypermobility Syndrome Pain. Current Pain and Headache Reports.
8. Simpson, M. (2006). Benign Joint Hypermobility Syndrome: Evaluation, Diagnosis, and Management. Journal of the American Osteopathic Association.
9. Hou, et al. (2023). Balance training benefits chronic ankle instability with generalized joint hypermobility: a prospective cohort study. BMC Musculoskeletal Disorders
10. Roberts & Hakim (2024). Chapter 75: Painful heels, and tired and clumsy feet Poor biomechanics in the feet causing localized pain, poor gait, and fatigue when walking. Symptomatic Editors: Clair A. Francomano, Alan J. Hakim,

Jeannie Di Bon

Jeannie Di Bon is a movement therapist, educator and author specializing in hypermobility, Ehlers-Danlos Syndrome and chronic pain. She is the founder of The Zebra Club app and the creator of the Integral Movement Method.