Three Ways Ankle Sprains Cause Chronic Knee Pain

knee_patella_intro01The 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:

  1. Hubbard TJ, Hertel J. Anterior Positional Fault of the Fibula after Sub-acute lateral Ankle Sprains. Manual Therapy. 2008; 13: 63-67.
  2. Mulligan, E.P., Evaluation and management of ankle syndesmosis injuries. Phys Ther Sport, 2011. 12(2): p. 57-69.
  3. 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.
  4. Fong, CM, Blackburn, JT, et al. Ankle-dorsiflexion range of motion and landing biomechanics.JAT. 2011; Jan-Feb;46(1):5-10.
  5. 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.
  6. 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.
  7. Lloyd, ML, Willson, JD, et al. Hip Strength in Females With and Without Patellofemoral Pain. J Orthop Sports Phys Ther. 2003;33:671-676.
  8. 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.
  9. Sarhmann, SA. Diagnosis and Treatment of Movement Impairment Syndromes. 2002. St. Louis, Mosby.
  10. 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.

17 thoughts on “Three Ways Ankle Sprains Cause Chronic Knee Pain

  1. movewellfit

    Hey Josh,

    Great info. Dude! I think there is a typo: you said the medial calf, hamstrings are glute med are inhibited due to altered reciprocal inhibition. Perhaps you meant to say they are weak??

    I hope all is good with your family and u!!

    P.s. your skins should make some noise if rg3 stays healthy.

    Date: Fri, 2 Aug 2013 18:58:55 +0000 To: maurice@movewellfit.com

    Reply
  2. Confused and appreciative

    I’ve never been able to diagnose what is wrong with my right knee other than it hurts when I use it at all vigorously on the inside of the kneecap. Recently I realized my right ankle has been sprained repeatedly and is permanently looser or more flexible than my left. I strongly believe that my ankle injuries are causing a situation for my knee to hurt when I jog or walk a lot. My knee pain is also activated by running my ankle through its range of motion with no weight on it. This doesn’t happen with the less injured less flexible left ankle and left knee. I can’t afford an MRI but it seems likely that my knee is not the cause of the knee pain??? I used to be a runner, but can’t run anymore. I’m 43 and I first sprained my ankle severely when I was 22 since then I have rolled it significantly maybe 10 times. Not sure what I can do to stop the knee pain. Physical therapists couldn’t find anything fundamentally wrong with my ankle. I swim now to keep my weight down and get exercise and get cardio but I would love to run regularly as well. I would appreciate any insight you have into how my ankle sprains could be related to my knee pain.

    Reply
    1. Joshua Stone Post author

      First and foremost, thank you for this comment. I apologize for the long delay in getting back to you. I was not notified of this comment and it just sat there in my spam folder.

      I think you might be on the right track. It is very possible that your ankle issue has led to knee injury. I’ve seen it happen many times.

      I train many clients virtually. I can use Skype or Google Hangouts. I can perform a functional assessment and then if I find functional deficit I can set you up on a training program. Based on your description, I believe we can find something.

      If interested please contact me at JoshStoneATC@gmail.com

      Reply
  3. Same guy

    Meant to say PT’s and a doctor couldn’t find anything fundamentally wrong with my knee or my ankle.

    Reply
  4. Rudy

    This is pretty cool. I sprained my ankle about 6 months ago and recently tried running again. My knee began having pain in the front. I never had need pain before. I looked all over the web looking for a possible connection. This article was the first the made sense. Thank you.

    Reply
  5. Marc Uldry

    I am fighting against a lateral RIGHT knee pain (ITBS) since more than 1 year! The very first time happened during a mountain running race while I had my LEFT ankle taped because of little sprain 2 weeks before. Since then I (almost) always felt a small pain, let’s say a discomfort, on my external right knee. Several months later, during a mountain running race again, I sprained my LEFT ankle, this time much more seriously. I stopped running and went for physiotherapie during 2 months. I was pretty sure that my old knee problem would disappear with such a running break. Not at all !! When I restarted running, a stronger pain arised after just 5-7 minutes on the same right knee. My god! Since 4 months I can’t start running again (cycling even let to discomfort). I went to Osteo twice, I got ortho insolde, I make streching and strenghtening exercise 2-3 times a week….but it doesn’t work. I think I can admit, I’m a desperate. Could you help me ? Regards, M.

    Reply
  6. Martin

    I have never connected my knee pain with ankle sprain. It’s been 6 years now I have a knee pain, worsening each year. Several MRI’s, many visits of different orthopaedist’s. They never came with the cause of the problem. My last visit half year ago brought me a diagnosis: Patellofemoral dysplasia Wiberg III, chondromalacia grade II. I asked the doctor what the cause is. He told me that it is genetic predisposition. I asked him if both of my knees are physically equal, and if so, why I had never had a problems with the other knee. He answered “Yes” and “I don’t know”. I like all kinds of sports, I can say I’m addict. Bike, running, beach, climbing, swimming and many others. The knee pain is still there no matter what kind of sport it is. Hurts more while biking and running, less while swimming crawl. I think that in 5 years I will develop invalid. Today I looked at my foot and noticed slightly twisted ankle outwards(only the right ankle of the leg where the knee pain is). I always thought it’s due to knee. And know I’m reading your article and find out it’s the other way. The thing is that just before my knee pain developed, I had multiple ankle injuries, sprains. When I say multiple I mean 6 times a year, pretty serious, both ankles. Do you think that this can be the cause of my problems and what can I do about it? If the right ankle is chronically damaged, how can i help the right ankle to be stable? I don’t feel my ankles right now and it’s been ok for several years in a row, but I have read somewhere that the ligament can be damaged, stiff, the signals from ankle to brain can be affected causing the knee pain as you suggested. Thanks very much for your advice.

    Martin

    Reply
    1. Joshua Stone Post author

      While I have not evaluated you, nor do I know your condition to the full detail, it is possible the ankle issue could be linked to the knee. Make sure you have proper ankle mobility, especially ankle dorsiflexion.

      Reply
    2. Martin

      Almost two years have passed from my post here and the things changed significantly. The last differential MRI in june 2016 showed, that the knee is not worsening, not the cartilage at least. But the orthopaedist came with the “theory” behind my knee pain. I have a hypertrophy of synovial membrane(plika), which causes the mechanical wear of the cartilage and thus the pain. The doctor applied a corticoid injection in the particular area. It was just for diagnosis purpose to prove the diagnosis or to reject it. Probably he was right, because it is 7 months now and I feel much better. That means the most of the time the knee is not in pain at all, 100% functional. I got back to my favourite sports like biking, swimming, climbing, badminton, running. Sometimes when I push too much, the knee gets worse, but unlike before, it gets better after two days, not two weeks, and the pain is not that strong. There is a decision for me to take the surgery or not. Maybe this information will help somebody with his\her problems. Good luck!

      Reply
  7. kristy

    hi i have chronic lateral knee pain for 5 years, (fibula head and proximal tib fib joint and now a little above my knee lateral lower thigh. before i injured my knee i was running with my foot turned in as i had a sore foot and have had many foot injuries previous, my foot isn’t sore but doesn’t feel like my good foot, i have been to many physio, drs surgeons etc and they say that the pain is in my head or nerve pain although I’m sure it is coming from my foot, my proximal tin fib joint is hyper mobile where as my foot is hypo mobile. everyone keeps focusing on the site of pain but not looking at whole picture, any suggestions?

    kristy

    Reply
  8. Pingback: The Ice-less Management of Acute Ankle Sprains | Stone Athletic Medicine

  9. Swati Bathla

    I am 23 year old and I have weak knees after my ankle got twisted while i was doing zumba. Those days i would workout twice a day. I don’t know the exact reason but i am unable to do any form of workout for more than an hour now. Knees would give up. There is always a crackling and crushing sound when i move.
    I went to a local doctor. He prescribed me with Coercip and Lubridol and suggest a few exercises. I am continuing my workout but knees wont feel any better. Please help

    What could be the possibilty?

    Reply

Leave a Reply

Your email address will not be published. Required fields are marked *