Whether you’re an avid runner or not, you’ve likely experienced an ankle problem at one point or another. Perhaps you twisted an ankle during a workout or simply stepped off a curb and “landed wrong.” Ankle sprains are very common injuries, especially if you venture off-road on treacherous trails for a hike or run. Ankle mobility and stability will dictate whether you get back hobbling or not, and keep you from being susceptible to injury in the first place. Strong ankles are all about supportive shoes and doing strength exercises, right? No, actually, they have nothing to do with either, and those philosophies can even increase your chance of an injury.
Your ankle is supported with the help of sturdy ligaments whose job is also to provide mechanical feedback to the rest of your body so you can move efficiently and smoothly. They’re a huge part of proprioception, which, along with your eyes and inner ear, lets your brain know where you are in relation to your environment. The ligaments help support muscles and tendons that store elastic energy for propulsion; they’re not meant for power. When ankles become fatigued, they fail to provide the necessary feedback, and your movements become slow, clumsy, and dampened. A common sign of this is when the ankles (or one ankle) easily roll inward while landing during the gait cycle, maybe not to the point of injury (a sprain), but enough for you to take notice. You may blame it on an uneven surface or some rocks you had to scurry across during a trail run, but ultimately, it comes down to the fact that your body is fatiguing due to a variety of reasons you will soon learn, and your ankles are one of the first places to let you know just that.
Estrogen and Ligaments
Ligaments are often stressed because of failing muscles and surrounding tendons, causing them to work harder than intended. Your ankles and other ligament-prominent areas (knee, shoulder, hand/wrist, foot, and pelvis) are also a key reflection of your health, especially hormonal health, as hormonal levels and fluctuations directly affect ligament receptors and tissue repair. Understanding this will not only help keep you injury-free but will also take your fitness and athletic potential to the next level.
There is a well-researched connection between the hormone estrogen and ligament injuries, specifically knee ACL injuries in women, more than other ligament injuries elsewhere. Joints that are under a mechanical load in the presence of estrogen are known to incur a higher rate of ligament injury due to how the hormone affects collagen synthesis, specifically the formation of fibroblasts, which are cells that make up collagen. (Collagen is the main component of connective tissue, and ligaments are one type of connective tissue.) This connection has been studied in another area of high ligament activity, the wrist, linking carpal tunnel syndrome prevalence to women with estrogen and progesterone receptor activity. Sex hormones such as estrogen and progesterone also affect water retention, and this can increase swelling within the synovium, which is the soft tissue found between joints. Hey, ligaments connect joints! So you can see how these joints can quickly become more injury prone due to pressure changes and alterations in tissue repair as a directly result of hormonal issues.
Though there aren’t any studies linking sex hormones and ankle sprains (at least none that I could find), I don’t need to wait for these studies to make some rational, scientific, and clinical correlations based on what I have seen treating patients with connective tissue injuries. ANY area with connective tissue (yeah, that’s everywhere) is going to be affected by hormone receptors to various degrees. Another and perhaps more important fact is that adrenal stress hormones like cortisol and adrenaline have more of an influence on ligaments than sex hormones, though they all play off each other in hormonal harmony (this will be explained more in a bit). Areas of prominent ligament activity will especially be susceptible, particularly the ankles and knees. The reason for this is that the muscles supporting the knee (as mentioned in the knee injury video) and the tibialis posterior—the major lower-leg muscle that moderates pronation—are closely related to hormonal balance, especially adrenal hormones.
The majority of women tend to be estrogen dominant, often exhibiting signs of PMS, all of which are common yet never normal. PMS is a symptom of a woman’s inability to properly detoxify estrogen, or an imbalance of estrogen with progesterone. Breast tenderness, back pain, menstrual cramps, irritability, and other symptoms are due to sex hormone imbalances. At this time, and for many women, during the luteal phase of the cycle (just after ovulation until the start of menses), a woman may be more susceptible to ligament damage. Yes, hormonal therapies, including oral contraceptives (“The Pill”), will increase the risk factor greatly for ligament-type injuries and damage.
The most common nutrients necessary for estrogen detoxification are vitamin B6 (usually in its active form, pyridoxal-5-phosphate), magnesium, zinc, folate (in its active 5MTHF form), and methylcobalamin (a type of vitamin B12). The amino acid L-cysteine is also vital for liver detoxification of all hormones, and you’ll soon see how this can be a double-edged sword if you’re deficient, as it’s needed for connective tissue repair (yeah, that means your ligaments). Cysteine is plentiful in eggs and whey protein. The herb rosemary can also be very effective in detoxifying estrogen from extrahepatic sources—that’s primarily your adipose tissue (fat stores). The more fat you have, the more estrogen you’ll make, and the more estrogen you make, the more fat you’ll become; not the most pleasant of biochemical systems, but it is what it is.
Men, for the most part, you are not included in the risk factors as much as women, but don’t think you’re necessarily safe from estrogen problems with your ligaments or overall health. More and more men are developing hormonal problems since estrogen-mimicking compounds are so common in the environment and present in various food sources (plastics, anything living in any water, canned foods, and all the processed soy products). Guys have estrogen receptors (some estrogen is normal and necessary), yet too much stress can and will alter testosterone breakdown and shunt it off to estrogen, leading to ligament weakness and other low-testosterone/high-estrogen symptoms, such as erectile dysfunction, low libido, low energy, increased body fat, loss of body hair (including head hair), and a liking for shows on the network Lifetime (just kidding on that last one).
Stress Hormones and Ligaments
The balance of hormones is often more important than overall sufficient levels. Progesterone levels in women and testosterone levels in men are often depleted as the nutrients, enzymes, and other hormones needed to produce these hormones are used to make our major stress hormone from the adrenal glands, cortisol.
The health of adrenal hormones is altered under stress. In the early stages of acute stress, cortisol levels are increased, but as stress becomes chronic or too much for the body to handle, cortisol levels can soon become depleted. The body will essentially steal from other hormones, particularly those sex hormones, in an effort to keep cortisol levels from plummeting too low. Your body, in all of its infinite wisdom, is much more concerned with you getting through the day rather than procreation or even being interested in sex. Of course, ligaments will be affected, not simply because of sex hormone imbalances but also the cortisol load. This is partly due to how cortisol is needed to balance blood sugar and partly because many of the same nutrients needed to break down (detoxify) hormones of all types are also needed to repair tissue, including ligaments. Next thing you know, you have no sex drive and your ankles and knees are killing you. That just sucks.
There’s also an important hormone called aldosterone that your adrenal glands produce. This is a mineralocorticoid that balances electrolytes in your body, specifically sodium and potassium. Any athlete concerned about their health and performance is going to be concerned about their electrolytes, but especially an endurance athlete, as sodium (salt) depletion is very common. This too is an adrenal problem, but it can soon turn into a ligament problem. Under chronic stress, aldosterone levels are depleted along with cortisol, and as that occurs, you’ll lose more sodium. Your body knows this and wants to hang onto some of that sodium, so it takes the sodium that is normally outside the cell and drives it into the cell. Along with that, salt goes fluid, which means increased pressure within the cell membrane (swelling) and yes, within the joint space—once again toying with your ligaments just as estrogen is known to do within the synovial membrane.
Blood Sugar and Ligaments
Adrenal stress will further impact the health of connective tissue, especially ligaments, due to its relationship with blood sugar. Now for a bit (more) of biochemistry and physiology: Blood sugar levels are monitored by cells in the pancreas called the islets of Langerhans. When blood glucose levels fall too low, the body must increase this level via two main mechanisms. The body may convert stored glycogen (sugar) into glucose (termed glycogenolysis), which occurs in the muscle and liver tissue, or it may generate glucose from some noncarbohydrate carbon substrate, such as amino acids, glycerol, or lactate. This process is called gluconeogenesis and occurs primarily in the liver.
Cortisol, produced in the adrenal cortex, will increase protein catabolism (breakdown), which in turn frees amino acids to be used for gluconeogenesis. The excretion of cortisol is synonymous with a stress response. Epinephrine (adrenaline), from the adrenal medulla and glucagon (from the pancreas) promote glycogenolysis, which increases plasma glucose levels by breaking down liver glycogen. Since the liver is the main target organ involved in both the epinephrine effect of glycogenolysis and the cortisol effect of gluconeogenesis, the health of the liver has a lot to do with not only blood sugar and hormonal detoxification and balance, but also connective tissue repair and integrity.
You can see that the more stress you are under, the more cortisol and adrenaline will become problematic and the more glucose (blood sugar handling) problems will result. You may have blood sugar handling problems such as headaches, irritability, waking up at night, or concentration problems. You may have a poor aerobic system or not be able to run well over one hour aerobically without consuming some sugar if you have these hormonal problems. A paleo-type diet is very beneficial here, as is training properly (see the Sock Doc Training Principles) to naturally help balance all hormones and heal all tissues. Major nutrients that are depleted in this hormonal-glucose cycle are magnesium, zinc, chromium, and manganese. L-Cysteine, mentioned earlier, is often depleted too, and this eventually leads to the body’s inability to repair connective tissue. That means you’re either going to get injured or you can’t recover from your current injury.
Stress and Excess Stimuli Alter Proprioception = Injuries
Proprioception and kinesthesia are terms commonly used to describe position and movement. Proprioception is a sense of where your body is, as determined by the conscious feedback it receives from muscular, tendon, and articular sources, and the unconscious feedback from the cerebellum of your brain. Kinesthesia is a sense of that movement, also highly dependent on the information received from your tissues back to your nervous system. The articular sources (joints) are supported by the ligaments, which connect them. The amount of external stress your ligaments can handle will be greatly influenced by the other aspects, which affect position and movement. That means if there are tendon and muscular problems, which are so common in athletes, there will be more stress to the joints and ligaments. It also means that other types of stress, both internal and external, that affect proprioception and kinesthesia, can cause ligament problems.
In addition to proprioception, body position and movement are also determined by your eyes and inner ears (the vestibular system). Excessive stress on your nervous system can quickly alter your body orientation and movement patterns. If your body is receiving more stimulation than it can handle, it’s similar to the anaerobic “excess lifestyle stress” that I often discuss. This can occur from too much training or racing, or from poor recovery, sleep, or diet. Eventually, your eyes can lose fine focus, throwing your balance off, and for those racing long miles on the trails, you know exactly how important this is. This is why if you close your eyes, it’s much harder to keep your balance, especially if your musculoskeletal feedback system is fatigued (or simply not trained). Stand on one leg with your eyes open and then close your eyes and see how you do. Both should be equally good, but for many, it’s not.
Muscle imbalances can occur in the head and neck region, affecting the inner ear and thus altering body position and movement too. Now more stress is placed on other tissues of the body, especially ligaments, as muscles and tendons fatigue; they must work extra hard to control movement and posture. Next thing you know, you’re starting to trip on just slightly uneven surfaces or roll an ankle again and again.
Additionally, when running and jumping, energy is constantly stored and released in the connective tissues of the foot and especially the ankle. The weaker these tissues are, the less power and speed you will generate. Conventional footwear often alters proprioception significantly, which can not only result in weakened structural tissues but also poor balance and movement. Orthotics promote problems too. If your body isn’t exactly sure how your foot is moving and exactly sure how it is loading, unloading, and recovering with each and every step, you’re at a high risk for injury. Add in the chronic nervous system and hormonal stress most people are dealing with, and you’re just waiting to injure your knee or roll an ankle.
Strong Body, Healthy Ligaments, Powerful Ankles
Ligaments do need some rehabilitation, though, as you hopefully realize after reading this article, it’s not as much as you once thought because it’s more of an issue with hormonal health and overall health. However, walking, standing, and moving (include running if you enjoy it) barefoot or in a shoe that does not alter biomechanics and proprioception are the simplest and most effective ways to aid in ligament repair and recovery, as well as to increase overall strength. Balance boards, wobble boards, and similar devices are also ideal for further development of balance and connective tissue health, but save these for when everything is uninjured or well within the healing phase. Of course, you should never stretch ligament injuries, as ligaments cannot retain their original shape and tension when stretched too much or too often past a certain point. Hormonal issues also contribute to ligament laxity, setting up an athlete for chronic injuries in a joint.
As I often say with any injury, you first have to remove the problem (often the stress on the hormonal system) and treat the muscles and tendons that have become problematic, resulting in more stress to the ligaments. Trigger point work and compression (as I note in various articles and in the Injury First Aid series) are the most effective ways you can assess and start to heal an injury. Once that occurs, then exercise rehab is the next step. Trigger point work on ligaments is sometimes necessary, but you should be very careful if you’re inexperienced and performing this type of therapy on yourself—you can cause more damage if you’re unsure of what you’re doing. Remember, I often advise staying off the actual area where the injury is felt. Instead, treat the surrounding “more meaty” muscles, and sometimes tendons, as this will help get those working again so the ligaments don’t need to do work they’re not meant to do. Now go train, think about all this information, and then read it again; it will make even more sense the second run through.
