Foot Pain & Ankle Instability: Rebuilding the Foundation with Foot-Core Strengthening
Every year, millions of athletes experience ankle sprains—one of the most common musculoskeletal injuries in sports. Though often dismissed as minor, these injuries can have serious long-term consequences. Studies show that up to 70% of individuals who suffer an ankle sprain develop chronic ankle instability (CAI), leading to persistent pain, weakness, and higher risk of re-injury (Gribble et al.). This issue is especially concerning for athletes whose performance depends on balance, agility, and explosive lower-body strength.
While most rehabilitation programs focus on external supports or ankle-focused exercises, recent evidence suggests the true foundation of ankle health may lie even deeper—in the intrinsic muscles of the foot. Strengthening these small but essential muscles can enhance balance, stability, and force production, addressing the root cause of chronic instability.
The Long-Term Consequences of Ankle Sprains
An ankle sprain may heal in weeks, but its biomechanical effects can persist for years. Repeated injuries can alter joint alignment, neuromuscular control, and even lead to degenerative changes. A large-scale epidemiological study of over 195,000 adults found that individuals with a history of ankle sprain had a significantly higher risk of developing post-traumatic ankle osteoarthritis later in life (Lee, Soyoung, et al.). This degeneration not only affects athletic performance but also mobility and quality of life in adulthood.
Moreover, chronic instability can lead to subtle but compounding structural changes. For instance, individuals with CAI often show measurable abnormalities in foot and ankle alignment, including fibular malpositioning and midfoot collapse, which further compromise mechanical efficiency and balance (Kobayashi, Takumi, et al., Abnormalities of Foot and Ankle Alignment; Kobayashi, Takumi, et al., Fibular Malalignment). These findings emphasize that ankle injuries are not isolated events—they disrupt the entire kinetic chain from the ground up.
The Foot as the Foundation of Stability
Despite this, traditional rehabilitation often neglects the foot core system—the intrinsic muscles that support the arch and stabilize movement. When these muscles weaken, the ankle must compensate, increasing stress and instability. In response, researchers have begun exploring foot-core–focused interventions as a means to prevent and rehabilitate ankle injuries.
Taddei et al. conducted a randomized controlled trial on runners and found that a 12-week foot-core training program significantly reduced running-related injuries compared to controls. Participants not only improved in balance and coordination but also showed enhanced lower-limb stability during dynamic movements. Similarly, a meta-analysis by Huang et al. found that short-foot exercises, which strengthen the intrinsic muscles of the arch, led to measurable improvements in foot alignment and muscle hypertrophy among individuals with flat feet. These adaptations contribute to better load distribution and reduced mechanical strain during sport.
Lee and Choi extended this research to individuals with chronic ankle instability, demonstrating that a six-week intrinsic foot muscle exercise program improved both dynamic balance and muscle activation patterns (Lee and Choi). These studies collectively point to a simple yet powerful insight: foot strength is ankle strength.
Restoring Function Through Targeted Balance and Force Training
Beyond intrinsic foot strengthening, structured balance and proprioceptive training remains critical to full recovery. Cuğ et al. compared different balance-training progressions and found that programs emphasizing unstable surfaces and multi-directional control produced superior gains in both postural control and ankle force output. These findings reinforce the importance of progressive loading and task-specific adaptation in rebuilding neuromuscular coordination (Cuğ et al.).
However, balance alone is insufficient if underlying mechanical misalignments persist. As Kobayashi et al. highlighted, individuals with CAI often exhibit structural deviations that must be addressed through corrective strengthening and mobility work. Focusing on restoring fibular alignment and arch support helps correct faulty joint mechanics and optimize load transfer during athletic activity.
Integrating Evidence-Based Practice
Modern rehabilitation guidelines have begun incorporating these insights. The 2021 revision of the Clinical Practice Guidelines for Lateral Ankle Sprains emphasizes a multifaceted approach—including mobility, balance, strength, and neuromuscular re-education—while encouraging clinicians to tailor programs to each patient’s deficits (Martin et al.). Similarly, Ruiz-Sánchez et al.’s systematic review of clinical practice guidelines found that effective treatment requires not only acute management but also ongoing preventive conditioning focused on foot and ankle function. This aligns with Halabchi and Hassabi’s recommendation for algorithmic, sport-specific rehabilitation approaches that account for the athlete’s long-term functional demands.
A Practical Application: Strength from the Ground Up
For athletes recovering from ankle sprains, integrating foot-specific exercises like the short-foot exercise, toe curls, and towel scrunches can serve as an essential foundation. Combined with progressive balance drills, resistance band eversion/inversion, and dynamic stability training, these exercises reprogram neuromuscular pathways from the ground up.
Devices like the FoosFoot™, which target intrinsic foot strength and ankle control, are designed around this exact principle. By strengthening the foot’s foundation, athletes can regain confidence, prevent re-injury, and improve overall performance—not just at the ankle, but across the entire kinetic chain.
Conclusion
Ankle sprains may start as minor setbacks, but without proper rehabilitation, they can set the stage for chronic instability and long-term dysfunction. The growing body of research makes one message clear: true recovery begins with the foot. By combining intrinsic foot strengthening with targeted balance and alignment correction, athletes can rebuild stability, prevent future injuries, and enhance athletic performance from the ground up.
Works Cited
Cuğ, Mutlu, et al. “Comparative Effects of Different Balance-Training–Progression Styles on Postural Control and Ankle Force Production: A Randomized Controlled Trial.” Journal of Athletic Training, vol. 51, no. 2, Feb. 2016, pp. 101–110, https://doi.org/10.4085/1062-6050-51.2.08.
Gribble, Phillip A., et al. “2016 Consensus Statement of the International Ankle Consortium: Prevalence, Impact and Long-Term Consequences of Lateral Ankle Sprains.” British Journal of Sports Medicine, vol. 50, no. 24, 3 June 2016, pp. 1493–1495, https://doi.org/10.1136/bjsports-2016-096188.
Halabchi, Farzin, and Mohammad Hassabi. “Acute Ankle Sprain in Athletes: Clinical Aspects and Algorithmic Approach.” World Journal of Orthopedics, vol. 11, no. 12, 18 Dec. 2020, pp. 534–558, pmc.ncbi.nlm.nih.gov/articles/PMC7745493/.
Herzog, Mackenzie M., et al. “Epidemiology of Ankle Sprains and Chronic Ankle Instability.” Journal of Athletic Training, vol. 54, no. 6, 28 May 2019, pp. 603–610, https://doi.org/10.4085/1062-6050-447-17.
Huang, Ching, et al. “Effects of the Short-Foot Exercise on Foot Alignment and Muscle Hypertrophy in Flatfoot Individuals: A Meta-Analysis.” International Journal of Environmental Research and Public Health, vol. 19, no. 19, 22 Sept. 2022, p. 11994, https://doi.org/10.3390/ijerph191911994.
Kobayashi, Takumi, et al. “Abnormalities of Foot and Ankle Alignment in Individuals with Chronic Ankle Instability: A Systematic Review.” BMC Musculoskeletal Disorders, vol. 22, no. 1, 12 Aug. 2021, https://doi.org/10.1186/s12891-021-04537-6.
---. “Fibular Malalignment in Individuals with Chronic Ankle Instability.” Journal of Orthopaedic & Sports Physical Therapy, vol. 44, no. 11, Nov. 2014, pp. 872–878, https://doi.org/10.2519/jospt.2014.5217.
Lee, Dong-Rour, and Young-Eun Choi. “Effects of a 6-Week Intrinsic Foot Muscle Exercise Program on the Functions of Intrinsic Foot Muscle and Dynamic Balance in Patients with Chronic Ankle Instability.” Journal of Exercise Rehabilitation, vol. 15, no. 5, 28 Oct. 2019, pp. 709–714, https://doi.org/10.12965/jer.1938488.244.
Lee, Soyoung, et al. “Epidemiological Study of Post-Traumatic Ankle Osteoarthritis after Ankle Sprain in 195,393 Individuals over Middle Age Using the National Health Insurance Database: A Retrospective Design.” Journal of Science and Medicine in Sport, vol. 25, no. 2, 2021, pp. 129–133, https://doi.org/10.1016/j.jsams.2021.08.018.
Martin, Robroy L., et al. “Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021.” Journal of Orthopaedic & Sports Physical Therapy, vol. 51, no. 4, Apr. 2021, pp. CPG1–CPG80, https://doi.org/10.2519/jospt.2021.0302.
Ruiz-Sánchez, Francisco J., et al. “Management and Treatment of Ankle Sprain according to Clinical Practice Guidelines: A PRISMA Systematic Review.” Medicine, vol. 101, no. 42, 21 Oct. 2022, p. e31087, https://doi.org/10.1097/md.0000000000031087.
Taddei, Ulisses T., et al. “Foot Core Training to Prevent Running-Related Injuries: A Survival Analysis of a Single-Blind, Randomized Controlled Trial.” The American Journal of Sports Medicine, vol. 48, no. 14, 6 Nov. 2020, pp. 3610–3619, https://doi.org/10.1177/0363546520969205