Sock Doc 21: When Things Don’t Go As Planned – Ankle Sprains and Migraines

November 3, 2023

On this episode we have The Sock Doc, Dr. Steve Gangemi, joining us. Steve is a natural health care doctor who founded and practices at Systems Health Care, an integrative wellness center in Chapel Hill, NC. Steve is also a longtime endurance athlete and is a wealth of knowledge for athletes looking to optimize wellness.

We are continuing our new series called “When Things Don’t Go As Planned” that will dissect your health and injury issues that come up when you least want them and can negatively affect your training and race season–how to heal, prevent and overcome going forward of common (and not so common) issues that athletes face. Listen to our first edition here. Send us your requests for topics!

When Things Don’t Go As Planned

Part 1: Ankle Sprains and Wellness 

Some stats

  • Injuries to the foot and ankle affect 40% of the population at least one point in their life.
  • Incidence of foot and ankle injuries is even higher for runners: approximately 60% of runners will have one injury every 2 years.
  • Foot and ankle injuries often lead to issues higher up the kinetic chain: knees, hips, back – even shoulders! Dysfunctional ankles affect the entire kinetic chain.
  • Consider the importance of ankle’s tendons and ligaments and how the integrity of these can be tied to holistic health, hormones, etc.
  • Proprioception is really one of the most important aspects of healthy, strong, resilient ankles.

Biomechanical notes

  • Ankle dorsiflexion influences dynamic balance in individuals with chronic ankle instability. (International Journal of Sports Physical Therapy 2013)
  • Ipsilateral hip abductors weakened after ankle sprains. (Journal of Athletic Training 2006)
  • Hip weakness predicts ankle injury risk. (Journal of Athletic Training 2017)
  • Any other correlations we see that you want to mention?

What kind of ROM do we need?

  • ~30 degrees of dorsiflexion during walking
  • ~35-40 degrees for more functional/athletic positions

Types of sprains

  1. Medial
  2. Syndermotic (high)
  3. Lateral – most common type of sprain – 85%
    1. 70% of ankle sprains have recurrent symptoms

Why are some of us more prone to ankle sprains and then recurrent ankle issues?

  • ROM issues, joint mobility and stiffness.
  • Proprioception or lack there of.
  • Shoes, footwear and lack of going barefoot.
  • What about role of hormones, stress, etc?
  • Why are some people able to recover on the fly from rolling their ankle vs some people sustain to a full-blown ankle sprain?
    • Proprioception–and the “preparation” going into circumstance (barefoot shoes).
    • The ligaments’ ability to react quickly and dynamically.
    • Structural integrity.
    • Also nutritional and metabolic component: estrogen, cortisol and stress hormones.

From the lens of health & hormonal status

  • More estrogen dominance these days
    • Generally, we see men’s T levels are lower these days while estrogen on the rise;
    • While women are not breaking down estrogen as readily (impaired detox etc);
    • All this leading to estrogen dominance, and this causes ligaments to not respond properly.
      • Research shows that female soccer plays have higher # of knee injuries during ovulation and late luteal, you also see it in carpal tunnel syndrome–all correlated to higher estrogen levels.
      • Sometimes higher estrogen levels are totally normal ie during pregnancy.
      • Elastin vs relaxin
        • Elastin—protein responsible for stretching, shrinking and recoiling; what is found in ligaments and connective tissue. Estrogen affects this protein, and this affects both men and women, thus affecting proprioception and ligament integrity.
        • Relaxin—hormone, mostly just during pregnancy.
  • Women sustain more ankle sprains in women
  • True and relative estrogen dominance
    • What Tawnee has seen in recent DUTCH tests in her clients: estrogen dominance, normal to low progesterone, relative estrogen dominance, impaired methylation, impaired detox, etc.
      • Progesterone deficiency can be tied to excess stress hormone (cortisol) production. Also contributing to relative estrogen dominance.
  • Role of endocrine disruptors, xenoestrogens, etc.
    • This can be a factor but in Steve’s opinion not 100% the cause; usually something else going on impairing the body’s ability to handle these types of things.
    • Analogy of EMF and how things like this are almost never the “sole cause” of someone’s health issues.
  • Detox & Liver health…
    • Ways to gauge impaired liver health: AST & ALT are not enough! These can be influenced by other things and they will not show up in detox issues.
    • Two pathways to be aware of for liver detox and breaking down estrogen:
      • Sulfation
        • Methylation: Folate, P5P/B6, B12, Mg, etc.
      • Glucuronidation
        • Mg, sugar handling, etc.
        • Artichoke high in glucuronic acid
        • Betaglucuronidase – enzyme that can upregulate and allow for reabsorption of estrogen, which tied into gut health overall. Impaired gut tends to have higher levels of this enzyme thus more potential for estrogen issues.
          • Estrobolome

Healing protocol

  • 70% of ankle sprains have recurrent symptoms
  • Steve’s No. 1 piece of advice: DO NOT WEAR THE BOOT.
    • “Horrible” orthopedic device.
    • Does more harm than good… will mess up gait, hips and back.
    • Gives a good barrier to avoid any further injury, but you lose proprioception and potentially introduce way more problems.
    • Crutches are more active, boot is passive.
    • Need load- and weight-bearing work to heal properly.
  • Timeline of healing
    • Rehab: ASAP
    • It’s ok to endure some pain or discomfort in pursuit of healing.
    • Every moment you rest and don’t do the work you lose valuable time to heal and re-train things the right way.
    • We often want the “soft” route but that doesn’t get us far.
    • Sometimes we do need to endure some pain and force to have a breakthrough. This is different than a “no pain no gain” mentality.
    • Obviously all this is said within reason—don’t be stupid and go running and jumping when you have a sprain.
  • Protocol should include:
    • Neuromuscular/proprioception work
    • Balance training; single leg balance work
    • Restoring ROM
      • Exercises for dorsiflexion, plantar flexion, inversion, eversion
      • Not static stretching alone but what are dynamic and mobilization examples?
      • Foam roll? Trigger points? Where?
    • Multiplanar strengthening
    • Glutes, feet and toes!
    • Myofascial release
  • Ongoing maintenance:
    • Test/re test
    • Lateral step down test
    • SL exercises
    • Mobility
    • SMFR
    • Pre/post exercise assessment, eg do the rehab exercises then check squat, lunge, DL, etc, do you see improvement?

Part 2: Migraines


  • What makes a migraine different than other types of headache?
    • Migraine w/aura vs w/o – what is aura
    • Vasodilation
    • Photophobia
  • Athletes who suffer from migraines can be sidelined from training or racing due to migraines. Can be debilitating!
  • Tawnee’s husband John gets migraines on occasion; he had the onset of one with aura during a very grueling trail HM that he did this past summer, and he was definitely a bit depleted and underprepared for it going into the race….
    • Generally, we don’t see a clear correlation of what else is happening when he gets them but it tends to be more times of high stress, screen time (blue light/bright light/intense work), dehydration.
    • Has gotten better with diet improvements over the years.
  • Tension headache more constrictive.
  • Sometimes, how do we really know it’s a migraine? Maybe another category like TMJ headache.
  • Dampening of sensory information tends to help ease migraine pain (visual, auditory, etc.).

In athletes, research says:

Headaches in athletes

  • This article has some good general info and classifications of types of headaches

The association between migraine and physical exercise

  • “It seems that although exercise can trigger migraine attacks, regular exercise may have prophylactic effect on migraine frequency.”
  • “Possible mechanisms for how exercise may trigger migraine attacks, include acute release of neuropeptides such as calcitonin gene-related peptide or alternation of hypocretin or lactate metabolism.”
  • “Mechanisms for migraine prevention by exercise may include increased beta-endorphin, endocannabinoid and brain-derived neurotrophic factor levers in plasma after exercise.”

Risk factors and triggers

  • Hormonal tie in
    • Females 3x more than men
    • Estrogen/progesterone imbalances and/or estrogen dominance, just like with ankle issues.
    • Cortisol levels that compromise progesterone levels.
    • Women who suffer from migraines can often trace them to happening the same time of their cycle each month, during ovulation and late luteal (before period).
  • Training stress/life stress—something is off, usually that’s when you will get the onset of migraine (or whatever issue you are prone to, e.g. cold sores, mastitis).
  • Neurotransmitter or gut issue that is causing the imbalance and triggering a migraine.
    • Abdominal migraine: serotonin levels of GI system are affected from inflammation (often related to food sensitivity, fungus, GI infection, dysbiosis, etc.)
    • Sometimes there will be no GI symptoms (nausea), sometimes there won’t be.
    • Enteric nervous system at work here, ie gut-brain axis or “second brain” affecting vagus nerve.
    • Serotonin is needed, often parallels estrogen levels so those can affect one another.
    • if your gut is affecting your migraines, as long as you’re not on an SSRI, the go-to would be St. John’s Wort. This is GREAT to restore serotonin levels.
    • St. John’s Wort is the go-to herb here.
      • 95% or more of serotonin made in the gut.
      • St. John’s Wort can help when things go awry.
      • Just improving the gut can help of course, but the issue is that can take a very long time, so with this idea of using St. John’s Wort, you can hit it both ways: Work on GI health but also use something like St. John’s Wort to help restore neurotransmitter levels, thus improve serotonin levels, which then will also help improve GI health and ultimately aid in migraine issue.
      • If your gut gets “off” easily, this is a good go-to ensuring there are no contraindications for your personal health profile, other meds, etc.
      • Other side effects: rarely it can cause anxiety, and depending on other medications you are on there can be side effects. Check first.
  • Eye issues, light/brightness—can lighting alone trigger one?
  • Correlation with the following: Posture, breathing patterns, muscle tension? … or even things like overworking/overtiredness, lack of sleep, lack of QUALITY sleep, etc…


    • Identify food sensitivities
    • Look at it as an opportunity to overall clean up the gut and do a gut healing protocol.
    • Consider in your diet:
      • Omega 6/3 ratio?
        • Inflammatory foods, seed oils, etc.
        • Supplement with fish oil? Can be part of an overall health protocol but fish oil alone doesn’t seem to be a “magic pill.”
      • SAD?
      • Nutrient deficiencies? Depleted from overtraining?
    • Supplements
      • Curcumin/turmeric
        • Understand that this is an anti-inflammatory compound that fights inflammation differently than omega 3 fish oil
        • Omega 3’s work off eicosanoids like fatty acid balances and platelet aggregation (stickiness)
          • Important for regulatory T cells to fight infections and support immune system.
        • Turmeric works off NF kappa B, inflammatory compound your body makes (fish oil doesn’t do this) and also helps with inflammatory cytokine IL-10, important when you have autoimmune conditions, infections, allergies. Turmeric more specific for immune system.
        • But overall, when you’re overcome your inflammation issue you shouldn’t and don’t need to continue taking it. Understand why you’re taking something! And go back to diet and training-stress balance first!
      • Mg, Riboflavin, Zinc
        • Mg: hormone breakdown
        • Riboflavin: gut
        • Zinc: immune system, progesterone & testosterone are made by zinc


  • What to do when you feel one coming on & what to do for overall avoidance of getting one.
  • Very rarely is there a single pill that will improve something. Successful thing to treat but rarely one answer on fixing them from happening.
  • Overall this goes back to a holistic lifestyle improvement.
  • Body is always trying to heal and tell us what it needs… always a reason, be wiling to get uncomfortable to heal, while also giving your body the love it deserves. It’s not fighting against you.

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