As a seasoned sports medicine clinician, I see plenty of clients with limited ankle mobility. Specifically, this often involves bilateral or asymmetrical restrictions in ankle dorsiflexion (DF). Most of the time, my clients are completely unaware of this limitation and its impact on their physical performance and well-being.
There are several potential reasons why one might possess less than optimal movement in the ankle. The most common causes include: joint stiffness following injury and/or immobilization, soft tissue tightness in the gastroc/soleus complex, scar tissue from a prior injury, anterior ankle impingement, chronic ankle instability and adaptive shortening of the Achilles tendon.
Athletes participating in jumping and cutting sports often experience ankle sprains. Even the most mild sprains may cause a loss of DF range of motion (ROM). I commonly see athletes who suffer recurrent mild sprains who never seek medical care or fully rehabilitate these injuries. Over time, they may continue to lose more motion as well as dynamic postural stability.
It is important to determine if the client has joint restrictions, soft tissue tightness, or a combination of both . Assessing DF ROM can be accomplished with a goniometer in a non-weight bearing position, however, measuring weight bearing dorsiflexion is a must. Often, these two measures differ. Research indicates that novice raters can effectively assess DF ROM in a distance to wall measure (8). The image below illustrates how to do this by placing a tape measure on the floor and having the client see how far they can stand away from the wall and lightly tap the wall with the knee while keeping the heel on the floor and moving over the second toe.
In addition, the weight bearing lunge test has also been shown to be another way to reliably assess this (9). Normative data for weight bearing ankle DF suggests healthy individuals have 30-50 degrees or about 10 cm of excursion where the knee can touch the wall with the heel down on the floor (1,6).
Measuring this in rehab would seem logical, but I would strongly encourage personal trainers, strength coaches and anyone involved with injury prevention to observe these values. The ankle sets everything in motion along the kinetic chain. Limited motion in this joint has major implications for running, cutting, jumping and sports performance.
Injury Risk.
A recent study published in the Journal of Athletic Training revealed greater ankle DF-ROM assessed during the WBL was associated with greater knee-flexion and ankle DF displacement during both squatting tasks as well as greater knee-varus displacement during the single-legged squat (3). This goes along with findings of greater DF ROM being associated with greater knee-flexion displacement and smaller ground reaction forces during landing, thus inducing a landing posture consistent with reduced ACL injury risk and limiting the forces the lower extremity must absorb (4).
What does this mean? In a nutshell, poor ankle DF leads to faulty compensatory movement patterns, namely increased pronation and valgus loading (medial collapse) at the knee. Consider this during squatting where deviations include pointing the toes out, ankles and knees caving inward, and excessive forward trunk lean. The body always picks the path of least resistance. In many cases, the weak link (or one of them) is limited ankle mobility.
This same pattern of pronation of the lower limb is the exact injury scenario seen when non-contact ACL injuries occur. It is worth mentioning that a recent study's findings suggest a lower degree of ankle DF in subjects with an ACL injury than in uninjured controls. (10). While there are several factors that influence ACL injury risk, we must certainly assess these restrictions and work to eliminate imbalances and improve overall ankle mobility. The first step is to identify if the restriction is related to reduced joint play, soft tissue tightness, or combination of both.
Interventions.
Attacking joint stiffness:
Physical therapists are well trained in identifying joint restrictions. Administering even a single talocrural mobilization is effective in immediately increasing DF ROM in clients with chronic ankle instability (5). Likewise employing mobilization with motion (MWM) as described by Mulligan is effective in restoring joint mobility (2). If the joint is stiff, this must be addressed prior to working on soft tissue restrictions. Seek out a physical therapist who can apply the necessary manual therapy techniques. Clients can also be taught how to administer self-treatment using a strap or resistance band for home/daily mobilization with motion work in a half kneeling position (see below).
While this is not as effective as hands-on therapy, it can be used to maintain gains achieved by manual work. Keep in mind if there is true bony impingement via an osteophyte, mobilization may not be overly effective, and this may require further medical evaluation by an orthopedic surgeon.
Mobilizing the soft tissue:
In many cases, there is tightness in the gastroc/soleus complex. Given these restrictions show up with a loaded bent knee, we must closely examine how the soleus and Achilles tendon factor in here. In runners, I often see medial soleus tightness and trigger points that need to be addressed to free up mobility and reduce overload on the entire chain (e.g. medial tibial stress syndrome, plantar fasciitis , IT band syndrome).
Some feel adaptive shortening of the Achilles tendon happens gradually over time as we live, work and play in shoes that naturally lift the foot into a plantar flexed posture and shorten the heel cord. It is impossible to quantify and objectively assess this as footwear selection, foot types and activity levels vary so much from person to person. In general, I believe those with limited ankle DF possess increased myofascial tightness in the posterior chain. Clinical treatment may include dry needling, instrument assisted soft tissue mobilization and manual stretching. For clients to effectively address this, I suggest the following steps as a foundation to reduce soft tissue restrictions:
1. Myofascial
release via foam rolling and/or compression therapy work - target the
gastroc/soleus region with the foot in neutral, internal rotation and external
rotation seeking out tight and tender regions.
Spend 30 seconds in each direction with rolling or opt to spend 3-5
seconds compressing specific tender points.
I also encourage active dorsiflexion and plantarflexion (pointing the
foot up and down) while compressing these regions. This can be uncomfortable but rather
effective.
2. Standing weight bearing lunge mobilizations at the wall - assuming you have measured the distance at which the heel starts to come off the ground, emphasize forcing the knee forward over the second toe trying to lightly touch the wall. Perform 10-15 repetitions. My preference is to avoid pronation during this as not to encourage an alternate strategy with respect to motor learning. I often cue client to push knee just outside the second toe. Hand support on the wall can be used if needed.
3. Bent knee step stretching - using the wall, a low box or slant board, instruct the client to lean forward using body weight to achieve a maximum stretch. Hold for 20-30 seconds and repeat 2-3 times. Research indicates more DF at the midfoot and forefoot can be achieved in pronation versus supination (7). You could consider this technique during static stretching if primary goal is more DF, but remembering how this may impact active movement/landing/cutting strategies must be considered.
4. Single leg anterior floor reach - the purpose of this is to drive home single limb stability, maximize closed chain DF and train the body to avoid pronation/valgus loading on each side. Perform 1-2 sets of 10 reaches. I consider this type of neuromuscular training an absolute must to eliminate imbalances and reduce injuries in higher risk populations.
For those clients with significant restrictions who are involved in higher demand pivoting/cutting sports, incorporating daily mobility work may be warranted until motion approaches more normative ranges. Measuring ankle mobility should be part of a comprehensive movement assessment that all runners, athletes and clients doing resistance training should undergo prior to beginning. The specific techniques discussed in this article provide a solid blueprint for how to assess and improve ankle mobility.
References
1. Bennell KL, Talbot RC, Wajswelner H, Techovanich W, Kelly DH, Hall AJ. Intra-rater and inter-rater reliability of a weight-bearing lunge measure of ankle dorsiflexion. Aust J Physiother. 1998;44(3): 175-180.
2. Cruz-Díaz D, Lomas Vega R, Osuna-Pérez MC, Hita-Contreras F, Martínez-Amat A. Effects of joint mobilization on chronic ankle instability: a randomized controlled trial. Disabil Rehabil. 2014 Jul 3:1-10.
3. Dill KE, Begalle RL, Frank BS, Zinder SM, Padua DA. Altered knee and ankle kinematics during squatting in those with limited weight-bearing-lunge ankle- dorsiflexion range of motion. J Athl Train. 2014 Nov-Dec;49(6):723-32.
4. Fong CM, Blackburn JT, Norcross MF, McGrath M, Padua DA. Ankle-dorsiflexion range of motion and landing biomechanics. J Athl Train. 2011 Jan-Feb;46(1):5-10.
5. Harkey M, McLeod M, Van Scoit A, Terada M, Tevald M, Gribble P, Pietrosimone B. The immediate effects of an anterior-to-posterior talar mobilization on neural excitability, dorsiflexion range of motion, and dynamic balance in patients with chronic ankle instability. J Sport Rehabil. 2014 Nov;23(4):351-9.
6. Hoch MC, McKeon PO. Normative range of weight- bearing lunge test performance asymmetry in healthy adults. Man Ther. 2011;16(5):516-519.
7. Johanson MA, DeArment A, Hines K, Riley E, Martin M, Thomas J, Geist K. The effect of subtalar joint position on dorsiflexion of the ankle/rearfoot versus midfoot/ forefoot during gastrocnemius stretching. Foot Ankle Int. 2014 Jan;35(1):63-70.
8. Konor MM, Morton S, Eckerson JM, Grindstaff TL. Reliability of three measures of ankle dorsiflexion range of motion. Int J Sports Phys Ther. 2012 Jun;7(3):279-87.
9. Powden CJ, Hoch JM, Hoch MC. Reliability and minimal detectable change of the weight-bearing lunge test: A systematic review. Man Ther. 2015 Jan 29. pii: S1356-689X(15)00006-5. doi: 10.1016/j.math.2015.01.004. [Epub ahead of print]
10. Wahlstedt C, Rasmussen-Barr E. Anterior cruciate ligament injury and ankle dorsiflexion. Knee Surg Sports Traumatol Arthrosc. 2014 Jun 13. [Epub ahead of print]
About the Author: Brian Schiff, PT, OCS, CSCS, is a licensed physical therapist, board certified orthopaedic clinical specialist, and performance training expert. He focuses on sports rehab and is the supervisor for EXOS @ Raleigh Orthopaedic in Raleigh, NC. He has extensive experience working with youth, collegiate and professional athletes, and currently serves as a PT consultant for the Carolina Hurricanes. Contact him at www.BrianSchiff.com or @brianschiff.
