Anyone who has worked with field and court sport athletes has undoubtedly
dealt with his fair share of athletes with ankle injuries. The ankle is the most
frequently injured joint in sport, accounting for one-third of all injuries. As
the Western approach to medicine is highly reactionary in nature, we typically
follow ankle injuries up with rest and taping to assist the body in stabilizing
motion. Unfortunately, in many cases, this isn’t enough to restore proper
function at the ankle and leads to a loss of ankle dorsiflexion and an increased
likelihood of repeated ankle injury in the future.
Why more dorsiflexion?
Sports are extremely stressful to the body, and the ankle joint is no
exception. Over the course of an athletic practice or competition, each foot
contacts the ground hundreds or thousands of times and goes into plantar flexion
for propulsion equally as many times. This repetitive strain can shorten the
plantar flexors, and over time, jarring of the joint causes natural gliding to
become restricted. Add to this mix the fact that the ankle is the most commonly
injured joint in sport along with countless taping jobs for ankle instability
and elevated heel shoes and you get a nasty cocktail of muscular and joint
restrictions that limit dorsiflexion.
A loss of dorsiflexion creates an inability to actively dissipate force in
the lower extremity and can lead to problems both locally and up the chain, as
the force must go somewhere. Furthermore, poor ankle dorsiflexion can lead to a
“bouncy” appearance of the gait, as the body’s weight is transferred to the
forefoot prematurely leading to inefficient locomotion.
Ankle anatomy and mechanics
Like most things, to get an understanding of how to fix an issue, you must
first understand the proper mechanism. In reality, when talking about the ankle
joint, we’re really speaking about two different joints—the “true ankle joint”
consisting of the tibia, fibula, and talus and the subtalar joint including the
talus superiorly and calcaneus inferiorly.
Traditionally, the true ankle joint is responsible for dorsiflexion and
plantar flexion movements while the subtalar joint makes pronation and
supination possible. As is often the case when discussing anatomy, it isn’t
nearly as simplistic to state that dorsiflexion only occurs at the true ankle
joint. Instead, there is a complex interplay of other, smaller joints in the
foot that are to some extent controlled by motion at the “big boy” subtalar and
true ankle joints.
The midtarsal joint—consisting of calcaneocuboid and talonavicular
joints—also plays an important role in dorsiflexion and understanding how it
works is essential to understanding a very common compensation pattern with
restricted dorsiflexion. The midtarsal joint consists of two axes of motion—the
oblique and the longitudinal axis. Of utmost consideration to this article is
the oblique axis of motion because it allows a large amount of movement to occur
including dorsiflexion and abduction. The oblique axis of the midtarsal joint
has a one to one ratio of abduction and dorsiflexion. This means that for every
one degree the joint abducts, one extra degree of dorsiflexion is created.
Herein lies the problem. This additional dorsiflexion created at the
midtarsal joint is only possible with increased pronation at the subtalar joint.
Thus, you’ll often observe overpronation and abducted feet in those lacking good
dorsiflexion range of motion at the true ankle joint. This compensation is
extremely common because we are very much a pronation dominated society on
account of our footwear choices and the subsequent weakening of the feet. This
poses a threat to the athletes’ well-being as a number of injuries have been
associated with overpronation including plantar fasciitis, Achilles’
tendinopathy, patellofemoral pain, metatarsal stress fractures, and more.
Clearly then, getting dorsiflexion from the oblique axis isn’t a good way to
gain dorsiflexion if longevity is a concern.
So how should it be achieved? At the true ankle joint first and foremost. At
this joint, dorsiflexion occurs by having the talus glide posteriorly into the
ankle mortise. In cases of repeated ankle sprains, this posterior glide becomes
increasingly small. It has been hypothesized that this occurs because of the
talus’ lack of muscular attachments, which makes anterior subluxation easier
following damage to its ligamentous attachments.
The ankle higher up
While the traditional approach sees an ankle injury as a problem specifically
disturbing function at the foot and ankle, this isn’t necessarily the case.
Those with repeated incidence of ankle sprain and functional ankle instability
present a unique series of circumstances. It’s quite common for those with
functionally instable ankles to exhibit low back pain.
In an attempt to figure out exactly why, Marshall and colleagues tested time
to stabilization and trunk muscle activity in those with functional ankle
instability (FAI) and a control group. The researchers found that the FAI group
had delayed time to stabilization and delayed activation of the trunk
musculature. Interestingly, there was no difference between the control group
and the FAI group’s vertical jump heights. Is it a good thing that we are
jumping our athletes and letting them participate in full sport activity despite
an inability to reduce force properly?
Interestingly, Todd Wright of the University of Texas has said repeatedly,
“If the ankle and foot are tight, there is a good chance that the core ain’t
right.” I tend to agree. The foot and ankle are extremely important in driving
the body, and any dysfunction at that level may lead to poor mechanics up the
chain. It may manifest as low back pain, knee pain, or even shoulder pain, but
regardless of its location, it could very well be the ankle that is causing the
issue. One may also wonder if we’re getting optimal results from our athletes’
“core” training without first restoring the function of the ankle.
Fixing the issues
As the issues can be both joint mobility restrictions and muscular tightness,
achieving proper dorsiflexion should be addressed with a multifaceted approach
including altering tissue lengths, joint mobility, and other modifiable
lifestyle factors.
Tissue length
While tissue length can be obtained with general static stretching, I’ve
begun to favor an eccentric heel drop protocol for improving this quality. This
decision is for several reasons.
1. Series elastic compliance: In stretching a muscle that is actively
contracting, you aren’t only able to stretch the parallel elastic component but
also the series elastic component. This in effect can allow greater gains in
range of motion and tissue length changes.
2. Connective tissue strength: It has been demonstrated that eccentric
heel drop exercises can improve tensile strength of the Achilles tendon, which
is simply a bonus of this type of protocol that I feel presents some
preventative benefit as well.
3. Increased sarcomeres in series: Eccentric exercise has been
associated with increases in sarcomeres in series. It is theorized that this
increase allows the muscle to be protected from stress, as each individual
sarcomere would have to lengthen less in a series of 10 versus a series of five
sarcomeres to achieve the same overall muscle length change.
4. FAI benefits: A loss of dorsiflexion accompanies repetitive ankle
injuries, and athletes exhibiting FAI demonstrate reduced eccentric plantar
flexion strength. To me, anything that can help change this is important, and
anything that can improve strength to expedite a return to full function is a
great thing to have in the program.
It’s important to note that in a heel drop series, the exercise should be
performed both with an extended knee and with a flexed knee to preferentially
engage both gastrocnemius and soleus, respectively.
Another exercise I really enjoy is a loaded backward walk.
Joint mobility
The traditional wall ankle mobilization is effective but can only go so far.
Occasionally, you’ll find that it can even be contraindicated in some
populations, as it may aggravate problems associated with anterior impingement
of the ankle. For optimum results, it is wise to go back to the mechanics of the
joint in learning how to mobilize it properly. If you recall, the talus is
supposed to glide posteriorly relative to the tibia and fibula with
dorsiflexion, so by pulling the lower leg anteriorly, we help facilitate the
appropriate actions.
In this video, you can see that the athlete has fixed the heel and drives the
knee over the toe exactly as a traditional wall ankle mobilization. It’s
important to keep the athlete from driving into pronation. It’s also important
to keep the knee in line with the second toe to make sure we’re getting mobility
in the right places, not reinforcing poor movement quality.
Lifestyle factors
It’s imperative to also reduce the negative influences in everyday life in
restoring joint function.
The foot is designed to provide a stable base upon which to push off and to
accept the loads of the body during movement. Unfortunately, the modern shoe
creates a significant hurdle in developing and maintaining this stability.
Typically, the modern shoe has an elevated heel, which shortens the tissues
on the posterior side of the lower leg, making the restoration of proper length
even more difficult. By providing a safe housing for the foot, modern shoes
prevent the intrinsic foot muscles that are neurological triggers for muscle
activation up the chain from firing at a high level. Combine this with thousands
of foot contacts per day, and we’ve got a huge problem.
In an effort to prevent this, I try to get my athletes out of their shoes as
much as possible. We very frequently do our warm ups unshod to allow the
proprioceptor-dense feet to interface with the ground and restore some of the
natural function. In some cases, I’ll attempt to progress to some running unshod
or in shoes that offer great flexibility and little to no cushion, but this is
done on a case by case basis and is implemented in a judicious manner.
Putting it all together
The foot and ankle are an extremely complex system that makes effective
locomotion possible. In its complexity, however, I hope you can see that there
are practical strategies that can help optimize its performance in sport and
life. I hope that you’ve taken away from this article a better understanding of
the ankle and its function as well as a practical approach to improving its
motion.
Resources
Behnke Robert S (2006). Kinetic anatomy. Champaign, Ill: Human
Kinetics.
Brukner Peter, Khan Karim (2006). Clinical Sports Medicine
(McGraw-Hill Sports Medicine). Boston: McGraw-Hill Book Company.
Butterfield Timothy A (2005). “Differential Serial sarcomere number
adaptations in knee extensor muscles of rats is contraction type dependent.”
Journal of Applied Physiology 1352–58.
Duclay Julien, Martin Alain, Duclay Alice (2009) “Behavior of fassicles
and the myotendinous junction of human medial gastrocnemius following
eccentric strength training.” Muscle & Nerve 39:819–27.
Fox Docherty, Applegate, Schrader (2008) “Eccentric plantar-flexor
torque deficits in participants with functional ankle instability.”
Journal of Athletic Training 43:51–54. Print.
Mahieu, Nele, McNair, Cools (2007) “Effect of Eccentric Training On the
Plantar Flexor Muscle-Tendon Tissue Properties.” Medicine and Science in
Sports and Exercise 117–23.
Marshall, McKee, Murphy (2009). “Impaired Trunk and Ankle Stability in
Subjects with Functional Ankle Instability.” Medicine and Science in
Sports and Exercise 1549–57.
Siff Mel Cunningham (2003). Supertraining. Annapolis:
Supertraining Institute.
Vicenzino Bill, Branjerdporn Michell (2006) “Initial Changes in
Posterior Talar Glide and Dorsiflexion of the Ankle after Mobilization with
Movement in Individuals with Recurrent Ankle Sprain.” Journal of
Orthopedic and Sports Physical Therapy 36(7):464–71.
Carson Boddicker is owner of Boddicker Performance, a Flagstaff, Arizona
based company with a focus on improving athletic performance using an integrated
training model to help each athlete reach an optimal level of competitive
preparedness. Learn more at
www.BoddickerPerformance.com.
Elite Fitness Systems strives to be a recognized leader in the strength
training industry by providing the highest quality strength training products
and services while providing the highest level of customer service in the
industry. For the best training equipment, information, and accessories, visit
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