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Thursday, January 10, 2019

Ankle Mobility Background & Importance
Chances are if you're reading this you've sprained your ankle once or twice (or a "bajillion" times), so let's talk about how to assess if those previous injuries are still limiting your performance. Overall ankle mobility and stability is important (see countless athletes out every day for sprained ankles). This article will primarily focus on ankle dorsiflexion, the deemed "most functionally important" of the ankle's planes of motion. Ankle dorsiflexion (DF) or the "pulling your toes to your nose" motion is something many take for granted. In an open-chain movement, it occurs as the talus slides and rolls on the superior tibia/fibula complex. Conversely, when the foot in contacting the ground (closed-chain), DF occurs as tibia and fibula "mortise" slides anterior on the proximal talus placing stretch on the syndesmosis and high ankle ligaments that connect the tibia and fibula. Multiple injuries to these structures is 1) not uncommon and 2) can lead to a build up of scar tissue leading to a gradual decrease in joint mobility (DF). Those limited in DF may see deficits in their ability to squat deeply or properly, walk or run with a normal gait pattern, or see decreased performance in their respective activities. It may be difficult to realize that your ankle DF is decreasing while it happens, but this blog intends to help you assess your DF and treat (if needed).

Compensations:

As you may know, the ankle is part of what we call the "kinetic chain" meaning ankle movement affects motion of the hip and knee and vice versa. Therefore, the reason many don't realize their DF is limited is because of the slightest compensations through the kinetic chain. The following is a list of common compensations you should watch for: decreased knee flexion (ski-boot walking), increased foot pronation (medial foot falls in), increased forward trunk lean during squats, anterior pelvic tilt, and early heel lift during gait. Remember, the body is a complex structure with a lot of moving parts so if someone (or yourself) walks into a clinic and has increased anterior pelvic tilt, for example, it doesn't necessarily mean they, or you, have decreased ankle DF.

Measurement

To test and re-test your DF, let's work through a method that's extremely easy to do yourself:

  • Tools needed: a wall/vertical surface and piece of paper, tape measure/ruler, and pen OR inclinometer/iPhone

Instructions for Ruler Method:

  1. Set up in a half-kneeling lunge with 2nd toe of front foot touching the wall (Place paper under front foot against edge of wall)
  2. Reach your front knee towards the wall trying to not allow your front foot to pronate (or collapse) and keeping heel touching the paper/ground
  3. Progressively move your front foot away from the wall (cm's at a time) until you can just barely reach your knee to the wall with your heel still intact with the ground (right)
  4. Mark where your 2nd toe is on the paper and measure that distance (cm) from edge of paper
Interpretation: it is thought that <9-10 cm distance indicates limited DF, or a side-to-side difference >10% if measuring for unilateral limitations

Instructions for Inclinometer/iPhone Method:
  1. Utilizing the same set-up as above, place inclinometer or iPhone (using the measure/level app) on the midpoint between knee cap and ankle on the bony ridge of the front of your shin 
Interpretation: <35-40 degrees indicates limited DF, or side-to-side difference >10% if measuring for unilateral limitations.

So, you measure and find that you have limitations, now what?

Interventions: Stretch, Mobilize, Load

I recommend utilizing the following interventions prior to squat or lower body emphasis days during your warm-up, or if there are profound deficits 1-2x/day minimum. This routine will commonly facilitate within-session changes in DF as well as allow you to then load the joint in its newly found range of motion. These interventions will most likely benefit most if performed without shoes.

Stretch: Standing Gastroc/Soleus Stretch 

  1. Perform a classic "runner's stretch" with the target ankle behind and knee straight (it may be helpful to put the toes up on a 1" platform, plate, or rolled up towel to facilitate the motion coming from the ankle- not shown in video). 
  2. Bring the target ankle closer to the body center and bend the back knee slightly to facilitate a soleus stretch (again keeping the toes on a platform- not shown in video)
  3. I don't necessarily hold these stretches for 30 seconds, I like to do 2-3 sets of 3 contract-relax series: 5 second contraction (actively DF ankle), 10 second deep stretch, repeat 3x ea. leg


Mobilize A: Foam Roll Gastrocnemius/Soleus 

  1. I recommend spending NO MORE than 1-2 minutes per gastrocnemius/soleus complex and plantar fascia per leg. Be efficient.
  2. I'll leave the rest to a video by Dr. Mike Reinold to show a nice little series of self-myofasical release techniques: 



Mobilize B: 1/2 Kneeling Self-Mobilization with Movement: 

  1. Anchor a 1/2"-1" band behind you and assume a 1/2 kneeling lunge position with the target ankle in front.
  2. Loop the band just below the 2 large ankle bones (malleoli) such that it stabilizes the talus. Stretch the band such that it is tight when in the 1/2 kneeling position to provide a posterior force on the ankle joint. 
  3. Maintaining heel contact and a stable foot (don't let arch collapse), drive your front knee forward in line or just outside of the foot. Avoid your knee caving in. Push the knee as far forward as possible without losing heel contact with the ground. 
  4. Perform this about 2-3 sets x 10 reps with a 2-3 second pause at end range



Notes: this may be performed with the front foot on level ground or on a 6-12" box/platform to increase the angle of pull of the band or placing a weight on the front knee to add a compressive load to the ankle (shown in videos above). If at anytime you feel a pinching sensation at the front of the ankle, make sure to back off the range of motion; i.e. don't try to push through this pain as it may indicate an anterior impingement injury. If struggling to maintain correct foot posture, here's a link to a video that Dr. John Rusin has provided to help: 



Load: Goblet Squat Self-Mobilization with Movement
  1. Keeping the band anchored behind you and looped below the two malleolin of the target ankle, step away such that the band is tight and your feet are even and shoulder width apart
  2. Hold a moderately heavy dumbbell or kettlebell in the goblet position and perform squats with a good upright posture 
  3. Perform this about 2-3 sets x 8-10 reps 
Putting It To Use:
I like to perform this circuit prior to squat or lower body lifting days in an Every Minute On the Minute (EMOM) style so that I am consistent, efficient, and don't take too much time during my warm up. What this means is that at the start of the 4 or 8 minute time period I'll do the stretches, start of the 2nd minute I'll foam roll, 3rd minute is 1/2 kneeling mobilization, 4th minute is loading and then repeat if I'm feeling extra tight for a second set. Rest during the time between an exercise ending and prior to the next minute starting.

Test-Retest: Be sure to use the measurement test before and after this mobility routine and track these changes over time. You should see immediate changes after completing these exercises as well as gradual long-term changes over time if you consistently perform this circuit. 

Other Resources:
Here is a video from Squat University that does a nice job of putting this together with a few different twists of their own:


Running Reform: Clinician's Guide to Ankle Dorsiflexion


--Trent Napp

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