Ankle Dorsiflexion Mobility Impairs the Lateral Step Down Test

Deficits with ankle dorsiflexion mobility can have a dramatic impact on functional movements such as deep squatting, lunging, and the lateral step down.  If you are familiar with the functional movement screen, you know that this is taken into consideration when a person does not grade out with a perfect score on many of the tests.

The Lateral Step Down Test

lateral step down testOne component that I have always felt is missing from the functional movement screen (FMS) is assessing the lateral step down.  I understand that the FMS needs to be applicable to a large variety of people and that the hurdle step test is included, but I have always felt I gain additional information from using the lateral step down test, especially in high level people.

I feel that the lateral step down test is an important test to include in your movement screening as it is often a movement that is dysfunctional in people with patellofemoral pain, patellar tendonitis, ACL injuries, and other lower extremity injuries.  During the lateral step down movement, the body is challenged in a very dynamic position to produce a combination of lower extremity strength, foot and ankle stability, core stability, and probably most importantly the ability to eccentrically control or decelerate the weight of the body.

A common finding during the test is the person that can’t resist medial displacement of the knee, resulting in hip adduction, hip internal rotation, and pronation at the subtalar joint.  This places the individual in a very disadvantageous position and makes them more susceptible to lower extremity injuries.  When analyzing people with this dysfunctional movement pattern, weakness of hip abduction and external rotation is commonly found.

Ankle Dorsiflexion Tightness Alters the Lateral Step Down

Ankle Dorsiflexion TightnessA recent study in JOSPT has found that ankle dorsiflexion restrictions can also cause poor quality of movement during the lateral step down test.  Examiners studied 29 healthy women and coached them through the lateral step down test.  The subjects were graded on the quality of their lateral step down with a 6 point scale.  Results showed that subjects that performed poorly in the lateral step down test had a significant amount of ankle dorsiflexion mobility restrictions when measured in both weightbearing and nonweightbearing.  Dorsiflexion was ~10 degrees more in subjects that scored well on the lateral step down test.

Interestingly, the authors did not find a correlation between hip abduction and hip external rotation strength with poor movement quality during the test.  I was surprised by this finding but realize that there were some limitations of the study, such as the use of healthy subjects that were coached well on technique.  I continue to believe this as experience and other past research has shown this, perhaps the limitations of the study can help explain.

In my experience, the three areas that I have focused on when someone does not score well on the lateral step down test are:

  1. Hip weakness, specifically hip abduction and hip external rotation
  2. Subtalar pronation
  3. Core stability

But the results of this study are going to make me assess ankle dorsiflexion a little more closely.  It makes sense that if ankle mobility is limited, the body would have to compensate to perform the task.  In this example, to achieve greater depth of motion while stepping down, the hip strategy observed was potentially due to the lack of ankle dorsiflexion.

In your experience have you seen this?  How many people incorporate the lateral step down test in their functional movement screen, and why or why not?  The results of this study should show us that ankle mobility, specifically ankle dorsiflexion tightness, can have a profound effect on the lateral step down test.

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18 Responses to “Ankle Dorsiflexion Mobility Impairs the Lateral Step Down Test”

  1. Step downs are part of my training for most clients because they are so functional and a common cause of injury outside the gym. I haven’t been using them for assessments, but it makes sense.

    When I train with them I include having the client hold a weight in the contralateral hand and tapping the foot forward across the midline, laterally, and backward across the midline.

  2. Chris Cameron, PT, DPT January 20, 2011 at 11:45 am

    I do primarily orthopedic foot and ankle rehab in my clinic and I commonly use lateral step downs as an assessment tool as well as an intervention for higher level patients.
    I think you hit the nail on the head, Mike. Patients with limited dorsiflexion usually always struggle with coordinating a step down and maintaining proper form. Athletes hate when such an “easy” exercise unmasks their compensations.
    Keep up the good work Mike. I love the website!

    Chris Cameron

  3. Brian Goonan PT January 20, 2011 at 6:01 pm

    The lateral step down test works very well – definitely agree it should be in the FMS.

    What I’ve also found is that using a leg press (ie our Shuttle Recovery) is a great way of preparing the client for lat step downs.

    And one other pearl I’ve seen is people with weak toe flexors, especially the FHL, will tend to be affected on this exercise. This makes sense when looking at the entire lower leg from a perspective of pronation vs supination.

  4. Mike,

    As always another great post. The picture does a great job of highlighting several key impairments too. I do use the step test especially when people complain of pain with stair descent. In addition to the common impairments that you mention, I also find profound hip flexor weakness which Tyler et al highlighted in patients with PFPS in an AJSM article about proximal thigh muscle function. Additionally, I find that one does not even need to jump to do a lateral step test as these impairments will emerge with just single leg stance in the sense that you will see excessive subtalar pronation, increased femoral internal rotation, concomitant loss of transverse plane trunk rotation and either a compensated or uncompensated trendelenburg. Additionally, if you don’t see it with single leg stance on flat ground, throw the patient on a foam 1/2 roller and you will see these impairments surface. It is my ultimate goal to normalize their biomechanics and the quality of their movement with eccentric loading because if the treatment and interventions are effective they should be able to perform such a task by the conclusion of sound rehabilitation. This can be corrected must faster than many therapists think too!!! The biggest pitfall that I see with rehabbing patients with a presentation similar to the young female in the picture is that they are given too many closed chain dynamic exercises before they even learn to simply balance properly on one leg. Keep up the great work.

    • Good thoughts Chris, I agree. Single leg stance would be good to check basic movements and balance. I still like the eccentric component of the step down, though too, both are great.

  5. Mike,

    I agree that the eccentric component is critical. Living in NYC, it makes me cringe when I stop to think about how often people with PFPS (stemming from biomechanical dysfunction) are forced to deal with stairs. Look forward to seeing your next post!

  6. Mike, what height box do you use for the test and is it a sagital plane step-down only? Thanks

  7. Greg Plodzik PT January 21, 2011 at 3:41 pm

    Hi Mike – Great post as always. I use step ups/downs all the time as an assement tool. Most of times I measure their DF on a step down and compare it to the contralateral side as well as look at what biomechanical issues that present themselves(increased pronation at STJ,increased hip IR,ect). I do this with all my chronic lateral ankle sprains, plantar fascia issues,PFPD, ITBS, hip flexor issues as long as it is not symtomatic. Also,I know the article is lateral step downs but you really should look at all planes not just frontal or sagital to get a true assement.
    Go Sox

  8. One common cause of ‘failing’ the step down test is not sitting back into the squat to initiate the movement, prior to allowing knee flexion. By initiating the movement with closed chained dorsiflexion and knee flexion, they are going to reach their dorsiflexion end ROM sooner during the step down test. This leads to the hip ir, valgum, etc. These people can benefit from improving glute activation to decrease these movement dysfunctions.

  9. Food for thought…Some of these patients with restricted dorsiflexion are limited by spurring/degenerative changes within the talocrural joint itself,causing weakness further up the chain. More common in the younger population than you would think…especially in snowboarders!

  10. Apparently I’m a little late to this post, (Thanks to Stop Chasing Pain on Facebook for the link), excellent post Mike.
    Question for anyone, I have “osteochondritis dissecans” in my ankle, and I’m going with the non-surgical approach and trying to rehab it myself, and I’m taking supplements such as glucosamine and fish oil. Is there anything that anyone can recommend for me to get some of the strength and all the ROM back, or at least allow me to continue training, any input would be greatly appreciated.

  11. Brendon Rabbitt PT January 9, 2012 at 3:46 am

    Could we please follow this up with drills to improve dorsiflexion.

  12. I have found that with many ACLs during step down will also utilize a secondary hip strategy or hip drop in order to reach for the floor. I have found that this hip drop is usually either secondary to lack of eccentric quad strength to perform adequate controlled lowering (in which case I will add weight to a smaller step down ) or secondary to lack of hip abductor strength (in which case the side planks and monster walks begin)

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