This week’s post is a video demonstration of a simple way to integrate reactive neuromuscular training (RNT) into your programming to enhance dynamic stabilization of the lower extremity.
In this video, I show a client that has an ankle sprain. While going through her rehabilitation, it became clear that she also needed balance training to really work her ankle, knee, and hip to stabilize during functional tasks.
To perform this exercise, you simple need a large resistance band (which are great from many stretching, strengthening, and stability exercises – here are the ones I use). Loop the band around a rack or other object and step within the loop. Place the band just above your knee.
I show a few exercise ideas in the video, progressing from simple balance, to unstable surfaces, to incorporating functional movements. By using the band, you can emphasize training the bodu’s ability to stabilize in the frontal and transverse planes while performing a sagittal plane exercise. This is essential to optimal function and a big key to my Functional Stability Training program.
I am super excited to announce that Eric Cressey and I’s latest product, Functional Stability Training for the Lower Body, is now available! Last year, we released the first module in our Functional Stability Training system, FST for the Core, which was hugely popular. Since then, Eric and I get weekly, almost daily, emails asking when more FST products were going to become available. Well, FST for the Lower Body is finally here!
Functional Stability Training for the Lower Body
FST for the Lower Body is a comprehensive program that combines the way I approach my rehabilitation programs with how Eric approaches his strength and performance programs. We talk about a ton of topics that merge our philosophies.
Functional Stability Training for the Lower Body takes a hard look at the lower extremity and how to most effectively optimize function. By addressing alignment, strength, mobility, and dynamic motor control, you can maximize your rehabilitation and training programs to reach optimal performance.
The lower extremities work in conjunction with the core to provide mobility, strength, and power to the entire body. Any deficits throughout the lower body’s kinetic chain can lead to injury, dysfunction, and a decrease in performance. FST for the Lower Body aims to help formulate rehabilitation and training programs designed to optimize how the lower body functions.
The FST for the Lower Body program can be applied to rehabilitation, injury prevention, and performance enhancement programs.
For the rehabilitation specialist, the information will help you restore functional activities faster. For the fitness and performance specialists, the information will help you achieve new progress with your clients to maximize functional and athletic potential. For the fitness enthusiast, the information will help you gain control of your lower body, maximize functional movement, and reduce wear and tear due to faulty movement patterns.
Here is the outline of presentations and lab demonstrations in the program:
Training the Hip for FST for the Lower Body
Assessing Lower Body Alignment and Movement
Preparing the Adductors for Health and Performance
Hip Internal Rotation Deficits: Why You Have Them and What to Do About Them
Training the Foot and Ankle for FST for the Lower Body
Understanding and Implementing Neuromuscular Control Progressions into your Programs
How to Integrate Neuromuscular Control Progressions
15 Things I’ve Learned About the Deadlift
Developing Lower Extremity Strength and Power Outside the Sagittal Plane
We’ve had some great reviews so far, here is one example:
I honestly feel the FST for the Lower Body may be our best product yet, so if you have seen FST for the Core or Optimal Shoulder Performance, you are definitely going to want to go through the FST for the Lower Body program as well.
Limitations in ankle dorsiflexion can cause quite a few functional and athletic limitations, leading to the desire to perform ankle mobility exercises. These types of mobility drills have become popular over the last several years and are often important components of corrective exercise and movement prep programming. Considering our postural adaptations and terrible shoe wear habits (especially if high heels), it’s no wonder that so many people have ankle mobility issues.
Several studies have been published that shown that limited dorsiflexion impacts the squat, single leg squat, step down activities, and even landing from a jump. These are all building blocks to functional movement patterns, so the importance of designing exercises to enhance dorsiflexion can not be ignored. While I will openly admit that I believe that the hip has a large influence on ankle position and mobility, it is still important to perform ankle mobility exercises. I will discuss the hip component in a future post.
There are many great ideas on the internet on how to improve dorsiflexion with ankle mobility exercise, but I wanted to accumulate some of my favorite in one place. Below, I will share my system for assessing ankle mobility and then addressing limitations. I use a combined approach including self-myofascial exercises, stretching, and ankle mobility drills.
How to Assess Your Ankle Mobility
Before we discuss strategies to improve ankle mobility, it’s worth discussing how to assess ankle mobility. I am a big fan of standardizing a test that can provide reliable results. One test that is popular in the FMS and SFMA world is the half-kneeling dorsiflexion test.
In this test, you kneel on the ground and assume a position similar to stretching your hip flexors, with your knee on the floor. Your lead foot that you are testing should be lined up 5″ from the wall. This is important and the key to standardizing the test.
From this position you lean in, keeping your heel on the ground. From this position you can measure the actual tibial angle in relationship to the ground or measure the distance of the knee cap from the wall when the heel starts to come up. An alternate method would be to vary the distance your foot is from the wall and measure from the great toe to the wall. I personally prefer to standardize the distance to 5″. If they can touch the wall from 5″, they have pretty good mobility. I should note that my photo below has my client wearing minimus shoes, but barefoot is ideal.
This is a great position to assess your progress, and as you’ll see, I’ll recommend some specific drills you can perform from this position to you can immediately assess and reassess.
Ankle Mobility Exercises to Improve Dorsiflexion
As I mentioned previously, I like to use a 3-step process to maximize my gains when trying to enhance ankle dorsiflexion:
Self-myofascial release for the calf and plantar fasica
Stretching of the calf
Ankle mobility drills
I prefer this order to loosen the soft tissue and maximize pliability before working on specific joint mobility. Also, I should note that I try to go barefoot during my ankle mobility exercises.
Self Myofascial Drills for Ankle Dorsiflexion Mobility
One of the more simple self myofascial release techniques for ankle mobility is foam rolling the calf. This has benefits as you can turn your body side to side and get the medial and lateral aspect of your calf along the full length. I will instruct someone to roll up and down the entire length of the muscle and tendon for up to 30 seconds. If they hit a really tender spot or trigger point, I will also have them pause at the spot for ~8-10 seconds.
What is good about the foam roller is that you can also add active ankle movements during the rolling, such as actively dorsiflexing the foot or performing ankle circles. This gives a nice release as well. Don’t forget to roll the bottom of your foot with a ball, as well, to lengthen the posterior chain tissue even further. There is a direct connect between the plantar fascia and Achilles tendon.
Some people do not feel that the foam roller gives them enough of a release as it is hard to place a lot of bodyweight through the foam roller in this position. That is why I often use one of the massage sticks to work the area in addition. You can use a massage stick in a similar fashion to roll the length of the area and pause at tender spots. I often add mobility in the half kneeling position as well, which gives this technique an added bonus.
Stretches for Ankle Dorsiflexion Mobility
Once you are done rolling, I like to stretch the muscle. If moderate to severe restrictions exist, I will hold the stretch for about 30 seconds, but often just do a few reps of 10 seconds for most people. The classic wall lean stretch is shown below. This is a decent basic exercises, however, I have found that you need to be pretty tight to get a decent stretch in this position.
I usually prefer placing your foot up on a wall or step instead, as seen in the second part of my video below. The added benefit here is that you can control the intensity of the stretch by how close you are to the wall and how much you lean your body in. I also like that it extends my toes, which gives a stretch of the plantar fascia as well. For both of these stretches, be sure to not turn your foot outward. You should be neutral to point your toe in slightly (no more than an hour on a clock).
Simple Ankle Mobility Exercises
I like to break down my ankle mobility exercises into basic and advanced, depending on the extent of your motion restriction. There are several basic drills that you can incorporate into your movement prep or corrective exercise strategies.
The first drill involves simple standing with your toes on a slight incline and moving into dorsiflexion by breaking your knees. Eric Cressey shows us this quick and easy drill that you can quickly perform:
Tony Gentilcore shows another simple ankle mobility drill, which is essentially just a dynamic warmup version of the ankle mobility test we described above:
Kevin Neeld shows a great progression of this exercise that incorporates both the toes up on the wall, essentially making it more of a mobility challenge and stretch. If you look closely, you’ll see that he is also mobilizing in three planes, straight neutral, inward, and outward:
Advanced Ankle Mobility Exercises
Jeff Cubos shares a video of the half kneeling mobilization with a dowel. The dowel is an important part of the ankle mobility drill. You begin by half kneeling, then placing a dowel on the outside of your foot at the height of your fifth toe. Now, when you lean into dorsiflexion, make sure your knee goes outside of the dowel. You can add the dowel to many of the variations of drills we are discussing:
Chris Johnson shared a nice video using a Voodoo Floss band to assist with the myofascial release and position the tibia into internal rotation:
For those that have a “pinch” in the front of the ankle of tight joint restrictions of the ankle in general, Erson Religioso shows us some Mulligan mobilizations with movement (MWM) using a band. In this video, he has his patient put the band under his opposite knee, however you could easily tie this around something behind you. In this position you step out to create tension on the band, which will move your talus posteriorly as you move forward into dorsiflexion:
As you progress along with your mobility, you may find that variations of these drills may be more effective for you. You can combine many of these approaches into one drill, such as Matt Siniscalchi shows us here, combining the MWM with the dowel in the half kneeling position:
As you can see, there are many different variations of drills you can perform based on what is specifically tight or limited. You may have to play around a little but to find what works best for each person, however these are a bunch of great examples of ankle mobility exercises you can choose to perform when trying to improve your dorsiflexion.
As football season is upon us, we often hear the term “high ankle sprain” used by announcers and in the media. This guest article from Trevor Winnegge will help to explain this orthopedic diagnosis, etiology, diagnostics and treatment.
What is a high ankle sprain?
A high ankle sprain, or syndesmotic sprain, occurs when there is an injury to the distal tibiofibular syndesmosis. Injury to the syndesmosis can occur to any or all of the following structures: anterior tibiofibular ligament; posterior tibiofibular ligament, including its superficial and deep (transverse) components; interosseous ligament; and interosseous membrane.(1) All of these ligaments function to stabilize the ankle mortise and prevent it from splaying, or widening, during the demand of gait, running, cutting, and sports. (Photo from Wikipedia)
Mechanism of High Ankle Sprain Injuries
While trauma to the ankle in any position has potential to injure the syndesmosis, ankle external rotation and forced dorsiflexion are the two most common injury mechanisms. Normally, the talus is positioned between the medial and lateral malleoli and is unable to rotate substantially. However, with a great enough force to the forefoot, the talus is forced to rotate laterally, thereby pushing the fibula externally away from the tibia, widening the mortise. This type of injury is often seen in football and skiing.
Typically, dorsiflexion causes the interosseous ligament to become taut. However, since the anterior aspect of the dome of the talus is wider than the posterior aspect, the wider portion of the talus pushes or wedges the malleoli apart during extreme dorsiflexion. This mechanism of injury is more common in running and jumping sports. High ankle sprains can occur isolated, can involve fracture of the fibula or medial malleolus, or tears of the lateral talofibular and medial deltoid ligaments.(2) High ankle sprains occur in up to 15% of all ankle sprain injuries.
High ankle sprains cause significant pain in the ankle and lower leg. All weight bearing and gait will be painful, if possible at all. There is usually a significant amount of bruising, however, there is typically NOT a lot of edema. Pain with any rotation of the foot, or dorsiflexion will be painful. Palpation to the ankle mortise and syndesmosis will be painful to palpation. Compression of the tibia and fibula above the ankle joint will result in pain at the syndesmosis.
A “Squeeze test” can be performed as a clinical test of syndesmotic instability. This is a simple, moderately reliable test where the examiner squeezes the proximal calf of the patient. A positive test occurs when this maneuver causes distal syndesmotic pain.(3)
Plain film Xrays are useful in ruling out fractures, but may be negative in an isolated high ankle sprain. Stress Xrays are most useful, where the foot is stressed into external rotation or dorsiflexion. This will show a widening of the ankle mortise. MRI/CT Scan can confirm the diagnosis and document severity of the injury.
Treatment of High Ankle Sprains
Treatment of high ankle sprains depends on the severity of the injury. Conservative care can be used to treat minimal to moderate injuries. Treatment may consist of a walking boot or nonweightbearing cast for anywhere from 1-4 weeks. Most athletes will return to sports in 6 weeks but many remain symptomatic for up to 6 months. A general rule of thumb, though not set in stone, is that the higher up the leg symptoms go, the larger the severity and longer the injury will take to heal.
Severe injury often requires surgical fixation. While wire and sutures are sometimes used, many doctors use 1-2 syndesmotic screws for fixation of the distal tibia and fibula, which allows for bony fixation to allow soft tissue scarring and healing. After fixation, weight bearing is surgeon specific. Some feel early weight bearing will transfer force through the screw, leading to breakage of the hardware and/or disruption of the syndesmosis. Sometimes, the hardware is removed prior to weight bearing, at anywhere from 2-4 months post operative.
Physical therapy for both conservative and non-operative care consists of range of motion, strength, stability and functional training to allow progression back to sports or activity. It is important to remember that this is can be a severe injury and healing times are much longer than a typical lateral ankle sprain, despite the lack of edema.(4,5)
Norkus S, Floyd R. The Anatomy and Mechanisms of Syndesmotic Ankle Sprains. J Athl Train. 2001 Jan-Mar; 36(1): 68– 73.
Norkus S, Floyd R. The Anatomy and Mechanisms of Syndesmotic Ankle Sprains. J Athl Train. 2001 Jan-Mar; 36(1): 68– 73.
Alonso A et al. Clinical tests for Ankle Syndesmosis Injury: Reliability and prediction of return to function. JOSPT. 1998, 27 (4): 276-284.
Press CM et al. Management of ankle syndesmosis injuries in the athlete. Curr Sports Med Rep. 2009 Sep-Oct;8(5):228-33.
Schepers, T. To retain or remove the syndesmotic screw: a review of the literature. Arch Orthop Trauma Surg. 2011 July; 131(7): 879–883.
About the Author
Trevor Winnegge PT,DPT,MS,OCS,CSCS has been practicing PT for over 11 years. He graduated from Northeastern University with a Bachelors in PT and a Master of Science Degree. He also graduated from Temple University with a Doctor of physical therapy degree. He is a board certified specialist in orthopedics and also a certified strength and conditioning specialist. He is adjunct faculty at Northeastern University, teaching courses in orthopedics and differential diagnosis. He currently practices at Sturdy Orthopedics and Sports Medicine Associates in Attleboro MA, where he treats many orthopedic conditions in addition to high ankle sprains.
My friend Dan Lorenz, MS, PT, ATC/L, CSCS recently summarized two new research articles on ankle taping. Many of us take ankle taping for granted and assume since it is so common that it must be effective. Below is Dan’s summary of the two articles with some of my comments below.
New Research on Ankle Taping
Two recent articles in the American Journal of Sports Medicine on ankle taping are relevant to the sports physical therapist. In a study by Refshauge et al, researchers sought to determine if ankle taping improved detection of inversion/eversion movements in individuals with recurrent ankle sprain. In 16 subjects with recurrent ankle sprain were tested in a taped and untaped condition. The threshold for movement detection was tested at three velocities.
Researchers found that the application of tape actually decreased the ability to detect movements at the ankle. They concluded that the efficacy of taping is unlikely to be explained by an enhanced ability to detect inversion or eversion movements. Two theories exist as to the mechanism of proprioceptive acuity that is believed to improve with the application of tape. One theory is that the close contact between tape and skin increases afferent traffic arising from the cutaneous receptors. The other is that the tape may increase cutaneous input that converges on muscle afferents, thereby increasing excitability of the motorneuron pool.
In another study, Purcell et al examined the differences in ankle range of motion before and after exercise in two tape conditions: traditional cloth tape and self-adherent tape (PowerTape). In both groups, the skin was clean, dry, and unshaven. For the white cloth tape condition, skin was sprayed with tape adherent and prewrap was used. The cloth tape job involved 3 stirrups, two heel locks (one medial and one lateral), and a figure-of-8 strip. In the self adherent group, self-adherent prewrap was applied midcalf to midfoot, incorporating two heel locks. Following this, the wrap was compressed with direct hand pressure.
The self-adherent tape was applied in a similar fashion as the cloth tape, except that heel-lock and figure-of-8 strips were alternated. ROM was measured before, after application of tape, and after 30 minutes of exercise using an electrogoniometer.
Researchers found that white cloth and self-adherent tape both restricted inversion to eversion ROM immediately after application, but with 30 minutes of exercise, only the self-adherent tape maintained the decreased ROM. For plantar and dorsiflexion, both tape groups decreased ROM immediately after application and after 30 minutes of exercise. Researchers concluded that self-adherent tape better restricts frontal plane ankle motion compared to cloth tape, although both do a satisfactory job decreasing sagittal plane motion.
It is always good to reflect back on what we do clinically as new research is published. These two articles are interesting and show that ankle taping can be effective in both altering proprioception and limiting ankle range of motion. However, the use of self-adherent tape appears to be more effective than traditional cloth tape.
One of the biggest criticisms of traditional cloth tape was that it loosens over time. It appears that the use of self-adherent tape, such as PowerFlex and PowerTape, are more effective. I have used both and do agree that the self-adherent tape feels great. What do you think?
Here is an example of the self-adherent tape technique:
My friend Art Horne from Northeastern University has just released a book on barefoot training and barefoot running. Art did a great job reviewing the topic, including reviewing the available evidence. Pretty cheap off Amazon too, click the image below to check it out.
Here is the publisher’s info on the book:
[box]Are you wondering why your running shoes resemble high heels? Ever think about why your big toe overlaps your second and why your arch really isn’t an arch anymore and resembles more of a pancake? Thinking about baring your sole? Barefoot training has recently become popularized as a potential benefit in injury prevention and rehabilitation programs. It is also purported to serve as an additional means to enhance athletic performance and running economy. However, limited clinical research is currently available to justify this practice and even less information is available describing how one may go about safely implementing a barefoot training program. This book explores the scientific and theoretical benefits concerning the merits of forgoing the modern running shoe for a simpler approach and offers real life solutions to all the obstacles standing between your feet and mother earth. Although it’s true that Americans love their shoes, what you learn about the merits of stuffing your feet and toes into these modern day casts might just have you singing a different tune – a tune your feet will certainly be much happier moving to. Welcome to Barefoot in Boston![/box]
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
One 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
A 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:
Hip weakness, specifically hip abduction and hip external rotation
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.
The concept of barefoot running is getting a lot of interest lately, as well as a lot of debate on running and medical forums, with the question “is barefoot running good or bad for you?” It is certainly not a new concept and running shoe companies have been catering for the so called minimalist runners for many years. The recent publication of the book, Born to Run ignited a lot of interest in it. In this post, Craig Payne shares some thoughts on the advantages and disadvantages of barefoot running. What do you think?
The Barefoot Running Controversy
The benefits that are claimed for barefoot running include increased foot strength, which is based on the claim that running shoes weaken muscles, that no research has shown; improved running biomechanics, which the research has not shown despite claims by barefoot runners (all the research has shown is that barefoot running is different to shoe running, not better); reduced injuries, which has not been shown by the research and a quick look at barefoot running blogs and running forums show a lot of runners seeking advice for the inquires they got while running barefoot.
Particularly common in barefoot runners is what has become known as ‘top of foot pain’ and metatarsal stress fractures. None of this means that barefoot running is not good, it’s just the claims made for it are not supported by the research in the way that those who make the claims like to think.
Many in the barefoot running community also claim that running shoes are evil and are the cause of many of the running overuse injuries that occur. Again, there is no evidence that this is actually the case, yet you can often see research quoted that they claim shows this. On closer inspection, the research does not actually show what is claimed. There is no research that running shoes help either. That does not mean they are bad, it just means that no one has yet done the research.
Elite runners and elite triathletes look for every edge that they can get and none of them run barefoot. Some do incorporate barefoot drills into their training, but do distance themselves from many of the claims for barefoot running. Even the elite African runners who grow up barefoot, choose to use running shoes. You often see statements about Abebe Bikala winning the 1960 Olympic marathon barefoot, but he went on to break a world record wearing running shoes in the 1964 Olympics. You often see statements about Zola Budd competing in the Olympic 1500 meter barefoot, but she started to get a number of injuries and had to resort to running shoes to prevent the injuries.
Bottom Line is that We Need More Research on Barefoot Running
Personally, I don’t have a problem with the concept of barefoot running. What I have a problem with is the somewhat religious fanaticism that some in the barefoot running go about with the claims they make and the misuse, misquoting and misrepresentation of the research that they make use of to claim to support their cause. Barefoot runners are not unique in this approach and others such as Pose and Chi runners make similar nonsensical claims.
My belief is that there is not one running style, technique or method that suits all runners and it’s up to the individual. Claims for the benefits of any running approach need to be carefully evaluated and not taken at face value and the research checked to see if it actually show what is being claimed. There is even an anti-barefoot running website that critically analyses all the claims made by barefoot runners.
About the author: Craig Payne is Senior Lecturer in the Department of Podiatry at LaTrobe University in Australia and a moderator on Podiatry Arena where a lot of barefoot running topics get discussed.
Comments from Mike: Sounds like there are definitely pros and cons to barefoot running, but until the evidence shows us otherwise, I’d lean towards running shoes. Especially if this is something you are not used to doing and you run for long distances, your foot may not be ready for it! What do you think? Have you had an experience with barefoot running, either good or bad? I know that I have seen a large increase in the amount of barefoot runners wearing the Vibram FiveFinger product, any experience with this product or others for barefoot running?
Mike is the President and Co-Founder of Champion Physical Therapy and Performance, located in Boston, MA. Champion offers an integrated approach to elite level physical therapy, personal training, and sports performance.
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