Do I Believe in Chiropractic Medicine?

Supposedly this is a painting of the first chiropractic "adjustment"

That is the question that was asked of me recently by a client. This question was offered to me in a hushed manner as if it was a taboo or risky thing to ask somebody.

In reality, I can understand the demeanor of the question due to the previous issues between the chiropractic profession and societies like the American Medical Association.

Curious to what my answer was? I told her that I do NOT believe in chiropractors...Pause...I also do not believe in physical therapists, athletic trainers, medical doctors or osteopaths. However, I do believe in critical thinking, sound clinical reasoning, clinicians that get results, evidence based practice, and the scientific method. There will always be good eggs and bad eggs in any profession. There will always be some patients that will respond to some clinicians/treatments/therapies/exercises better than others. It doesn't mean they are bad but they weren't appropriate at that moment in time.

I think she has lost her marbles.

As Charlie Weingroff would say, "I don't care if all you do is spread peanut butter on somebody, if it makes them move better or with less pain from baseline to post-testing."

Test - Intervention - Retest.

That is starting to be my new gold standard for how I feel about different clinicians. I could turn this into a profession bashing fest but its almost like discussing stereotypes...they just are not true for everybody. Not to mention it would be unprofessional of me. ;-) 

I am also biased towards systems of evaluation like SFMA/FMS/PRI/MDT because they guide treatment and funnel down issues to specific dysfunctions. This is a step in the right direction compared to trying to guess why somebody strained a hamstring, or treating all shoulder impingements the exact same way.

In conclusion, when you really start to look at stuff on a broader scale you will notice that the overlap between professions of physical medicine is constantly increasing and the points of distinction really aren't that distinct. I also see the need for more clinicians to be willing to work together. Do not let ego get in the way of referring to another provider just for the sake of keeping your cash flow constant. The real future is who can become distinct by delivering the best outcomes and results to the patient. This is customer service after all.

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Please Leave Your Poor Hamstrings Alone!

"Tight Hamstrings, The Epidemic That Never Existed."

 -Dr. Erson Religioso, DPT

Trying to touch my toes at my first SFMA seminar.

This little nugget of knowledge developed during a conversation that my good friend Dr. E of The Manual Therapist and I were having together after his recent post. It is crazy how many times you will hear people mention how tight their "hammies" are or how often you can look at people exercising in public and the only thing they stretch is their hamstring group after some light arm circles. It is bewildering to me sometimes.

I think there is a real epidemic in progress and is growing at an exponential rate. However, the epidemic is NOT hamstring tightness...The real epidemic is a plethora of people, old and young alike, that can not touch their toes. Touching your toes without bending your knees is...or should be a fundamental human movement pattern. I know many of us fear lumbar motion and especially extreme lumbar flexion but spinal (that includes lumbar) motion is completely normal and necessary. We aren't talking about lumbar flexion under load here.

On top of the population of people that can not touch their toes...there are plenty of people that can do so. However, I didn't say everyone that could do this was able to do it satisfactorily. Using the Selective Functional Movement Assessment (SFMA) standards a person should be able to touch their toes without bending the knees, should have a uniform spinal curve throughout all of the spinal segments, have a sacral angle of > 70 degrees, and should utilize a posterior weight shift or hip hinge to achieve this goal. An inability to achieve this pattern satisfactorily represents an inability for athletic movements such as the deadlift, and an inability to reflexively stabilize the spine.

So what does this have to do with hamstrings? Most people that can not touch their toes often jump the gun and assume that it is due to posterior chain tightness or tight hamstrings. In reality, this is rarely the case. In fact, I would recommend you always get a second opinion or never evaluate yourself. I actually made this mistake myself and it was evident in a previous post where I did an SFMA video of my own multi-segmental flexion (toe touch pattern). I was wrong in my assessment and I actually had a core stability/motor control dysfunction.

This wasn't evident to me because during a certain breakout assessment I falsely associated the sensation of neural tension to equal soft tissue tension. I didn't realize my mistake until I was auditing the SFMA certification course for the second time. I volunteered myself to be the case for teaching the multi-segmental flexion breakouts. This SFMA course was being taught by Behnad Honarbakhsh, MPT, BHK, CSCS, CAFCI, CGIMS, DO (c) (whom I thought was brilliant) and low and behold in front of the entire class he humbled me and showed me my true dysfunction. Nobody knew that I was humbled because I didn't discuss my prior self-assessment. However, I probably hadn't touched my toes since I was a toddler before elementary school. Michele Desser and Dr. Todd Arnold quickly took me out into the hallway and had me perfom rolling and core stability exercises for about 5 or so minutes. They then brought me back into the seminar and showcased how I went from being about 14 inches from touching my toes down to about 2 seconds. Later that night, back in the hotel room I practiced some more on my own and was able to touch my toes.

So lets find out where I went wrong really quick to showcase how you can check to see if your hamstrings are tight or not.

Step 1. Check to see if toes can be touched. If not, continue on. 

Why can't I? We don't know. Don't blame the hamstrings yet.

Step 2. Remove Parts and Compare Left to Right. 

Here I unweight one of my legs and check for change. Nothing. Continue on. Still not the hamstrings.

Step 3. Long Sitting Test - Unload body parts. 

Now the hips and below will not be bearing weight and only the spine will be partially loaded against gravity. Still can't touch the toes? Continue on. (Still not the hamstrings despite my P.E. teachers scolding me for my tight hamstrings as a kid)

Step 4. Unload More, Check Left to Right, and begin Active versus. Passive Comparison.

In this test you are looking for & 70 degrees of hip flexion with both knees remaining straight, feet dorsiflexed, and hips neutral. An inability here STILL is not due to tight hamstrings.

Step 5. Checking Passive Motion compared with Active Motion from the previous step. 

An inability here to increase motion here beyond what you achieved actively = Ding. Ding. Ding. Winner Winner, Chicken Dinner. You DO have tight hamstrings! There are a few more steps you may take after this finding to pinpoint where the mobility dysfunction is located. However, If you increase more than 10 degrees compared to active but still do not reach normal hip flexion (now 80 degrees instead of 70) then you have a mobility and stability/motor control dysfunction present! If you find that you go from ~40 degrees to normal like I do below then you sir...DO NOT HAVE TIGHT HAMSTRINGS. You have a stability/motor control dysfunction. Continue on to step 6.

Step 6. Now you must find out how poor your motor control deficit is.

To pinpoint this you regress yourself to the most basic form of stability and motor control...rolling around on the ground. If you can not roll from supine to prone with each of your different limbs then you have a primitive motor control dysfunction. Restoring the ability to roll may fix your inability to touch your toes. However, at this point we are encroaching on the area of the 4x4 matrix of the SFMA. If you aren't in pain currently then I would recommend you finding an FMS certified professional and get screened and start with working on your most dysfunctional issues there first.

Look at me now...Just a tiny bend in the knees. Working on it. No hamstring stretching needed.

In conclusion, don't evaluate yourself and if you do...Get it rechecked by another set of eyes. The plumbers pipes always leak. Don't be that plumber. Secondly, practice your systems of evaluation or assessment if you have one so you can own it. If you don't use a system how can you be sure you aren't throwing spaghetti against the fridge and hoping that something sticks? What are your metrics for improvement? It has been said a million times and I'll repeat it. You do not need to use these metrics but you should be using something to set a baseline, intervene, and then compare to baseline to check for change.

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Thoracic Extension Doesn't = Thoracic Extension

Howdy Folks! Today I wanted to take a quick moment to comment on some discrepancies that I have noticed when hearing people discuss thoracic mobility and the need for thoracic extension. Anyone that is familiar with the Functional Movement System is probably well aware of the lack of thoracic mobility that many people seem to suffer from. This is something that you often see targeted by FMS corrective exercises or may be a common finding during an Selective Functional Movement Assessment (SFMA) for some.

On the other hand, there is the kind folks associated with the Postural Restoration Institute (PRI) that are trying to promote thoracic flexion and minimize hyperextension of the thoracic spine. Then I have heard stories from colleagues at PRI courses mention how they are lacking thoracic extension only to be told they have too much. So what is the answer? Do we need thoracic extension? Who is right here?

Well I believe that both of these systems or schools of thought are trying to achieve the same thing, and are essentially saying the same thing despite it sounding different. I am arguing that people are not differentiating between the different hinge points of the spine and the exact levels of the thoracic spine that they are referencing. Look at this first squat picture below. Nobody from either school is going to like this squat form and PRI'ists will notice the excessive thoracic extension from T8 and down while FMS'ers will notice the lack of thoracic extension from T1-T4.

Now if I hit my first sticking point and decide to take another breathing cycle to help draw my ribcage down and promote lower thoracic flexion I am able to come down even further in my overhead deep squat as you can see below in the next picture. However, it is still less than ideal squat form. I still struggle with getting adequate upper thoracic spine extension

Now what happens if we lessen the burden of the upper thoracic spine and by switching this experiment over to a front squat? I am still hyper-lordotic in the lumbar spine and still extend the very last few segments of the thoracic spine.

If I perform another big exhale into the balloon I am able to decrease the lordotic curve, increase thoracic flexion from T8-T12 and my femurs actually break parallel! However, if you look closely you will still see a little bit of hyper-kyphosis in the first few segments of the upper thoracic spine.

In conclusion, I think there is a lot of confusion by some people when they learn about or speak about the thoracic spine between these two different schools of thought. In reality, I think that both schools are really trying to achieve similar things but sometimes there is definitely a lack of differentiation. I also think that these pictures can also help signify the importance of proper breathing, and the power of the diaphragm, obliques and transversus abdominus over form, function and movement. Just some food for thought! Thoughts?

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Help Me, Help You: I'm on Google Help Outs!

Hey everybody! It's an exciting yet very interesting time for me right now. I am half way done with data collection for my master's thesis, and if I finish it on time then I'll be graduating in the beginning of May.

On top of that and the focus of this post is that I am trying a new hat on for size with an endeavor into the world of Google Helpouts.  Google Helpouts is a relatively new service where Google tries to pair up everyday people needing specific help with experts in the respective fields of need. For instance, if I needed help with my car Google would set me up with a car mechanic to see if they could assist me via video chat.

So here is the part where I come in... I want to use Helpouts to assist people with moving better, feeling better, and performing better. I believe with my movement based system of assessment (FMS & SFMA) I will be able to help others achieve these goals. I am going to approach this initially with an injury prevention, movement analysis, performance enhancement and nutrition focus.

I look forward to broadening my pool of people to work with and if that person is you I can't wait to get started in assisting you to achieve your goals. Google has generously offered me a code allow you to have your first Helpout session with me for free (ADAM99V). Each session will last a minimum of 45 minutes if needed at a rate of $25. Check out my profile and schedule a Helpout with me ASAP! Can't wait to see what this brings! 

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Rocktape: Fascial Movement Taping Levels 1 & 2 Course Review

Swollen Knee? Try this on for size.

Howdy Folks, this past weekend I had the opportunity to attend both levels of Rocktape's Fascial Movement Taping(FMT) Seminars. This was a Saturday/Sunday conference and to an outsider it probably looked like an odd waxing/hair removal ritual with the use of some brightly colored kinesio-tape. In the past, I have been very skeptical of things like kinesio-tape and other various magical fixes for ailments. However, I have a background with and an interest in using movement assessments as an integral part of injury evaluations, treatments and prevention work. Therefore, I found myself intrigued at the description of the FMT course and by the amount of respected clinicians that were beginning to incorporate this tape/taping school of thought into their clinical practices. Here is the description straight from Rocktape's website:

"...Not your average taping course. Fascial Movement Taping Certification is a 2-part certification process led by industry leading experts in functional movement assessment and treatment. Fascial Movement Taping (FMT) is based on the obvious yet largely overlooked concept of muscles acting as a chain. Say good-bye to thinking about origins and insertions and memorizing directions of tape. Say hello to a framework of ‘taping movement, not muscles’."

I was immediately attracted to what they were promoting ("Taping Movement, Not Muscles") and how they were separating themselves from the reductionist style of taping muscles via origin and insertion. So...I signed myself up for the most readily available seminar! I also noticed that Dr. Perry Nickleston, DC, FMS, SFMA, NKT was lecturing/teaching this conference. This excited me because I knew of his writings via his blog, Stop Chasing Pain, and I also knew that he was integrating this style of taping with movement assessments via the SFMA and FMS. Perfect. This seminar was hosted on the campus of the National University of Health Sciences in Lombard, Illinois.

Day 1

Both days the course started at 8:00am and while I usually like to arrive to things like this at least 20-30 minutes early I have to admit that I ended up being about 5 minutes late for this course. There were primarily two reasons for this, a fresh blanket of snowfall left us with undesirable travel conditions and I ended up getting lost on the campus due to the poor communication of the room location. Fortunately, it seemed as if the bulk majority of people got a little lost including Dr. Perry himself!

The first day of the course followed a rough outline of these topics:

• History
• Effects & Potential Benefits of Taping
• Differences between other kinesiotaping schools of thought and FMT's
• Importance of and the interplay between the brain, skin, the nervous system, pain and the relationships with human movement.
• Tape Properties
• Taping for Acute Care/Fluid Dynamics/Edema Control
• Indications
• Contraindications
• Precautions
• Taping for Acute & Chronic Pain Control
• Taping for Proprioception
• Taping for Posture
• Neuro-Taping
• Scar Taping

That is a lot of stuff to cover in just the first day alone but in reality so much of the different topics build upon one another and have a lot of interplay. Also, this is a rough outline of what Dr. Perry went over...in reality Dr. Perry jumped between topics, subjects and ideas at seemingly random times. Not because he was unorganized but because he wanted to promote critical clinical thinking that sometimes begins as unorganized and seemingly random observations. Skilled clinicians must then take these random puzzle pieces and turn them into something meaningful for both the patient and themselves.

Edema strips...I pretended to have some bursitis for my partner

Dr. Perry also delivered the content with an energetic and interested tone. He wasn't the boring monotonous type but you could tell he had a vested interest into what he speaking about. While he did use colorful language at times it was definitely not tasteless and provided some much needed levity for when your brain started reeling from all of the knowledge bombs being dropped upon it.

For this review I can't go into everything that I learned nor does anyone want to read that much about it. I also don't want to spoil all of what we learned but I would like to highlight some of the things that I really liked.

• Integration of many schools of thought, such as:
• Regional Interdependence
• Tensegrity Theory
• Current Neuro-Pain science
• The works/ideas of great minds like:
• Shirley Sahrmann
• Vladimir Janda
• Lorimer Moseley
• Gray Cook
• David Butler
• Karel Lewit
• & More
• Movement Assessment

Things were both practical and philosophical.

Day 1 was definitely a day for developing a framework or laying the foundation for what we would learn on day 2. However, there were many universal concepts and taping techniques that we learned on day 1 that could be used and applicable after walking out the door that night. In fact, that is exactly what I did...Let me set the stage:

In the morning when the conference had begun I had received a text message from one of my patient's (a collegiate basketball player) that their back was very stiff, painful and locked up. They were barely able to dress themselves because of this. This wasn't pleasant news considering I was 2 hours away at the conference and wouldn't be able to treat him until that night...even worse was that he had a basketball game to play that night at 7PM. However, one of my colleagues was going to travel with the team and prep them before the game. He was able to help treat him before the three hour bus ride began and when they finally arrived. The bus ride was reportedly miserable and the athlete had to stand up or lie in the aisle for the bulk of the ride. With 30 minutes to go before tip-off the athlete was better than that morning but still wasn't sure of his ability to perform.

This is when I arrived to the game, I had been thinking of applying a tape job that I had learned that morning that involved taping the thoracolumbar fascia and the paraspinals for pain control and muscle spasm. I thought it was worth a shot and would hopefully work in synergy with the other various treatments he had received that day. I didn't have any Rocktape with me and just used some cheap kinesiotape from my kit(ended up starting to fall off halfway through the game). Nevertheless, the athlete reported that he felt much better and more comfortable with the tape and subsequently was able to play the entire game. Could this have been purely placebo? Possibly. Could it have been related to the prior treatments from my colleague? Absolutely. However, I don't care if it was just a placebo that made him able to perform...There was no downfall to trying and he wasn't suffering from an injury that should have removed him from participation. The entire experiences was a giant +1 for how I felt about what I was learning from the seminar.  Potentially I am even biased because of this experience but pain is a construct and I was able to help alter how he assessed his status.

Pre-FMT Seminar.

Post-FMT Seminar...Much better.

Day 1 Memorable Quotes/Knowledge Bombs:

• Tape Movement, Not Muscles (Rocktape Slogan)
• "Movement Never Lies"
• "Treating scars is really cool s#^t!"
• "Movement is the common denominator of injury"
• Your body is always training and working out...against gravity.
• "If you have a body, then you are an athlete."
• "...you need all of that s**t to be STABLE!"
• "If I change your posture, can I change your mood?"
• "You need to have blueballs if you want to stick out"
• Go stronger, longer - It's viagra for the whole body.

Day 2
Because I already made a novel out of day 1 let me try and keep this short and sweet. While day 2 definitely was full of mental "sweets" it definitely did not come up short. Day 2 was more dedicated to assessing movement and then applying taping techniques in attempt to change movements.

Applying the spiral chain tape job to one of my athletes.

To start off Dr. Perry began with a segment on the importance of movement for life, how movement is a behavior, and how we all have our own unique movement habits or patterns. All things I whole-heartedly buy into and believe in. He then tied that part all together nicely by throwing this classic Gray Cook quote at us, "It took a habit to make that pattern, and it's going to take a habit to break the pattern."

Dr. Perry then had a great slide where he compared using the Snellen Eye Chart as a vision assessment to using movement as an assessment. He stated that if you weren't able to read the letters he knew you needed corrective lenses and if you can't move well then you probably need corrective exercise. Albeit he admits that some people can't reach perfect, whereas some only need a tiny tweak.

Let me outline the major areas of what we learned about on day 2:

• Movement Science
• Fascia and Fascial Anatomy
• Big influences from both Schleip and Thomas Myers here...
• Fascial Chains/Slings
• Movement Assessment, Taping Movement, and applicable Rehab/Corrective Exercises
• Maybe you don't like the SFMA or FMS...Doesn't matter, the importance of testing any motion that is used for ADL's or sport specific exercises is just as beneficial and vitally important.
• The Importance of Breathing and the role of the diaphragm
• Releasing the diaphragm
• Taping the diaphragm
• Tweak Taping
• Process of testing and then taping various skin glides to improve movement or patient's asterisk(*) sign
• Pregnancy Taping
• A nice tape application to assist pregnant women with low back pain, etc.
• & Performance/Sport Specific Taping

We were not discussing abstinence, yet.

There was a lot of discussion during these two days about the importance of the brain & nervous system and the role they play in both pain and movement. I really appreciated a lot of the theories that this course was basing its methods from. There was a very simple slide at the end of the first day that summed up the differences between FMT's theories and other brands or styles of taping:

• Functional vs. Structural
• Movement vs. Muscles
• Sensory vs. Mechanical
• Assisting vs. Resisting
• Elastic vs. Rigid
• Integrated vs. Isolate

There was a lot of SFMA/FMS type movement tests and many of Dr. Perry's own favorite movement tests thrown into this day. We discussed important aspects of the movements, potential compensations, movement lynchpins, and ways to approach correcting and taping said movements. There was a lot of moving and not a lot of sitting during this course.

Here I used the "Big Daddy" 4 inch tape, for posture.

Overall, I would say that I definitely enjoyed the course and I have found myself practicing a lot of what I learned in the clinic this past week. I don't think the tape is a be-all-end-all treatment and it is definitely not taught as one but it is another tool for the toolbox. I enjoyed the discussion and dissection of movement, nerves and the brain, and the implications of everything combined. Would I sign up again if I had to remake the decision? In an instant. Do I recommend it to others? Yes, but I feel like I definitely benefited from having previous exposure to the SFMA/FMS. There were a few massage therapists and personal trainers in the class and I couldn't help but wonder if they were able to digest everything as easily.

Day 2 Memorable Quotes/Knowledge Bombs:

• The brain wants to feel safe, there is no safer place than the ground
• "Pass your finger through the fuzz" - keep moving.
• "If you don't own breathing, you don't own movement"
• "The feet are the window to the soul/sole." - Karel Lewit
• Flip them over and tape their yang.

Dr. Perry, Myself, and Dr. Nick...Both of them making me look tiny.

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A Year in Review: 13 Lessons of 2013

Happy New Year and welcome to 2014! This is my first post of the year and my 75th post overall.  This is going to be a reflection on some of the things that I learned in the previous 365 days. I was inspired to write this post after reading many of Mike Reinold's similar posts over the last few years. I guess I learned a lot this year because this turned into an epically long post. Sorry.

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My SFMA: A Case Study - Cervical Breakouts

Time to make an assessment of myself

Today's post is second part of my self-SFMA(Selective Functional Movement Assessment) case study series.  Specifically, We will look at the dysfunctional cervical spine movement patterns from my SFMA Top Tier Post.  In the first post/video, I was dysfunctional/non-painful (DN) for the Cervical Flexion Pattern, and the Cervical Rotation Pattern to both the Right & Left.  However, I was functional/non-painful (FN) for Cervical Extension. In case you missed it, here is the 7 top tier tests again.

The SFMA works by assessing 7 general top tier movement tests. From there you perform a "breakout" of each dysfunctional pattern to determine the cause of dysfunction. Dysfunction movement patterns are broken down using an algorithm that funnels and filters the problem into either a mobility dysfunction or a stability &/or motor control dysfunction (SMCD).

Assessment:
This video will look at the dysfunctional cervical spine patterns. Specifically, cervical flexion and cervical rotation to the left and right. I was functional for the cervical extension pattern so that pattern does not require a breakout assessment. Here is the breakout video:

Results:
Cervical Flexion Top Tier = DN (Unable to bring chin to sternum. Why? We don't know yet.)

Active Supine Cervical Flexion Test = DN (Still Unable to bring chin to sternum. Why? We don't know yet.)
If I was now FN we would know that there is a postural and motor control dysfunction or stability/motor control dysfunction...or both, affecting cervical flexion. This includes the c-spine, T-spine, and shoulder girdle postural dysfunction. Laying supine removed the postural and stability requirements of the gravity dependent/loaded standing position from the top-tier tests

Passive Supine Cervical Flexion Test = FN (Chin is now to sternum)
We can now assume the cause of the dysfunction was due to an active cervical spine flexion stability dysfunction or motor control dysfunction...or both. We know it is not a mobility issue because I had full motion when all stability and motor control requirements were removed and the movement was performed passively. If it was due to mobility reasons then my GF would not have been able to passively bring my chin to my chest. Mobility problems always present with consistent findings!

Cervical Rotation Top Tier = DN to the Left & Right (Can not rotate chin to mid-clavicle or at least 80 degrees, Why? We don't know yet)
This test no longer requires this degree of rotation and the ability to bring the chin to the clavicle, at least this is how I was instructed in October of 2013.

Active Supine Cervical Rotation Test = FN (At least 80 degrees of rotation bilaterally without a significant asymmetry)
We now know that the dysfunction was related to a postural and motor control dysfunction or a stability and motor control dysfunction...or both. This is why my top tier cervical spine rotation test was dysfunctional, not because of my perceived tissue "tightness."


Treatment:
It is said that there are many ways to skin a cat...that being said the SFMA is a tool or a system of assessment. It is not a specific approach to treatment. However, there are general guidelines based off of the findings and it also lays a road map of treatment for you(eg. mobility before stability, working your way down the top tier tests). Specifically, in my case I do not have any mobility dysfunctions within the cervical spine but if I follow the philosophy of the SFMA then I need to address the SMCD of the cervical flexion pattern before attempting to correct SMCD dysfunction of the cervical rotation.

There are many avenues for treating this dysfunction from dry needling to IASTM to MDT principles to using the 4x4 Matrix or etc. I can't advocate that one approach will be better for addressing my dysfunction than another...but I do have a system of assessment to judge the efficacy of each potential intervention. Perhaps IASTM and MDT combined will work great for 90% of my patients but I don't know that...all I need to know is how to assess-intervene-reassess. Oh and I should probably stay within my practice act, so use what tools you have and those that you are comfortable with.

Thoughts? Do you think my breakouts and assessment have been accurate so far? What would you do with me? I know what I would do....finish the SFMA breakouts, first. Come back as I continue to break out my many dysfunctional movement patterns.

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1 Month of The SFMA: My Reflections

It has now been exactly a month since I took the Selective Functional Movement Assessment certification course in St. Louis, MO. You can read my initial course review here. I have been trying to incorporate the SFMA into my clinical practice as much and as often as possible since then. I wanted to take the time to highlight some thoughts and self-reflections from this process so far.

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Ankle Dorsiflexion: The What, Why, and How.

Dorsiflexion. This important motion occurs at the ankle and is seen when the dorsal(top) aspect of the foot and the anterior(front) aspect of the tibia(shin) move closer together. This motion is seen with and is necessary for proper execution of many basic human movements including squatting, running, walking, jumping and more. This motion is a vital part of most functional movements and proper function up and down the entire kinetic chain. Even minor tasks such as sitting and standing from a chair or walking up and down stairs requires adequate dorsiflexion of the ankle.

There are many issues related to inadequate dorsiflexion including many lower extremity injuries and and foot deformities. Evidence exists that problems here can be related to falls in the elderly, patellar tendinopathy, ACL injuries, lower extremity kinematic changes, and patellofemoral pain syndrome to name a few. This motion could be limited by several different problems such as soft tissue mobility(muscles and fascia), bony abnormalities, joint capsule restrictions(belongs with soft tissue mobility), and impingement of these structures.

The human foot and ankle are masterpieces of complexity and natural engineering.

When a person is deficient in dorsiflexion they are not automatically limited in the aforementioned movements(besides dorsiflexion, duh) or tasks such as a squat. The human body is great at incorporating compensatory movements to allow a continuance of motion to increase our ability to survive but at the cost of our ability to thrive. 

For example, lets say I have a patient named Jim Shorts who comes to me with complaints of knee and low back pain as well as a history of chronic plantar fasciosis. Jim loves going jogging, playing basketball, and working in the garden with his wife. 

These are very common symptoms and could be caused by a variety of issues but for the sake of this post lets discuss how they could be related to dorsiflexion of the ankle. Before we even begin to evaluate Mr. Shorts lets think about how dorsiflexion might be needed during each these activities. 

Running

• The ankle plantar flexors(think calf muscles) and plantar fascia may be eccentrically (resistively stretched) loaded at initial foot strike depending on landing type (heel strike vs mid-forefoot landings).

Initial Contact

• As the gait cycle changes from initial contact to mid-stance, the ankle moves into a more dorsiflexed position. At this moment, vertical ground reaction forces are at their highest(Active Peak on the graph below) and loading of the achilles tendon is reaching its maximum peak. To allow proper dispersal of these forces and to allow some of this energy to be stored and then reused the achilles must act as a spring.  Dr. Mark Cuccuzzella has made a video that highlights these principles of running mechanics and he does a much better job of visually and audibly explaining it than I can in writing.
• Steve Magness, writer of the blog Science of Running, and Head Cross Country coach at the University of Houston wrote a great post on the most vital components of running here as well.

Midstance

• The ankle plantar flexors are now on maximum stretch(maximum dorsiflexion) and are maximally loaded now must assist the posterior chain(gluteus muscles and hamstrings) to propel the body forward and slightly upward(propulsion phase & toe-off).

These components involving the ankle and its ability to dorsiflex are vital to running and any sports that involve running. If motion is impaired we should not expect to be efficient or safe from injury. Would you expect a car to have maximum performance or to be safe from harm if you had improperly sized or damaged shocks? 

I like the analogy of the ankle plantar flexors to be a group of rubber bands. If you have soft tissue problems then these rubber bands may be tied full of knots or could be thought of as dried out and having lost their snap. If you have bony or joint capsule restrictions then you may not have the ability properly stretch out a healthy rubber band to allow maximum performance or perhaps this inability caused a degradation in the health of the rubber band itself. Double Jeopardy.

Basketball & Gardening

• Requires the ability to run(discussed previously)
• Requires the ability to jump
• You need to be able to shoot a jump-shot, lay-up, dunk or to go up for a rebound.
• Requires the ability to land after jumping
• You need to safely come down after jumping and be able to dissipate the forces from impacting the ground.
• The above can be summarized by the ability to squat. (*Only the squat applies to gardening, unless you are into some extreme gardening stuff that i've never heard of before.)
• You also need to be able to properly squat to get into sport-specific positions of basketball such as a defensive stance and you don't want to bend at the waist to work in your garden(some people still will). 

Looking at Mr. Shorts

So we begin to evaluate Mr. Shorts and we have him perform some functional movements to evaluate his movement behavior. For example, we ask Jim Shorts to do a deep squat like he would while gardening and we notice that his heels can not touch the ground and he excessively flexes his trunk forward to allow his arms to work at ground level.

Next, I have Jim show me his defensive basketball stance. We immediately notice that his knees extend past  his toes and that he has that same forwardly flexed trunk position as before. He also complains that this position immediately exacerbates the pain in his knees and low back.

At this point I decide to try something. I take either a heel lift and place it into Jim's shoes or place his heels onto a 2in. board and have him repeat his deep squat. This time Mr. Shorts is able to squat down with his heels flush to the ground (or board) and his back appears to be parallel with his shins from a side view. The only difference here is that we eliminated the demand for proper dorsiflexion. Technically, this might not be the only reason for his limitations but I wanted to show how improper dorsiflexion could change a functional movement. 

This example shows us how problems with movement at the ankle can increase forces and perhaps damage tissues further up the kinetic chain. The next step for us would be to decipher what type of dorsiflexion restriction Jim Shorts actually has but that post is for another day so lets move on to figuring out how to evaluate your own ankle dorsiflexion.

Self Evaluation

Lets discuss how you can evaluate your own ability to dorsiflexion at home. Here are a few links to some of my favorite techniques and how-tos for evaluating ankle mobility.

1. This first link is credited to Mike Reinold's blog and is an all-encompassing post that is very concise and does a great job of saying everything that I am trying to say with this post. He even has many great videos for working on improving your own mobility.
2. This link is to a blog post by Jay Dicharry, MPT, CSCS...Author of the book, Anatomy for Runners. Jay is probably one of the premier clinicians and researchers out there today when it comes to running mechanics, research and injuries. This post discusses more than just ankle dorsiflexion and is definitely recommended.
3. This next link is actually to a video made by Jay Dicharry. This video will show you a quick and easy list of self-evaluation techniques and fixes for somebody looking to transition to minimal running shoes. However, I feel that these are vital to athletes and runners regardless if they are barefoot or wearing Hoka one-ones.
4. How much dorsiflexion do you actually need? Jay Dicharry recommends at least 25 degrees of dorsiflexion at the ankle and 30 degrees of dorsiflexion of the big toe(measured at 5 degrees of ankle dorsiflexion). Mike Reinold and the minds of the Functional Movement System, such as Gray Cook sponsor the idea of the knee reaching about 5 inches past the toes while in a half kneeling stance. One study found that athletes with less than 36.5 degrees of dorsiflexion had an..."18.5 to 29.4% risk of developing patellar tendinopathy compared to a 1.8 to 2.1% risk for athletes with dorsiflexion greater than 36.5 degrees." I believe most of these values to be too similar to chose one set of thought over the other and suggest them as mere guidelines and not cut points.

How do I fix this?

I had originally planned on writing an entire section on my favorite joint mobilization, static stretching, and soft tissue mobilization techniques but the links I provided in the self-evaluation section have some great techniques included with them already. I feel like I can not top those techniques and I highly recommend them. However, I do want to summarize some thoughts about trying to increase dorsiflexion.

1. I believe that a vast majority of us living in 1st world countries that grew up with or have been wearing shoes for decades with an elevated heel have limitations in ankle dorsiflexion. There are exceptions to this but I have provided you with information to check for yourself.
2. I admit that going barefoot or  utilizing a more minimal shoe during training may not be feasible for everyone. However, I do feel that incorporating and wearing a shoe with less heel-to-toe drop or less of an elevated heel during everyday activities such as at work, around the house or out on the town can be very beneficial for restoring proper ankle dorsiflexion. What you wear on your feet 90% of the time probably has a more profound effect on your tissues than the shoes you wear 5-10% of time you spend training each week.
3. When it comes to increasing the actual mobility with manual work I believe a multi-faceted approach is best. A combination of joint mobilizations, static stretching(post exercise), foam rolling, etc is probably going to be more effective for you unless you or a manual therapist has determined that only one specific issue is limiting you. It would not be uncommon for several of these issues to be a limiting factor for a person.
4. Do not ignore above and below, tibial internal & external rotation as well as plantar fascia mobility influence movement at the ankle as well.
5. DO NOT try to treat the symptom by eliminating the need for proper dorsiflexion. Utilization of heel lifts, immobilization, restrictive tape jobs, new shoes and etc. are only treating your symptoms. These MAY be appropriate for short-term relief but they do NOT fix your problem. If you try to take the easy way out and try to eliminate this motion then you are setting yourself up for a different set of problems up and down your entire kinetic chain.

In conclusion, this is going to be an issue with a majority of people. This problem exists in both the physically active and inactive populations. Only the minority of people that I've tested have had adequate ankle dorsiflexion. I would love to see how this compares with a third world country where people have not had the "luxury" of wearing shoes with elevated heels since birth. I bet you can find plenty of pictures in a national geographic magazine where the indigenous tribespeople have perfect squat form and can hold it comfortably with ease.

Updates

Here are a few related videos that I have made that should be of value to this topic as well! Enjoy!

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