Howdy Folks, today I wanted to
discuss a growing body of literature that highlights a relationship between
ankle dorsiflexion and movement patterns (kinematics) that are associated with
anterior crucial ligament injuries. One such article that was recently
published online by the Journal of Athletic Training was conducted by Dill et
al1.
Photo Taken from Dill et al journal article.
What did these authors do exactly?
They actively recruited and grouped subjects by their levels of ankle
dorsiflexion. Specifically, they wanted a population of subjects with limited
(Less than or equal to 5 degrees) ankle dorsiflexion and subjects with normal
amounts (> or equal to 15 degrees) of ankle dorsiflexion. A unique aspect of
this study was that the authors used a weight-bearing lunge test for assessing
ankle dorsiflexion.
It could be argued that this test is both more
functional and easier to assess in the clinic compared to nonweight-bearing
ankle dorsiflexion measurements. They also took non-weight bearing ankle
dorsiflexion range of motion measurements but the authors hypothesized that
this measurement may have caused discrepancies in previous studies because this
method isn’t a good representation of the functional movements and tasks that
were assessed. The weight-bearing lunge test can be assessed using common
smartphone apps like Clinometer or the iPhone’s compass application if an
inclinometer is not readily available.
Photo Taken from Dill et al journal article.
What are the functional tasks that
they tested? Well they had the subjects perform an overhead squat, a
single-legged squat, and a jump-landing task. These tasks have been in previous
research and are common in clinical settings as well to assess lower extremity
movement patterns that help evaluate risk of ACL injury. These are relatively
easy to perform tasks and are representative of common physical activities and
functional movements in general.
What did these researchers find?
They found NO differences between normal and limited ankles when using the
traditional nonweight-bearing ankle dorsiflexion range-of-motion assessment.
However, there were significant differences when they looked at the two
different groups for both the single-legged squat and the overhead squat using
the weight-bearing lunge test. They did NOT find a difference in movement
patterns when they looked at the jump landing task.
Previous research by Fong
et al2 found a difference with the jump landing task but the current
study utilized an immediate countermovement jump for maximal height but the
latter researchers did not. This could have been the reason for the differences
in findings because the immediate countermovement jump may not have required a
significant amount of ankle dorsiflexion to complete.
The next question that you may be
asking yourself is what are the kinematics that are associated with increased loading
of the anterior cruciate ligament and which of them were present in the
subjects with limited ankle dorsiflexion? Well excessive frontal plane, and
transverse plane motion accompanied with an anterior tibial shear force (in the
sagittal plane) place the greatest stress on the anterior cruciate ligament.
Noncontact injuries to this ligament are associated with a minimally flexed or
relatively extended knee position. That being said, the subjects with ankles
that had limited ankle dorsiflexion did not flex their knees as much as the
subjects with normal ankle dorsiflexion during the single-legged squats and
overhead squat. This means their knees were relatively extended and as
mentioned earlier that is not ideal when it comes to loading of the anterior
cruciate ligament. Additionally, the limited group had less ankle dorsiflexion
displacement compared to the normal group as well.
So what should you take conclude
from all of this and take back with you into the clinic? Well, for one it
should be noted that using a non-weight bearing ankle dorsiflexion assessment
may not be sensitive enough. The weight-bearing lunge test was much better at
identifying these subjects with altered movement patterns. This test is much
more field-expedient, is reliable, and can be assessed without the need of a
goniometer. Finally, it is evident that there is a growing body of evidence
that limitations in ankle dorsiflexion result in kinematics that are associated
with increased loading of the anterior cruciate ligament of the knee. This is
just another example of how the entire kinetic-chain is important when screening
for or assessing injuries. Do you currently assess ankle dorsiflexion when
looking to return patients to physical activity or when preventatively
screening for risk of injury?
Dill KE, Begalle R, Frank B, Zinder S, Padua DA.
Altered Knee and Ankle Kinematics During Squatting in Those With Limited
Weight-Bearing Lunge Ankle-Dorsiflexion Range of Motion. J Athl Train. [Epub Ahead of Print].
Fong CM, Blackburn JT, Norcross MF, McGrath M,
Padua DA. Ankle-dorsiflexion range of motion and landing biomechanics. J Athl
Train. 2011;46(1):5–10.
Happy Holidays and a Happy New Year to all of my readers! I'm not sure if I actually have any dedicated readers yet but happy holidays to any happenstance readers as well! This post is a highlight of my top 5 viewed posts of 2013. I know it isn't technically 2014 yet so maybe I will be proved wrong. However, if you are new to my blog or haven't read all of my posts then maybe this recap will enlighten you to a popular post that you missed.
Hey guys! Here is a quick video that I shot the other day while working with a patient of mine. I just wanted to share a technique for ankle mobility that utilizes the Edge Mobility Band (or a theraband).
Case: 21 year old male, collegiate basketball player, 4-weeks post ankle sprain. Imaging revealed avulsion fractures of the medial deltoid and lateral calcaneal-fibular ligaments. Patient was ordered by the team physician to be immobilized in a boot and on crutches for the first three weeks following injury. Initially coming out of the boot, dorsiflexion and plantar flexion were almost a zero for both active and passive ROM.
In the video, this obviously didn't return ankle ROM to normal ranges but definitely increases it with just one set. I often repeat this 2-4 times depending on the patient's tolerance to the compression. I often have the patient walk a longer distance if tolerated as well. It also substantially lowers the patient's perceived discomfort associated with ankle "stiffness" and "soreness". I use this in conjunction with several different mobility techniques but is nice because certain techniques like a traditional posterior glide are much too uncomfortable for me to use with this patient at this stage. This is a pain free alternative for him!
Today's post is kind of half personal story/half conjecture/half observation(wait, that doesn't add up!). To begin, I have now been wearing a minimalist/zero drop type shoe everyday for both casual use and exercise/running. The only time I wear a shoe that is not completely flat is when I wear my dress shoes with my suit for basketball games.
One of my current favorites
I am a huge proponent of wearing zero drop shoes with a wide toe box and the absence of a "toe spring". I feel this shoe design interferes the least with proprioception, normal foot mechanics, and proper tissue length. Think of non-zero drop shoes as being like a mini-high heel.
Today's post is centered around a patient that I have been working with lately. This athlete is a sophomore collegiate runner that competes in middle distance running events.
History:
This patient is now a 19 year old male that began running in 4th grade. He was in a running club affiliated with his grade school and was soon running around 160miles a year. He began to suffer minor injuries during middle school and somebody had prescribed him orthotics. He struggled with stress fractures, hip pain, and plantar fascia pain all through middle school. Despite these issues, he still managed to run a 4:43 Mile as an 8th grader.
Throughout high school he continued to struggle with injuries such as hamstring strains/tendonosis, spinal stenosis and low back pain, chronic ankle instability and piriformis issues. He also struggled with plantar fasciitis/osis during this time as well.
Once this athlete got to college he tried to transition to minimalist footwear in attempt to "correct" his heel strike. He did not suffer at all until halfway through his first cross-country season when he had a week long flare up of pain that was similar to his previous plantar fasciitis/osis. He was fine again until the beginning of his first indoor track season. The pain became unrelenting despite being prescribed new orthotics and undergoing an expensive shockwave therapy procedure. The patient decided to just cross train and rest for the remainder of his freshman year as a collegiate runner.
This is where I entered the picture and had a few small conversations with this athlete regarding his plantar pain and I gave him a few exercises to perform on his own such as a self-mulligan mobilization with movement technique for ankle dorsiflexion and repeated end-range plantar flexion prior to runs. The patient used these few exercises all summer long until he returned for his sophomore year with good results but was not completely pain free.
I heard that he was still struggling with his plantar pain and offered to help him with a proper evaluation and treatment plan.
Hey Readers! Here is a quick video that I made a week or so ago on how to do a Mulligan Mobilization With Movement technique to increase ankle dorsiflexion. Ankle dorsiflexion seems to be a common theme on my blog but it is a common restriction but a very important motion to have! In this video I show you a way to do it this alone or with a partner/patient. This won't be a new concept for some but I hope those who have never heard of it find it useful! Enjoy!
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Caution
All content on this blog is meant as instructional and educational. The author and guest authors of this blog are not responsible for any harm or injury that may result. Always consult a physician or another proper medical professional for medical advice.
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