Therapeutic modalities had an entire course devoted to it in my educational curriculum and there is more and more research being done on the topic. There is plenty to learn about the theory and application of each individual type of modality from ultrasound to electrical stimulation and plain old ice.
I definitely learned a lot and the use of modalities has been definitely beneficial for me as a clinician, especially for acute injuries. However, I have found myself and others at fault for relying upon modalities too much. There are too many clinicians relying upon the "powers" of modalities instead of using the power of movement and rehabilitative exercises. I'm not saying that they don't have their place because they definitely do but they often are too heavily relied upon.
I am quickly reaching my one year anniversary since finishing my undergraduate education and becoming a certified athletic trainer. A lot has happened since then including starting work on my master's degree, my master's thesis and working with many different athletes and teams via my graduate assistant position. I have learned a lot and it would be impossible to list everything but I figured it would be a good idea to reflect back on a few major themes.
Somehow, someway during my initial years of schooling I
developed this idea that the profession of athletic training needed to compete
heavily with other professions. I used to think that I needed to boycott the
teachings of other professions like physical therapists, strength and
conditioning specialists and person trainers. I also had an urge to compete against others within my own
profession and try to be most intelligent or most competent clinician/academic. Finishing school and starting my professional career has definitely changed my thought processes.
While some level of competitiveness is necessary in a world
where multiple professions compete for patients or clients from the same pool
of people due to similar skill sets. However, I have begun to realize that this
previous thought process hurt three groups of people. Thinking and behaving the
way I did disadvantaged myself (the clinician), potential patients, and the
different professions.
Recently, I have worked to open myself up to the ideas of
others and other professions. Just think, where would human intelligence even
be now without the collective body of knowledge that is shared between
individuals? We might be able to think the same but the accumulation of
knowledge that is passed around and down through time is what makes it special.
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.
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.
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.
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.
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.
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.
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.
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.
Do not ignore above and below, tibial internal & external rotation as well as plantar fascia mobility influence movement at the ankle as well.
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!
Howdy potential future readers. I am not sure if I will ever get any future readers but hello if I somehow do garner your attention. I am starting my first blog, this blog, because I would like to create a source or forum where I can communicate ideas with others who may or may not have similar ideas with myself. This type of atmosphere can help me learn from others, help others or debate with others.
The fact that nobody agrees on anything is great. It is a good thing in the world of science and it keeps the regular world from becoming too boring. I would like to write about topics that interest me and as a 23 year old graduate student and Certified Athletic Trainer (not trainer) I have interests in diet, running, health, science, cycling and health care. Some may feel like the future posts will be too far ranging at times but I see all of these topics as inter-related and integrated with each other.
I hope to share personal stories, stories of others, related news and articles of research related to the aforementioned topics and more. I am not promising myself or anyone that I am an English laureate. I can't even promise myself that my writing can rival the average 5th grader's writing but I will attempt to create legible posts for your sake.
My first real post will be based upon the topic of the never pleasant runner's trots and its relationship with diet. This preview to my first topic might repel some potential readers and it may catch the attention of others. Just like runner's trots, it is probably a risk that I shouldn't take.
Below is a couple of pictures of myself to help give voice to my writing.
Disclaimer: Please note that some of the links on this blog are affiliate links and I will earn a commission if you purchase through those links. I have used all of these products listed and recommend them because they are helpful and are products from companies that I trust, not because of the commissions that I may earn from you using these products.
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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