Ankle.docx

ANKLE: THE TWO MOST IMPORTANT ANKLE MOTIONS (DORSIFLEXION AND PLANTARFLEXION) ARE ASSESSED AND TREATED.

Dorsiflexion: Dorsiflexion is the most functional motion of the ankle. It is used in walking, running, squatting, jumping and landing. If dorsiflexion is limited there will be compensations throughout the kinetic chain creating multiple layers of dysfunction. Dorsiflexion should be tested when a patient has trouble with walking, running, squatting, jumping, landing or pain in the ankle or foot. It can be used as a secondary assessment for knee, hip or lumbar spine problems as well.

Dorsiflexion Testing Video

Demonstrate and instruct patient to:

1. 2. 3. 4. 5. 6. 7. 8. 9.

Standing with feel shoulder width apart, place hands against the wall shoulder width apart. Place the foot of the side being tested a few inches from the wall. Bending the knee, lean weight forward and down, until the knee touches the wall. Slide the foot back and repeat until the heel stays on the floor and the knee can't touch the wall. Slide forward slightly until the knee is just touching the wall and the heel is on the ground. This is maximum dorsiflexion. Do not allow the hip to adduct or tibia/foot to externally rotate. Keep weight on both feet. Measure distance from wall to toes with blocks.

There are many ways to test dorsiflexion, this is the best. Don't test dorsiflexion kneeling or non-weight bearing. There are 4 blocks: 3", 2", 1" and 0.5" this allows for all increments from 0 to 6.5. Blocks are provided for you at the Ankle hands-on seminar for no additional charge.

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Normal range is 6 inches.

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Range should be symptom free.

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Range should be easy (requiring little effort).

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Note location, type and severity of symptoms to compare pre and post treatment.

There is no need to perform a "gastroc stretch." Full dorsiflexion with the knee straight almost never happens in a functional environment and the gastroc would have to be insanely restricted to limit the motion. The only activities that come close are ski jumping and possibly race walking.

Tissue Specificity: When a range of motion is limited in the ID system we have to ask: What tissues have to

lengthen to allow full motion? The following structures have to lengthen to achieve full dorsiflexion, and therefore can limit dorsiflexion:

1. Soleus 2. Tibialis Posterior 3. Flexor Hallucis Longus 4. Flexor Digitorum Longus 5. Posterior Talofibular Ligament 6. Posterior Tibiotalar Ligament When dorsiflexion is limited one or more of these tissues is responsible. If dorsiflexion is full then these tissues do not have significant adhesion.

The next question is "How do we determine which of these structures are limiting dorsiflexion?"

Selective Tension: When a structure crosses two joints you can bring one joint to end range, hold that position, then test the other joint to see if there is still some slack. If there is slack, that tissue is not blocking the range of the first joint. Dorsiflexion: Selective Tension Video

Have the patient hold the end range of dorsiflexion. Lift the big toe and place your finger under it, this selectively tensions the flexor hallicus longus. If this motion can be accomplished with minimal resistance the flexor hallicus longus still has slack and is not blocking dorsiflexion. If you can't lift the big toe, or it is very difficult, the flexor hallicus longus is restricted and needs to be palpated and treated with Manual Adhesion Release. MAR: Flexor Hallicus Longus

Have the patient hold the end range of dorsiflexion. Lift the 2nd and 3rd toes (don't worry about 4th and 5th toes) and place your finger under it, this selectively tensions the flexor digitorum longus. If this motion can be accomplished with minimal resistance the flexor digitorum longus still has slack and is not blocking dorsiflexion. If you can't lift the 2nd and 3rd toes, or it is very difficult, the flexor digitorum longus is restricted and needs to be palpated and treated with Manual Adhesion Release. MAR: Flexor Digitorum Longus

If the big toe, 2nd and 3rd toes pass the selective tension test (toes can be extended) we now have 4 structures on our list for limited dorsiflexion:

1. 2. 3. 4.

Soleus Tibialis Posterior Posterior Talofibular Ligament Posterior Tibiotalar Ligament

There is no way to functionally distinguish among these 4 structures. However, the posterior ligaments most often restrict the remaining range. This puts the posterior talofibular ligament and posterior tibiotalar ligament at the top of the list. The ligaments have a greater ability to alter the axis of rotation than the soleus or tibialis posterior as they are very close to the joint. MAR: Posterior Talofibular Ligament

MAR: Posterior Tibiotalar Ligament

After the ligaments are cleared. The tibialis posterior is deep to the soleus so the soleus needs to be relatively free of adhesion to reach the tibialis posterior. Priority is established here based on anatomy and depth of tissues.

MAR: Soleus

MAR: Tibialis Posterior

Effective assessment and treatment of these six tissues will normalize restricted dorsiflexion in the vast majority of cases. If you are not obtaining results you need to get better with your technique. Do not search for other magical procedures or secret structures to work on. Focus on getting better, a lot better, at these basics. Most treatment problems result from not first palpating the adhesion and having too much compression with treatment. Palpate, palpate, palpate. Take it easy on the compression. Attend the live seminars.

Test- Treat- Retest: Test dorsiflexion after treatment. Compare range and symptoms pre and post. Any increase in range is progress regardless of symptoms. An increase in range and a decrease in symptoms is double good. It is also a good idea to test the functional motion that is limited: squat, gait etc. Be sure to point out to the patient the improvements in range, function and how the symptoms are better/different. Sometimes you have to shove this down their throat. Don't be shy. Take credit for you awesome skills! Say something like: "Wow, do you see that?... You are getting a full 2 inches more motion... High five." You get the idea. Unlayering: Multiple layers of dysfunction is normal. You may find the flexor hallucis longus is restricted. Treat this and the flexor hallucis longus test is now negative with improved dorsiflexion range but still not full. Then you may treat the soleus and again improve range. Then you might treat the posterior tibiotalar ligament and further improve range. Expect multiple tissue to limit the motion and move from tissue to tissue as the ranges, symptoms and palpation dictate. Ninety Nine percent of musckuloskeletal providers would have the patient stretch in the test position. Think about how rudimentary this fundamental idea is: if a motion is blocked just push on it hard until it is fixed! It's non-specific and it doesn't work (by work I mean a lasting reduction in dysfunction and a corresponding improvement in function). Rest assured you have a shiny new race car while everyone else is driving a moped!

Functional examples of dorsiflexion

The point of these examples is to show how important it is to have full range with dorsiflexion. Do not worry about "seeing" if dorsiflexion is full during jumping, squatting, running etc. You just need to perform the test for dorsiflexion range as described at the beginning of this page. You can also add a pre and post functional test (squat, running, jumping etc.) to determine relevance and demonstrate improvement to your patient. Overhead Squat: Case Example

This video shows the impact restricted dorsiflexion has on the overhead squat. It is very easy for limited dorsiflexion to destroy squat form, cause low back and hip problems and make the lift weak. Box Jump: Before and After

This video further demonstrates the importance of full dorsiflexion with jumping and landing. Huge biomechanical improvements are made after only 1 treatment- better leverage, strength, endurance and load distribution.

PLANTARFLEXION: Plantarflexion is a secondary motion of the ankle. It can be assessed after dorsiflexion is normalized, range is grossly limited or if local symptoms are present.

PK TEST (PLANTARFLEXION KNEE FLEXION TEST)

The PK test assesses knee flexion and ankle plantarflexion. Here we will focus on plantarflexion. The test is normal when the tibia, anterior ankle and dorsum of the foot are in complete contact with the floor. In addition (if the knees are healthy) bodyweight will add overpressure challenging the structures further. In the final position range should be full (full contact with floor), loaded (weight on heels) and produce no symptoms at all (patient could sit there comfortably for several minutes). If the PK Test is positive assess the anterior compartment and extensor retinaculum using IAR.

Anterior Compartment IAR

Extensor Retinaculum IAR

LOCKOUT TEST Lockout Test

The lockout test assesses functional plantarflexion, including length of the dorsiflexors and strength of the plantarflexors. The test is normal if the patient can easily lock the ankle in full plantarflexion on one leg bearing full body weight. Pain, limited range or difficulty is a positive test. If the patient fails the lockout test with one leg peel back and use two legs. If they pass the two leg lockout test but fail the one leg they definitely need strength training. A simple heel lift off of a step for two sets of as many reps as possible once a day will work great.

When the lockout test is positive make sure dorsiflexion and the PK test have been assessed and corrected. If the lockout test is still positive there is a force production issue with the plantar flexors. Strength exercises may need to be implemented. In some cases tendon tears and joint morphology issues need to be considered.

ANKLE FLOW: PROPER TESTING

Ankle inversion and eversion are not included in the core material, as they are not primary ankle motions and are relevant for only a small percentage of patients. Copyright 2018 Integrative Diagnosis LLC

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