Category Archives: Ankle

The Effect of Stretching Alone

19 Sunday Feb 2017

Posted by in Ankle, Flexibility, Uncategorized

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Stretching is a common principle used to improve resistance during activity, when feeling a sensation of tightness, or to lengthen a short muscle.  But how much is enough?  We as practitioners prescribe 30 second holds, repeat 30 second holds, or to hold for up to 2 minutes.  Some studies show a benefit from holding for those lengths of time.  But that is in the short-term.

What is the effect in the long term?

A randomized controlled study by Youdas et al. assessed the effects of a closed-kinetic chain stretch of the ankle dorsiflexors over a 6 week period.  They compared a control group versus 3 experimental groups (30 second hold, 1 minute hold, and 2 minute holds).  This was conducted 1 time a day.  Sixty to seventy-two hours later after the final day of the 6 week period the ankle range of motion was taken again.  They found no significant change in the range of motion between the experimental and the control groups.

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So what does that mean?

As practitioners, we know that stretching will help with lengthening a muscle.  We prescribe the stretch for multiple times a day and hope that is followed.  But in reality, how many people are able to set time aside (three, four, or five times a day) to complete the prescribed home exercise program as well as remember to complete in their busy schedules.

Should we be prescribing stretching multiple times a day or should we prescribe the stretch 1 time a day but combine it with functional activities that make use of that range gained from the stretching?  Example, complete a calf stretch for 60 seconds and then teach them to walk with a longer step length and trying to keep the heel down a little longer during terminal stance to use that increased motion.

We can know and educate individuals the right thing to do for themselves with stretching or exercise but the carryover comes from incorporating it into everyday life.

 

Reference:

Youdas JW, Krause DA, Egan KS, Therneau TM, Laskowski ER. The effect of static stretching of the calf muscle-tendon unit on active ankle dorsiflexion range of motion. J Orthop Sports Phys Ther. 2003; 33(7):408-417.

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An Ambiguous Dorsal-Lateral Foot Pain Case Study

07 Saturday Feb 2015

Posted by in Ankle

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I found this case study interesting and beneficial when considering treatment for painful ankles.  The article presents with very vague symptoms with limited objective measures eliciting abnormal findings.  I thought this article showed the importance of assessing joint end feels during standard range of motion assessments.

This article examined a 54 year old male software engineer with chief complaint of right dorsal lateral foot pain described as an ache at the dorsal joint line of the cuboid and fourth metatarsal.  Symptoms were of insidious onset about 3 years ago when hiking.  He noticed the symptoms about 1 hour into the hiking and quickly resolved when he stopped hiking.  The subject continued to hike about 1x/week.  He then noticed an increase in symptoms about 1 year ago due to unknown cause with the symptoms occurring about 10 minutes into walking and took about 30 minutes to resolve.  The subject presented with negative x-rays and MRI’s and did not respond to orthotics or electrical stimulation; all provided by a podiatrist.

Physical therapy examination revealed:

1. Tenderness to the dorsal base of the fourth metatarsal

2. Manual Muscle tests of foot, ankle, knee, and hip to be 5/5

3. Negative ligament stress tests for anterior and posterior talo-fibular ligaments, calcaneal-fibular ligament, deltoid ligaments, anterior interosseus, and medial and lateral subtalar ligaments

4. Gait assessment did not show any obvious deviations or pain

5. Posture did not present with any asymmetries or faults

6. All range of motions were normal at the hip, knee,, ankle, and midfoot but the subject had pain at the end range of nonweight bearing plantar flexion and mid-range weight bearing dorsiflexion.  He also presented with a more firm capsular end feel at end range of nonweight bearing dorsiflexion.

7. Joint mobility of talocrural, tarsal, and metatarsal articulations showed decreased posterior and lateral glides with restricted firm capsular end feel of the talus on the tibia.  All others were normal.

Treatment consisted of a high-velocity low amplitude traction joint mobilization of the talocrural joint causing an audible cavitation and a palpable distraction of the joint.  This improved accessory motion of the talocrural joint, the end feel of joint mobility, and the elimination of pain during range of motion assessment.

The subject was given a home exercise program that consisted of wearing shoes as much as possible during the first week to allow the fourth metatarsal to heal and two exercises: completing squats with proper alignment and then a lunge with the affected leg forward and slight internal rotation of the tibia to promote external rotation of the talus both for 10 repetitions 4-5 times a day.

The subject’s symptoms improved and he was able to return to his activities.

Callan B. Clinical reasoning and multi-modal treatment for dorsal-lateral foot pain: a case study. Ortho Pract. 2015; 27(1): 26-31.

The Importance of Ankle Range of Motion for Knee Pain

25 Thursday Dec 2014

Posted by in Ankle, Patellofemoral Pain, Uncategorized

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Knee Mechanics

It is important to assess multiple areas of the body when treating knee pain and more specifically patellofemoral pain (PFP).  One major contributor to knee pain is hip strength.  Good hip strength is important to aid in appropriate knee alignment and mechanics.  Another important contributor is foot alignment.  Many individuals with PFP exhibit over pronation of the midfoot/flatfoot.  This will cause the lower leg to turn in and place more stress of the patella on the femur.

But one aspect that I believe needs more consideration is ankle range of motion; specifically ankle dorsiflexion range of motion.

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A study by Rabin et al. found that individuals with PFP had less than optimal movement during a lateral step down test and exhibited significantly less ankle dorsiflexion range of motion (4.7° in weight bearing and 5.3° in non-weight bearing) than individuals with optimal movement and without pain.  More specifically, they found that men had a significant difference of 8.5° with non-weight bearing measurements.

Could this limitation in ankle dorsiflexion range of motion be a precursor for maladaptive behavior found at the foot, knee, and hip?  The researchers proposed that the limitation in ankle dorsiflexion will cause less forward movement of the tibia when walking, running, and going up and down stairs.  This may cause excessive compensatory movement of the midfoot, such as over pronation, in order to get the needed range to complete those tasks.  This will also cause the knee to turn and place more force of the patella on the femur.

A recommendation to improve ankle dorsiflexion for people with PFP is to complete a stretch against the wall or counter holding for 30 seconds and completing 2 times.  Use this stretch (presented in the video below) until knee discomfort subsides and a lunge position with the knee on the floor can be tolerated.

A more dynamic lunge stretch (shown in the video below) can be completed to further improve ankle dorsiflexion range of motion.  Hold this position for 5 seconds and complete 20 times.  These motions should be completed on both sides even of you do not have discomfort at both legs.

 

Limitations of the study:

  1. It was not possible to determine whether limited ankle dorsiflexion range of motion is the cause of abnormal lower quality of movement or a consequence.
  2. The findings are limited to visual assessment of the quality of movement during the lateral step down test.
  3. The subgroup analysis was not preplanned and they completed the analysis only after observing abnormal tendencies in the subjects.
  4. The examiners were not completely blinded to the quality of movement assessment.
  5. The sample of subjects were younger than other populations of people with patellofemoral pain so results should not be generalized to all individuals.

Reference: Rabin A, Kozol Z, Moran U, Efergan A, Geffen Y, Finestone AS. Factors associated with visually assessed quality of movement during a lateral step-down test among individuals with patellofemoral pain. J Orthop Sports Phys Ther. 2014; 44(12): 937-946.