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Know Your Numbers: Ankle Pain, Foot Pain, and Ankle Dorsiflexion

Know Your Numbers: Ankle Pain, Foot Pain, and Ankle Dorsiflexion Barefoot Rehabilitation Clinic
ankle-dorsiflexion

15 Jan Know Your Numbers: Ankle Pain, Foot Pain, and Ankle Dorsiflexion

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Without an ankle dorsiflexion (knee to wall test) measurement, don’t bother trying to get your ankle pain or foot pain fixed. ~Barefoot Rehab

So … you have a calf, ankle, or foot problem.

Hopefully, it hasn’t gotten so bad that you have plantar fasciosis or achilles tendinosis.

Do you know how many inches of ankle dorsiflexion you have?

If you don’t, you need to.

The most important test when it comes to measuring the integrity of the leg and foot is ankle dorsiflexion or the Knee to Wall Test.

It is the most functional range of motion for the ankle because as human beings, we walk arguably more than any other activity we do (excluding sitting and sleeping).

Before you push off to swing your foot through when you walk, your ankle approaches your end range of dorsiflexion.  Without sufficient range of motion, your body compensates.  One compensation is when your hip flexes early to avoid touching the end range of dorsiflexion (contributing towards hip flexor overuse and adhesion).  Another compensation occurs when your foot externally rotates (contributing to first metatarsal overuse, adhesion, and risk of bunion) and you walk like a duck.

Quack, quack.

We also need access to ankle dorsiflexion range of motion to squat to maximum depth with an upright chest.  Restricted dorsiflexion results in an immature squat (with your chest way over your knees to counterbalance your butt, which is too far back) or the feeling that you are falling backwards.ankle-dorsiflexion-during-squat

Three Key Tips to Tip The Scales of Success

Your ankles are on your feet and carry your body around for most of the day when you walk and stand (obviously, not when you sit).  Your ankles are load-bearing and work the majority of the day, even when you’re not exercising, running, jumping, or lifting.  The load faucet, due to the nature of ankles, drips into your capacity bucket all day long when you’re on your feet.

By comparison, your shoulders, which are hanging freely from your clavicles, are not load-bearing and therefore, recover more quickly than ankles.  With shoulder injuries, you can turn the metaphorical faucet off by not using shoulders.  You don’t use (load) your shoulders when you sit, walk, or stand.

  • Ankles = Load – bearing = work harder throughout the day = difficult to give time to repair.
  • Shoulders = Not Load – bearing = work less throughout the day = easier to give time to repair.

As we discussed in Why You’re In Pain, when Load exceeds Capacity, you get pain.  When you’re in pain and Load continues to exceed Capacity, you don’t heal.

Key Tip #1: If you’re serious about restoring ankle dorsflexion range of motion or recovering from your calf, ankle, or foot injury, then you need to deload.  In this case, that means minimizing walking and especially, prolonged standing.

Key Tip #2: Orthotics are a must when it come to load management.  In some cases, an over-the-counter insert can decrease load and reduce symptoms.  In our office, we use the best orthotics out thereSole Supports (FYI – We get nothing for telling you how amazing these supports are).  They’re wonderful orthotics casted seated in a maximally supinated position, thus cushioning the arch with each step you take. A non-maximally supinated orthotic does not cushion the arch like this.  The orthotics take into account your body weight and foot flexibility as well, which makes them quite individualized.

Key Tip #3: Stretch the right tissue.  Too many people waste their time stretching the calf with their knees straight.  The gastrocnemius rarely ever has adhesion and does NOT stop the knee to wall test.  It’s best to stretch the ankle with the bent. See the “Specific Dysfunction” part below about which tissues are relevant.

Ignoring these key tips could mean that you’re doing all of the right stretches and getting all of the right treatment and if your range of motion isn’t increasing, you are simply not giving your tissue a chance to recover and loosen up.

Mobility: Knee to Wall Test | Ankle Dorsiflexion (AD)

Don’t judge my orange SkyZone socks.  First, that place is like heaven for adults who want to peg kids in the head with dodgeballs, as I did and wrote about in The Good Body Project.  Second, the socks come with grips on the soles of the feet that give you extra traction when you’re trying not to slide across wooden floors.  Super comfy!

ankle-dorsiflexion-in-knee-to-wall-test

The ability to touch a wall with your toes 5″ away from a wall and your heel down is something that anyone should be able to do, when healthy.  The “Knee to Wall Test”, or in mechanical terms, ankle dorsiflexion, will let us know if you have that ability.

What do I need to Measure this Test? In our office we use white blocks in 3″, 2″, 1″, and 1/2″ increments.  It’s easier for patients to visualize their range of motion with a 3-D block.  You can just as easily use a ruler on the ground.

ankle-dorsiflexion-with-blocks-and-ruler

What is the Knee to Wall Test assessing? The mobility of your calf, ankle, and foot integrity. These structures include bone, ligaments, tendons, cartilage, and muscles.

What Specific Dysfunctions are relevant here? Unlike the lumbar spine that tends to accumulate many structural dysfunctions, the ankle tends to be structurally healthy.  That’s good news for us!  This means that the majority of individuals with restricted ankles should be able to increase range of motion except when trauma has caused permanent damage.  When dysfunctions are present, pathologies around the mortise joint are the most common and what would limit this range.

Relevant muscles include:

  • tibialis posterior – the stretch is in the middle of the calf, deep.
  • flexor digitorum longus – the stretch is in the medial portion of the calf, deep.
  • flexor hallucis longus – the stretch is in the lateral calf, deep.
  • posterior tibiotalar ligament – If this is problematic, you’ll feel a pinch on the front of the ankle. This ligament cannot be stretched or mobilized. The only way to affect this tissue is with a manual therapist who would take the small edge of a finger and put it under the malleolus to treat it.
  • posterior talofibular ligament – see “posterior tibiotalar ligament” above.
  • soleus – This muscle, while relevant on occasion, is not as significant as the 1st 5 structures above.  What this means for you if you’re mobilizing, go as deep as possible.  The structures above are deep to the soleus. Use an object with a smaller surface area – lax ball, or even a golf ball – than an object with a larger surface area – foam roller.

Completely irrelevant muscles include:

  • gastrocnemius (This muscle is stretched with the knee straight. Don’t bother stretching this muscle as it almost never has adhesion.)

What You Need to Know: A calf stretch during the SLPF Test has a completely different physiologic cause than this test.  It’s nerve in the former, muscle in the latter.

How to Test: Take your shoes off.  Put a ruler against the wall.  Start with your toes against the wall, standing on top of the ruler.  Heel down.  Keeping your heel down, move your knee straight forward toward the wall without letting your knee cave in towards your first toe.  If you knee touches the wall with your heel down, you have that range of motion.  Move your toes 1″ away from the wall at a time, continuing to be sure that your heel is down and your knee doesn’t cave in.  The last range of motion before your heel is about to lift or when your knee just barely touches the wall is your Ankle Dorsiflexion Range of Motion.

Watch the three minute video below if you’re of a visual person.

ankle-dorsiflexion-heel-downankle-dorsiflexion-move-knee-to-wall

Write this number down.  Any mobilization, stretching, or treatment interventions are attempts to increase this number.  If the number isn’t increased after a month, you’re wasting your time.

PASS:

A pass for this test is the ability to touch a wall with your toes 5″ away from a wall and your heel down (best visualized from the side).  When observed from the back, the knee should be over the 2nd toe.  Notice, for integrity’s sake, I only have 4.5″ of range of motion in the picture below titled “Passing End Range of Motion”.  I want to show you what a full range of motion looks like.  For the passing test’s sake, imagine another 1/2″ block thrown in there.

ankle-dorsiflexion-passing-end-range-of-motion ankle-dorsiflexion-blocks

  • Range: 5 inches (don’t be confused by my 4.5 inches of maximum range – I fail this test).
  • Effort: Fast and easy.
  • Symptoms: No symptoms, including stretching.

FAIL – LOW RISK:

A fail is any range of motion between 3″ – 5″ with the heel down, the knee touching the wall and the knee over the 2nd toe.  For the athletes out there, the lower end of the spectrum here is the minimum amount of dorsiflexion needed to perform a hip width, toes slightly out, Olympic-style squat.  In this case, 3″ was my personal measurement, given the length of my femur (thigh bone), tibia (weight-bearing leg bone), and foot.  Your body is different than mine, so your number will likely be different as well.

  • Range: 3 inches – 5 inches.
  • Effort: Fast and easy.
  • Symptoms: Because your range of motion is limited, some tissue will be stopping your range of motion, which means that you will likely feel a “stretch” sensation somewhere in the calf, posterior ankle, or foot.  You could also have an impingement (“pinching sensation”) in the front the ankle, which would indicate that the posterior tibiotalar ligament or posterior talofibular ligaments are adhesed.  Don’t even bother rolling out if this is the case.  See a manual therapist to remove the adhesion in those ligaments.  If you have pain, you have a problem and you should either rest before you test again or see a qualified therapist.

FAIL – HIGH RISK:

A fail, with an individual having no business doing any non-essential walking or exercise, is anything less than 3″ with the heel down, the knee touching the wall and the knee over the 2nd toe.

  • Range: Less than 3 inches.
  • Effort: Slow and cautious, indicative of “protective tension” and “red-lighting” from the central nervous system.  This protective mechanism occurs when tissue is damaged and the body is subconsciously protecting further load from occurring to the damaged tissue.  If you feel a “stretch” when combined with this slowness, the cause of the “stretch” is actual muscle contraction or “protective tension”, not the lengthening normally thought of as a “stretch”.  This means that if we cut look at the tissue on a microscope, we would see the muscle’s active units, the sarcomere, sliding past each other (indicating contraction), not moving further away from each other (as seen in a stretch).
  • Symptoms: See above in the “Low Risk” section.  If the range is this bad, it’s possible that this range of motion has been restricted for a long duration of time, which means that you’ve been compensation for a long time as well.  Knee and hip symptoms during this test indicate that you should really consider getting help.

Movement Faults:

If your heel lifts (see A), if your knee can’t touch the wall (B), or if your knee caves in (out of alignment with the 2nd toe), you’re toes are too far from the wall and you need to move closer.

ankle-dorsiflexion-fault-heel-lift

ankle-dorsiflexion-fault-knee-not-touching

ankle-dorsiflexion-back-view

ankle-dorsiflexion-fault-pronated-ankle

I Know My Numbers – What do I do now?

Insanity: doing the same thing over and over again and expecting different results. ~Albert Einstein

There are a plethora of mobility and stretching resources out in the interweb for you to experiment with to improve your ankle dorsiflexion.  I like this post with 7 advanced mobility exercises.  It is not our intention to give prescriptive answers, simply to bring awareness to where your body currently is in time.  One meta-analysis done in 2006 supports the notion that static stretching from 5-30 minutes can create small improvements in ankle dorsiflexion.

Use whatever tools you’d like to use for a month, stretching about from 5-30 minutes a day, for 3 days a week, for a month.

After a month, re-test.

If you’ve gained range of motion, wonderful!  Wash, rinse, repeat, and continue stretching.

If you’re no more flexible or mobile than you were before, STOP THE INSANITY AND THE STRETCHING!  It’s now time to see a Manual Adhesion Provider or Active Release Technique Provider to diagnose your condition and potentially remove the adhesion in relevant tissue to restore your mobility before you go on layering strength on top of unhealthy tissue.

barefoot_stopstretching

Want to test the rest of your muscles and joints? It’ll only take 2 minutes per test, but you need a friend to help.

speechbubblesWhat are you ankle dorsiflexion numbers? Please share range, effort, and symptoms below and we can discuss what you should be doing to restore musculoskeletal integrity.

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Dr. Chris Stepien, DC, Full-Body ID Certified, ART Certified, CSCS, and CrossFit Level 1 Certified, is a Sports Therapy & Chronic Pain Resolution Specialist with Barefoot Rehab in Parsippany, NJ.  When you’re in pain that hasn’t gone away and you’ve been to at least 3 other doctors, Dr. Chris wants to help you. And when you’re sad, depressed, or not enjoying life, Dr. Chris wants to hug you. He invites you to reach out, no matter what your concern is. Barefoot Rehab is here to serve you.

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25 Comments
  • Know Your Numbers: Ankle Pain, Foot Pain, and Ankle Dorsiflexion Test | Primal Docs
    Posted at 20:51h, 15 January Reply

    […] Know Your Numbers: Ankle Pain, Foot Pain, and Ankle Dorsiflexion Test […]

    • Maria Sexton
      Posted at 18:17h, 19 November Reply

      I was told I suffered a grade 3 ankle sprain almost 6 weeks ago. I stumbled across this site and out of curiosity tried the knee to wall test. My range was less than an inch and at 1 inch there was pain. My orthopedic doctor has yet to even lay hands on my ankle. I am to begin physical therapy in 2 days and I am afraid of pain or accidental injury from improper diagnosis. My ankle, when I stand and put weight on it slides in and down making my foot look like it is flattening out. This is also very painful. The pain is on the outside, Inside and in front but above my ankle as well as below my knee on the outside of my calf.

      • Dr. Chris
        Posted at 11:12h, 20 November Reply

        Hi Maria, the good thing about injuries like yours is that the diagnosis is usually correct. Based on what you mention about your symptoms and how the ankle moves, it sounds correct. You should keep doing this test to assess how you are progressing. The goal is 6″ of range of motion. If PT doesn’t help you get there, you may need a manual therapy specialist. Let me know how I can support you.

  • The Truth About Plantar Fasciitis (and Arch Pain)
    Posted at 12:56h, 19 January Reply

    […] which is often very true with restricted ankle dorsiflexion and plantar flexion (see below – Measure your ankle dorsiflexion through the directions here).  Tissues can be tight for various reasons that warrant further detail to resolve (ie. muscle […]

  • Do You Trust Your Doctor & Advanced Pain Management: The Research on Expert Intuition
    Posted at 15:39h, 08 February Reply

    […] sustainable improvement in her functional range of motion (her restricted and relevant test is ankle dorsiflexion, showing 2.5″ on both sides) and no improvement in her capacity upon walking barefoot. […]

  • Foot Positioning in the Squat and Ankle Dorsiflexion Range of Motion
    Posted at 23:38h, 20 April Reply

    […] I already showed you how to measure your ankle dorsiflexion here. […]

  • Know Your Numbers: The Thigh to Chest Test
    Posted at 20:58h, 01 June Reply

    […] awaiting 30 days from now to reassess, you might as well get baseline measurements for your ankles and your low […]

  • Know Your Numbers: The Lunge Stretch Test
    Posted at 14:28h, 15 June Reply

    […] 30 days from now to reassess, you might as well get baseline measurements for your hip flexion, ankles and your low […]

  • Sally M
    Posted at 21:34h, 12 July Reply

    I have roughly minus one inch of dorsiflexion on my right foot (knee roughly one inch from wall when toes touch wall). I run about 30 miles a week and feel fine except when running uphill, in which case the arch of the right foot feels strongly overstretched to the point of pain. The left foot has positive dorsiflexion of about one inch and feels fine when running. I tried daily calf stretching (both with straight knee and bent) for a few months but dorsiflexion didn’t improve. I felt no stretch in my ankle, just compression at the front of the foot. Is there any way to compensate for lack of dorsiflexion when running, since it doesn’t seem to be improving.

    • Dr. Chris
      Posted at 21:57h, 12 July Reply

      Hi Sally, Unfortunately, there is not a way to compensation for a lack of dorsiflexion. When you run, you need more dorsiflexion than 1″. My recommendation is that you stop running, or at least, stop running so much. Because you don’t have 100% capacity in your ankles, your mileage combined with your greatly diminished capacity will only worsen the ankles quickly and surely, other joints upstream (knees, hips, low back). Only time will tell. Riding a bike would take the ankles out of the equation. Is this something you would consider?

      Of course, the other option is to find a myofascial worker who can help you regain that range of motion. If you feel compression in the front of the joint, the posterior ankle ligaments are likely involved. There is NO way for anyone to stretch or mobilize these tissues without a skilled provider.

      I hate to be the one to give this recommendation. Know that my perspective comes from wanting to see you able to walk ( and run if you have to) decades down the road. That’s why I make this recommendation. Let me know your thoughts.

      • Sally
        Posted at 06:48h, 02 June Reply

        I’ve switched to barefoot running (in fact I’m barefoot or in Xero sandals 100% of the time) and feel great! Still get a negative result on the wall dorsiflexion test on my right foot, but not having foot pain any more.

        • Dr. Chris
          Posted at 11:33h, 02 June Reply

          Wonderful Sally.

          With 1″ of dorsiflexion, you should continue to be mindful over the months to years how your feet and calves feel. Barefoot running puts MORE load on these structures (generally), not less. But if you’re having more relief, whatever tissue was causing your pain is being loaded less, at least in the short term.

          If you’re really mindful and you do get a little symptom here or there, respecting those symptoms will help you to do the right thing by whatever is damaged.

          • Sally
            Posted at 12:55h, 02 June

            I have MINUS one inch actually on my less flexible side…

        • Dr. Chris
          Posted at 15:59h, 02 June Reply

          Yeah. You have a giant mass of an iceberg brewing underneath the surface, you just can’t see it yet. Please keep your running down to low volume and introduce intervals if you’re going to run at all. I’d be really surprised if 6 months from now, you’re still running barefoot like this.

          Forgive me for being the bearer of bad news, but I’d rather you get reality than false statements.

          • Sally
            Posted at 08:41h, 16 June

            That’s exactly what you said last year. I’ve increased mileage with no pain. I get that you’re trying to make money here, but why lie?

          • Dr. Chris
            Posted at 11:28h, 19 June

            Hi Sally, I’m glad you’ve been able to increase your mileage with no pain. It’s very common that over months to a few years, people can increase the amount of activity they have, even with severely restricted joints. So I’m not surprised you have no pain. My previous messages are warning signs that you will have growing pains over the next few years due to the 1″ of ROM. The more you monitor your activity, take care of your soft tissue, and understand “what’s going on underneath the car’s hood,” the more you’ll be able to prevent this. My intention in replying again is bringing this mindfulness to your running, not to upset you in any way. I apologize if I’ve done so.

            As far as trying to make money, I’m not quite sure what you’re talking about. Do you think I”m trying to get you to NJ as a patient? I don’t know where you live in the world but that’s usually not possible for people.

  • Know Your Numbers: The Face-Up Heel to Butt Test
    Posted at 17:49h, 16 July Reply

    […] now to reassess, you might as well get baseline measurements for your hip flexion, hip extension, ankles and your low […]

  • Seth Hamilton
    Posted at 19:01h, 22 December Reply

    I have a dorsiflexion of 1 1/8th inch. I “fractured” my talus in Feb 2015, and it doesn’t seem to be getting any better. Any suggestions to restore my range of motion if the exercising doesn’t work?

    • Dr. Chris
      Posted at 14:34h, 27 December Reply

      Hi Seth, I’m sorry about the fracture. Before asking your question, the real question is, “What is stopping your dorsiflexion at 1 1/8th inch?” If it’s soft tissue, you can gain that ROM back. If it’s due to the fracture, the talus, and a bony stop (imagine a wallet in a door hinge), then you cannot get it back.

      Let me ask you a few questions.

      – Did you need surgery?
      – Do you have the images of the fracture?
      – Did your doctors tell you if they thought you would get that ROM back?
      – Have you had a skilled manual therapist feel your deep calf tissue (or posterior ankle ligaments) to determine if they’re pulling tight and stopping that ROM?

      Answer those questions, feel free to send me any imaging or reports you have (delight [at] barefootrehab [dot] com), and I’ll take a look for you.

  • Dean Webber
    Posted at 14:20h, 30 April Reply

    Really glad I found this site! I have roughly 2″ dorsiflexion on both ankles, and have tried visiting numerous chiropractors and physios with no improvements (over a year!). It’s really hard trying to find a decent practitioner! Besides coming to your clinic (wish I could but I live in Japan!) could you give me some tips on how to tell a good practitioner from a lazy one. Thanks

    • Dr. Chris
      Posted at 22:17h, 30 April Reply

      Hi Dean! Glad you enjoyed the post. Sure, here are a few tips:

      1. Does the doctor have testimonials and case study proof of range of motion gains?
      2. Does the doctor claim to fix everyone (100% of the time) or are they realistic about the gains that can be made (expressing humility and realism – some people won’t have increases in ROM based on structural damage or overuse).
      3. If you do see a doctor and you don’t notice any range of motion changes in 5 visits, find another doctor.

      Hope this is helpful.

  • Mary Ann Johnson
    Posted at 16:49h, 03 May Reply

    I have bilateal foot drop. I had back surgery of decommpression and fushion of L4 L5 and,S1 with hopes of it helping but no improvement. My legs, hips and everythung below waist are weak. I’m doing physical theraphy with no improvement. I had an emg and dr said findings could be consistent with cidp. What kind of dr do I need to go to. I have been in wheelchair since Christmas of 2016.

    • Dr. Chris
      Posted at 17:09h, 03 May Reply

      Hi Mary Ann, I’m so sorry for your struggles. What happened around Christmas 2016? Was there any trauma? Were you really stressed out? Were you doing anything with your body prior to that time? Maybe a new workout or work activity?

      If your doctor is right, CIDP is a neurological condition. You should see a neurological specialist.

      Physical therapy wouldn’t work because while you’re “weak”, it’s not a “muscle weakness” issue but a “nerve isn’t activating muscle” issue. So that makes complete sense.

      Someone like me wouldn’t be able to help you UNLESS the nerve part was managed.

      Hope this is helpful. If I can do anything else, please let me know.

  • BarefootRunner
    Posted at 17:27h, 29 November Reply

    “The ability to touch a wall with your toes 5″ away from a wall and your heel down is something that anyone should be able to do, when healthy.”

    These numbers simply don’t work for shorter people. My foot length is 24cm. Heel-to-knee length is 44cm. To get my knee to touch a wall with my toes 5″ (13cm) away would require an angle of arccos((24+13)/44) = 33 degrees between foot and shin, or the ability to flex the foot 57 degrees upward from perpendicular to the shin. That seems like a rather extreme amount of flexion.

    “A fail, with an individual having no business doing any non-essential walking or exercise, is anything less than 3″ with the heel down, the knee touching the wall and the knee over the 2nd toe.”

    I measure zero on the wall test when fully warmed up. I’ve spent my life walking, hiking, and dancing and I’ve been running for several years. During 2017 I transitioned to barefoot running and am currently at 40km a week with no issues.

    • Dr. Chris
      Posted at 17:57h, 29 November Reply

      Hey there,

      I agree that the numbers don’t work for much shorter or taller people. But it works for most people.

      I don’t know how old you are. But with 0″ of dorsiflexion in this test, I will make 3 assumptions that may not be true:

      1. You’re genetically gifted when it comes to having strong connective tissue.
      2. You’re probably healthy in your other joints.
      3. It’s likely only a matter of time before something breaks down in your ankle or foot.

      But yes, I agree that 5″ isn’t passing for every individual.

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