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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

More tests to come later.

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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9 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 […]

  • 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.

  • 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 […]

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