15 Jan Know Your Numbers: Ankle Pain, Foot Pain, and Ankle Dorsiflexion
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.
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.
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.
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 there, Sole 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!
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.
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.
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.
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.
- 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.
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.
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.
More tests to come later.