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Restricted Ankle Dorsiflexion Self-mobilization

Cosby, Nicole L. PhD, ATC1; Grindstaff, Terry L. PhD, PT, ATC, SCS, CSCS*D2

Section Editor(s): Reuter, Ben PhD, CSCS*D, ATC

Strength and Conditioning Journal: June 2012 - Volume 34 - Issue 3 - p 58–60
doi: 10.1519/SSC.0b013e31824526e8
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SUMMARY JOINT MOBILIZATIONS ARE INDICATED WHEN AN IMPAIRMENT IN JOINT CAPSULAR MOBILITY IS IDENTIFIED. THE ABILITY FOR THE CLIENT OR PATIENT TO PERFORM A SELF-MOBILIZATION OF THE ANKLE MAY HELP MAXIMIZE OUTCOMES. SELF-MOBILIZATION TECHNIQUES OF THE ANKLE CAN BE PERFORMED WITHOUT THE AID OF A CLINICIAN OR STRENGTH AND CONDITIONING PROFESSIONAL.

1Department of Kinesiology, Point Loma Nazarene University, San Diego, California

2Department of Physical Therapy, Creighton University, Omaha, Nebraska

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Figure

The Flexibility and Rehab Tips Column provides practical information on the role of rehabilitation and flexibility on both performance and the modification of injury risk.

COLUMN EDITOR: Ben Reuter, PhD, CSCS*D, ATC

Nicole L. Cosbyis an assistant professor in the Department of Kinesiology at Point Loma Nazarene University.

Terry L. Grindstaffis an assistant professor in the Department of Physical Therapy at Creighton University.

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BACKGROUND

Dorsiflexion range of motion of the ankle is necessary in normal daily activities, such as standing up from sitting, reaching activities, and dynamic standing balance (7). Approximately 10° of dorsiflexion is needed to walk on level surfaces, descend stairs, or kneel, and 20–30° of dorsiflexion is needed to perform running or sprinting activities (15). Contractile (muscular, tendon) tissues, such as the gastrocnemius and soleus, and noncontractile structures (ligament, joint capsule, and bone) may prevent the ankle from reaching dorsiflexion range of motion (6).

Assessment of the muscles and joints contributing to ankle dorsiflexion is necessary to determine the specific structures (contractile/noncontractile) that may limit motion (4). Typically, ankle joint range of motion is measured with the patient in a non–weight-bearing position. Measurement of dorsiflexion range of motion with the knee in an extended position assesses the influence of the gastrocnemius and soleus on dorsiflexion range motion, whereas measurement with the knee in flexion is more specific to the contributions of the soleus muscle. Clinicians typically measure ankle range of motion using a standard goniometer or bubble inclinometer. If impairment is identified, specific corrective strategies should be used to improve motion. Typically, static stretching of the gastrocnemius and soleus muscles improves contractile restrictions in dorsiflexion. Gastrocnemius and soleus stretching can be performed in weight-bearing and non–weight-bearing positions. Stretching these muscles in a non–weight-bearing position requires the patient to sit on a table or a floor with the knee extended (gastrocnemius) and bent (soleus) (4). In the weight-bearing position, the patient may use a slant board, stairs, or some object to create an elevated surface to allow the ankle to dorsiflex, placing the posterior musculature on stretch with the knee extended or slightly flexed (5). Stretching in a weight-bearing position is indicated when pain from the ankle injury is no longer a limiting factor. Stretching of these muscles would address contractile restrictions and are usually well understood by the rehabilitation clinician or strength and conditioning professional.

Noncontractile structures (joint capsule and ligaments) also contribute to joint range of motion. When there are restrictions in posterior talar movement within the talocrural joint, full dorsiflexion cannot occur. Joint mobilization is indicated when there are restrictions in noncontractile structures. Specific to the talocrural joint, improved posterior glide of the talus is thought to improve dorsiflexion range of motion in the presence of a capsular restriction (2,3,13). Joint mobilization of the talus in a posterior direction is a common intervention used to address restrictions in capsular and joint mobility (1,11,14). Joint mobilization techniques are typically performed in a clinical setting, prescribed by a clinician who has specific training in manual therapies and is allowed to perform these techniques within their scope of practice. Strength and conditioning professionals who encounter athletes or clients with suspected decrements in joint mobility should refer to an appropriate clinician for further examination (i.e., physical therapist, athletic trainer). When joint mobilization is indicated, individuals may also benefit from performing self-mobilizations outside of clinical settings. The use of self-mobilizations may help improve range of motion (ROM) and reduce disability, which may optimize the patient's ability to perform functional tasks. Therefore, the purpose of this article is to present a self-mobilization technique for the ankle, which can be used to improve talocrural joint mobility (posterior talar glide) and subsequently improve ankle dorsiflexion range of motion. The use of a self-mobilization technique allows the client or patient to perform the technique without the aid of a clinician or strength and conditioning professional.

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TECHNIQUE

Joint mobilizations are used to decrease pain, increase ROM, and treat joint dysfunction after injury; they should not be used in patients with bone fractures, osteoporosis, bone disease, extreme inflammatory conditions, or pathologies with neurological involvement. Manual joint mobilizations are typically graded on a 5-point scale (10). Grades I to IV are used to describe the treatment movements: grade I joint mobilizations are small-amplitude movements performed at the beginning of the range of motion; grade II joint mobilizations are large-amplitude movements performed within a resistance-free part of the range of motion; grade III joint mobilizations are large-amplitude movements performed into resistance or up to the limit of the range of motion; and grade IV joint mobilizations are small-amplitude movements performed well into tissue resistance (9). Typically, grade I and II joint mobilizations are used to modulate pain, whereas grades III and IV are used to improve joint mobility. Grade V treatments consists of a small amplitude quick thrust and may also be known as a manipulation (9). Manipulations and mobilizations should only be performed by a professional who is licensed and/or trained to perform manual therapy.

The self-mobilization ankle technique can be used during the subacute and chronic phases of healing when pain is no longer a limiting factor and the goal of treatment is to improve posterior talar glide and reduce talocrural restrictions. Self-mobilizations should not be used in patients with suspected fracture, hypermobile joints, neurological signs, or in individuals who are not comfortable performing the self-mobilization intervention. The talocrural joint self-mobilization technique is performed in a weight-bearing staggered stance (lunge) position (Figure 1a) with the lead ankle being mobilized. This position is commonly used to measure weight-bearing ankle dorsiflexion ROM using a bubble inclinometer (2). During the ankle self-mobilization technique, a strap is placed across the anterior aspect of the talocrural joint and secured to a stable object, located in back of the patient. The purpose of the strap is to provide a fulcrum during the self-mobilization to facilitate posterior glide of the talus on the ankle mortise. While the patient is in a neutral position, they are asked to translate the knee forward through pain-free ankle dorsiflexion (Figure 1b). The strap is used as a fulcrum for the mobilization and is similar to the use of a foam roll or a towel when performing a self-mobilization of the thoracic spine.

Figure 1

Figure 1

A common compensation in individuals with restricted talocrural joint mobility is a greater amount of foot pronation during ankle dorsiflexion (2). Placing a small wedge (folded towel) under the medial aspect of the foot may help maintain a neutral position of the subtalar joint (5,12). Although there is little consensus regarding adequate number of sets and repetitions, we suggest performing 2–3 sets consisting of 30–60 seconds of repetitive oscillations (3,8), which consist of slow small-amplitude movements within the range of motion. Typically, joint mobilization grades are not discussed for self-mobilization techniques; however, patients may perform the equivalent of a grade III or IV joint mobilization during the task.

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CONCLUSION

Joint mobilizations are indicated when an impairment in joint mobility or a limitation in accessory joint motion is identified. Individuals with a history of lateral ankle sprain (2) or those who report anterior ankle impingement (pinching sensation on the anterior aspect of the talocrural joint during maximal weight-bearing dorsiflexion) may have restrictions in joint mobility despite normal ankle dorsiflexion ROM (2). Specific assessment by a clinician may be performed to confirm restricted joint motion (4). Following joint mobilization of the ankle, individuals have reported decreased pain (11,14), returned to activity quicker (3), demonstrated increased ankle dorsiflexion ROM (1,3,8), and improved function (11,14); however, these outcomes are yet to be explored after the use of a self-mobilization technique. The ability for the client or patient to perform a self-mobilization of the ankle joint may help improve ROM and improve self-reported function in patients after an ankle injury.

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REFERENCES

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