Poor Ankle ROM and Lower Limb Injuries

Dorsiflexion, that flexion of the foot in a dorsal, upwards, direction is imperative to walking, running, squatting and much more.  

 

As a common dysfunction identified in the physiotherapy and podiatry worlds, and a risk factor associated with a variety of injuries, I have compiled a brief article outlining the research in the literature for dorsiflexion associated with tightcalf muscles and ankle joint restrictions.

 

Pope et al showed that having poor dorsiflexion puts a patient at 2.5 times the risk of injury than those associated with average flexibility, and eight times higher than those associated with high flexibility. I have already dived into its association with medial tibial stress syndrome and anterior compartment syndrome in separate articles. However, in clinics, I have also been asked about: 

  • plantar fasciitis
  • ankle sprains
  • Achilles tendinopathy
  • patella tendinopathy 

I wrote up this article is to build on my knowledge, help our partnering clinics and to stimulate discussions with other health professionals to build on my clinical perspective as an engineer and former athlete. Please reach out to discuss if you'd like!

Poor Dorsiflexion & Plantar Fasciitis 

Let's start with an injury with an apparently clear association. A reduced range of ankle dorsiflexion has also been linked to plantar fasciitis, with individuals with less than 5degrees of ankle range of motion (ROM) being eight times more likely to present with symptoms consistent with plantar fasciitis [1]. Why? One hypothesis is that in response to limited dorsiflexion, the foot may excessively pronate to compensate, resulting in increased tensile loads on the plantar fascia [2,3].

 

In their match case-controlled study (each subject matched on age and gender), Riddle et al determined that obesity, work-related weight-bearing and poor dorsiflexion were independent risk factors for plantar fasciitis. However, limited ankle dorsiflexion on the involved side significantly increased the risk of plantar fasciitis after adjustment for the other variables in the model. The odds ratios suggested limited dorsiflexion may be the most important of the three factors [1]. 


Is this an association you have or haven't seen when treating the injury? Please reach out!

Poor Dorsiflexion & Ankle Sprains

This relationship was less clear, and I would love to hear your thoughts. While Beynnon et al demonstrated that ankle dorsiflexion is not linked to lateral ankle sprains in college athletes, and Wiesler et al has similar findings in a ballet dancer population, poor dorsiflexion has also been associated with repetitive ankle sprains [6].It has also been found to be a significant predictor of the risk of incurring such an injury with poor flexibility associated with five times the risk of ankle sprain associated with average [11].


Chronic ankle instability (CAI) refers to repetitive bouts of lateral instability ('ankle giving way'). Leanderson et al showed the CAI group had significantly less ankle dorsiflexion ROM than controls during the time of maximal dorsiflexion while jogging. There was no statistical difference in static rear foot alignment between the groups, and the CAI patients demonstrated improvements in posterior talar glide and dorsiflexion ROM after receiving posterior talar mobilisations.


What do you see in your clinic?

Poor Dorsiflexion & Achilles Tendinopathy

While it might make sense that if the gastro-soleus complex is tight resulting in poor dorsiflexion, it may have effects on the Achilles tendon, there is conflicting evidence that a decreased non-weight-bearing (NWB) dorsiflexion is associated with Achilles tendinopathy. 

 

In a prospective cohort study on 70 Australian infantry recruits who were followed for 6-months, it was demonstrated that limited ankle dorsiflexion ROM (bent knee) might increase the risk of the recruits developing Achilles tendinopathy during training [7]. However, two other studies evaluating dorsiflexion with bent knee demonstrated no association [8, 9].

 

With the knee extended,Kaufman et al found that limited ankle dorsiflexion (<11.5°) is associated with Achilles tendinopathy compared with normal ankle dorsiflexion (11–15°)[8]. But, Mahieu et al found there was no association [9]. 

 

While reduced ankle dorsiflexion ROM is generally considered a risk factor, the conclusive evidence is missing. What do you think?

Poor Dorsiflexion & Patella Tendinopathy

Reduced ankle dorsiflexion range appears to be associated with patella tendinopathy. Ludvig et al demonstrated, in a prospective cohort study of ninety junior basketball players over one-year, that low ankle dorsiflexion range was a risk factor for developing patella tendinopathy. Complementary statistical analysis showed that players with dorsiflexion range less than 36.5° had a risk of 18.5% to 29.4% of developing patella tendinopathy within a year, as compared with 1.8% to 2.1%for players with dorsiflexion range greater than 36.5° [11]. 

 

Similarly, Malliaras et al assessed the association between several performance factors and the injury across 113 male and female volleyball players. These performance factors were:sit and reach flexibility, ankle dorsiflexion range, jump height, ankle plantar flexor strength, years of volleyball competition and activity level. Only reduced ankle dorsiflexion range was associated with patellar tendinopathy[12]. This may be because the coupling between ankle dorsiflexion and eccentric contraction of the calf muscle is essential in absorbing lower limb forces when landing from a jump. 

When does the Solushin become a suitable adjunct?

Results from the Ankle ROM Prospective Cohort Study

The Solushin has been demonstrated in a prospective cohort study to improve ankle dorsiflexion ROM by21% after just an hour of wear across 30 participants (pending publication). 

 

It does this by applying counter traction to the three origin sites of the soleus muscle: posterior to head of the fibula, mid-diaphysis and at the musculotendinous junction with theAchilles tendon. These counter traction nodes are similar to your thumbs performing trigger point therapy. The three origin sites of the soleus are known for their high tension, and as seen in clinical practice, by massaging these sites, we can cause a reduction in tension in the soleus. 

 

Compressive rod along tibial border

Node posterior to head of fibula

Node at mid-diaphysis

Node at Achilles tendonitis

As a result, the Solushin may be a suitable adjunct if your patient is presenting with poor dorsiflexion due to a tight soleus muscle, and you believe it is implicated in their injury. 

 

I recommend you identify this first and incorporate the Solushin as just one part of a holistic approach to treating the injury. I am unsure if there will be any clinical benefit if the poor dorsiflexion range is due to ankle joint restrictions (scar tissue, fluid etc), so it would be essential to rule that out as well.

Please reach out!

If you are interested in hearing more, please contact me directly via my email at the bottom of this article.


If you are hesitant, I understand- there have been plenty of products introduced to the market that did not do what they promised to do. But here is where we differ, we were also victims of those gimmicky products so, while we make no claims to this being the magic Wham! And the pain is gone; we have built our foundations on clinical evidence only claim what we have demonstrated.


We also work with clinics so we can continue to develop our clinical perspectives and make you a device that improves the quality of treatment you can provide, rather than making it obsolete.


If you've made it this far down, thank you for giving it a read! Don't forget to contact me. It'd be great to chat and hear your thoughts.


- Ben Lindsay

ben@solushin.com


About the author:

Ben Lindsay is the Managing Director and engineer behind the Solushin medical device. A former national medalist swimmer, Ben aspires to learn from physicians, physiotherapists and podiatrists so he can develop tools to improve the quality of care for their patients.

References

  1. Riddle, D.L., et al., Risk factors for Plantar fasciitis: amatched case-control study. J Bone Joint Surg Am, 2003. 85-a(5): p. 872-7.
  2. Sarrafian SK. Functional characteristics of the foot andplantar aponeurosis under tibiotalar loading. Foot Ankle. 1987;8:4-18.26. 
  3. Wright DG, Rennels DC. A study of the elastic properties ofplantar fascia. J Bone Joint Surg Am. 1964;46:482-92.
  4. Beynnon BD, Renstro¨m PA, Alosa DM, Baumhauer JF, Vacek PM.Ankle ligament injury risk factors: a prospective study of collegeathletes. J Orthop Res. 2001;19:213–220
  5. Wiesler ER, Hunter MD, Martin DF, Curl WW, Hoen H. Ankleflexibility and injury patterns in dancers. Am J Sports Med.1996;24:754–757.
  6. Leanderson J., Wykman A., Eriksson E, Ankle sprain and postural sway in basketballplayers. KneeSurg Sports Traumatol Arthrosc. 1993; 1:203-205
  7. Rabin A, Kozol Z, Finestone AS. Limitedankle dorsiflexion increases the risk for mid-portion Achillestendinopathy in infantry recruits: a prospective cohort study. JFoot & Ankle 2014; 7: 48
  8. Kaufman KR, Brodine SK, Shaffer RA, et al. The effect of footstructure and range of motion on musculoskeletal overuse injuries. Am JSports Med 1999;27:585–93.
  9. Mahieu NN, Witvrouw E, Stevens V, et al. Intrinsic riskfactors for the development of Achilles tendon overuse injury: a prospectivestudy. Am J Sports Med 2006;34:226–35.
  10. Pope R, Herbery R, Kirwan J. Effects of ankle dorsiflexionrange and pre-exercise calf muscle stretching on injury risk in Armyrecruits. Australian Journal of Physiotherapy 1998; 44; 3: 165-172
  11. Ludvig BJ, Danielson P. LowRange of Ankle Dorsiflexion Predisposes for Patellar Tendinopathy in JuniorElite Basketball Players: A 1-Year Prospective Study. Am J Sports Med; 39;12: 2626-2633
  12. MalliarasP, Cook JL, Kent P. Reduced ankle dorsiflexion range may increase the riskof patellar tendon injury among volleyball players. J Sci & Med inSport 2006; 9; 4: 304-09. 

Leave a comment