Do you have Foot and Ankle Pain?
The foot and ankle complex can influence the entire kinetic chain. In addition, if you have chronic foot and ankle problems, looking at the low back, hips and knees is also prudent as these areas can influence or perpetuate chronic foot and ankle dysfunction.
The foot is composed of phalanges, metatarsals and tarsals. These bones together with ligaments and muscles create the joints in the foot as well as arches (transverse and medial longitudinal).
Moving to the lower leg are the tibia (inside) and fibula (outside). These articulate distally (below) with the medial and lateral aspects of the foot, forming the ankle joint and proximally (above) with the patella and femur to form the knee joint.
The proximal end of the femur articulates with the pelvis, forming the hip joint.
Foot and Ankle Dysfunction and the Human Movement System Chain Reaction (“The foot bone’s connected to the hip bone”)
If the foot excessively pronates, the adjoining muscles, bones and joints will cause the knee (or knees) to adduct or move inward. The resulting tension in the hamstrings (short head of the biceps femoris) and hip muscles (TFL), will alter the positioning and biomechanics at the hip. This will further affect length-tension relationships of the muscles surrounding the hip and affect stability and mobility.
Common Foot and Ankle Injuries
The plantar fascia runs from the heel (calcaneus) and fans out to insert on the metatarsal heads. It helps to support the medial longitudinal arch of the foot. If repetitive activities are performed with an ankle joint that lacks optimum range of motion or a foot that is excessively pronated, then the fascia becomes inflamed and painful. Most people report heel pain, particularly getting out of bed in the morning or after prolonged periods of sitting.
The gastrocnemius and soleus muscles located in the calf, share a common Achilles tendon that inserts into the calcaneus (heel). Overuse activities, such as running and jumping are common causes of Achilles Tendinopathy, which presents as pain, swelling and impaired performance.
Overuse caused by excessive running, walking, poor shoes or improper biomechanics (e.g. over pronation) can lead to irritation to the periosteum (the membrane lining the surface of bones). Pain can be felt on the anterior (front) or posterior (rear) compartment of the lower leg.
Ankle sprains are reported as the most common sports-related injury, with lateral (outer) ankle sprains being the most common. These injuries cause small tears in the ligaments and stretching of the local musculature. They can lead to ankle instability and recurrent injury.
A Systematic Process to Evaluation and Treatment of Foot and Ankle Impairments
Identification of dysfunction is best achieved through an integrated assessment process, which includes:
- Static posture observation
- Movement assessments such as the Overhead Squat
- Range of motion evaluation and;
- Strength assessments
Once muscle imbalances and joint dysfunction is assessed, a comprehensive treatment strategy can be designed to inhibit and lengthen tight muscles, activate weak muscles and “groove new motor patterns through corrective exercises.
Sample Foot and Ankle Assessment Process and Observations
Static Posture- Feet excessively pronate
Overhead Squat- Feet turn out or flatten
Gait- excessive pronation
Range of Motion- Decreased ankle dorsiflexion (e.g. tight calves), decreased knee extension (e.g. tight hamstrings) and decreased hip extension (e.g. tight TFL)
Muscle testing- Weakness in the tibialis anterior, posterior, medial gastrocnemius and/or medial hamstrings; Weakness in the gluteus medius or maximus
Palpation- Restricted motion the ankle mortise joint and lumbo-pelvic-hip complex
Sample Foot and Ankle Treatment plan
- Inhibit: lateral gastrocnemius, peroneals and biceps femoris (hamstrings) using trigger point therapy and fascial release. Home exercises: Self myofascial release.
- Lengthen- Pin and stretch to lateral gastrocnemius, peroneals and biceps femoris (hamstrings). Home exercises- Static stretching.
- Mobilize- manipulation to restore joint motion and break up adhesions at the ankle and lumbo-pelvic-hip complex.
- Activate- Positional isometrics to anterior and posterior tibialis and medial hamstrings. Home exercises: Isolated strengthening exercises for the anterior and posterior tibialis and medial hamstrings
- Integrate- Home exercises: Single leg balance reach, Step-up to balance.
Foot and Ankle pain can have several labels. Regardless of what the diagnosis is, a functional assessment and integrative kinetic chain approach is the key to long term resolution of the problem.
This Integrative protocol was developed by the National Academy of Sports Medicine (NASM) in conjunction with research carried out at The University of North Carolina.
It is the protocol used by professional sports teams such as the Phoenix Suns in their assessment and management of sports injuries and musculoskeletal pain and dysfunction.