Module 6 Foot and Ankle Impairment- Complete[1]

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Corrective Exercise Strategy for Foot and Ankle Impairments

2 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment Copyright © 2007 National Academy of Sports Medicine Printed in the United States of America All rights reserved. Except for use in a review, the reproduction or utilization of this work in any form or any electronic, mechanical or other means, now known or hereafter invented, including xerography, photocopying and recording, and in any information-retrieval system is forbidden without the written permission of the National Academy of Sports Medicine. Distributed by: National Academy of Sports Medicine 26632 Agoura Road Calabasas, CA 91302 800.460.NASM Facsimile: 818.878.9511 http: www.nasm.org Author: Micheal Clark, DPT, MS, PT, CES, PES Rodney Corn, MA, PES, CES, NASM-CPT Scott Lucett, MS, CES, PES, NASM-CPT

3 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment Table of Contents Introduction 4 Common Injuries 5 Corrective Exercise Strategy for Foot and Ankle Impairment 7 Review of Foot and Ankle Functional Anatomy 9 Assessment for Foot and Ankle 20 Corrective Strategies Program Design 21 References 27

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4 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment Introduction The human body is susceptible to movement dysfunctions and neuromusculoskeletal imbalances. Some of the reasons for this include repetitive movements, overuse, sedentary living, and improper movement techniques. These dysfunctions in turn lead to many of the common injuries seen today. The foot and ankle complex is a region of the body with great influence on the entire Human Movement System. This region represents the platform from which our base of support is derived and is the main contact point between the ground and the body. As such, it must withstand the highest amount of contact force (ground reaction force) with each step taken as it is closest to the impact site (heel strike). If there is movement impairment centralized within the foot and ankle region it can lead to various symptomatic responses, seen in Table 1. These include plantar fasciitis, Achilles tendonitis, and posterior tibialis tendonitis (shin splints). As the body is an interconnected chain (kinetic chain), compensation or dysfunction in one region such as the foot and ankle can and will lead to dysfunctions in other areas of the body. 1,2 More proximally, dysfunction for the foot and ankle can also lead to patellar tendonitis (jumper’s knee) and iliotibial band (IT-band) tendonitis (runner’s knee), low back pain, hamstring, quadriceps and groin strains, as well as many shoulder and upper extremity injuries (Table 1).

5 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment Common Injuries Associated With Foot and Ankle Impairment Local Injuries Proximal Injuries Plantar fasciitis Achilles tendonitis Posterior tibialis tendonitis (shin splints) Patellar tendonitis (jumper’s knee) IT-band tendonitis (runner’s knee) Low back pain Hamstring, quad and groin strains Table 1. Common Injuries Associated with Foot and Ankle Impairment For example, if the foot externally rotates and/or everts during movement it is generally the collective motion of the foot/ankle and lower leg. Therefore, the displacement of the foot will more than likely be a result of altered lower leg motion/alignment which is indicative of overactivity of the lateral gastrocnemius, peroneals, short head of the biceps femoris, and/or the tensor fascia lata (TFL), and underactivity of the medial gastrocnemius, posterior tibialis, medial hamstrings, gracilis, sartorius, popliteus, and/or gluteus medius and maximus. Locally, the lateral gastrocnemius, when activated, can externally rotate the lower leg as well as cause eversion of the calcaneus. The peroneals (longus and brevis), when activated, will evert the foot. The peroneus longus can cause external rotation as well. Proximally, the short head of the biceps femoris and the TFL can externally rotate the lower leg because of their attachments to the fibula and tibia, respectively. When the medial gastrocnemius, posterior tibialis, medial hamstrings, gracilis, sartorius, popliteus, and/or gluteus medius and maximus cannot be sufficiently activated to counter these actions, compensation occurs.

6 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment This combination of over- and underactive muscles can also cause the knee (tibiofemoral joint) to adduct and internally rotate. The lateral gastrocnemius and biceps femoris each externally rotate the lower leg relative to the femur and flex the knee. When the knee is flexed and the lower leg is externally rotated relative to the femur, it produces a lateral displacement (abduction) of the lower leg causing the femur to internally rotate and adduct. 3 This can be further perpetuated by the TFL which specifically produces internal rotation of the femur and external rotation of the lower leg. 3 Collectively, this places disproportional stress on the patellofemoral and tibiofemoral joints (i.e., patellar tendonitis and general knee pain). 1 Overactivity of the TFL can lead to underactivity of the gluteus medius. The flexion and internal rotation of the hip/femur caused by the TFL places the posterior fibers of the gluteus medius as well as the gluteus maximus in a lengthened position which alters the length-tension relationship and decreases recruitment due to altered reciprocal inhibition. 2 In turn, this creates a destabilized lumbo-pelvic-hip complex (LPHC), which can lead to low back pain, hamstring, quadriceps, and groin strains. 2,4 Any alterations in pelvic positioning and stability will directly affect the latissimus dorsi which attaches to the pelvis via the thoracolumbar fascia network. 4 The latissimus dorsi has direct influence on the shoulder region through its attachment to the scapula and humerus and this can lead to many shoulder and/or cervical injuries. Each of the typical injuries listed can be problematic for any individual and the reduction in pain or severity is the focus of many exercise programs. However, these injuries are primarily symptoms representing a problem in the Human Movement System. The National Academy of Sports Medicine (NASM) has developed a systematic corrective exercise strategy to identify and address the problem rather than the symptoms. This allows the Health and Fitness Professional to develop a safe and effective solution for any client. The purpose of this text is to demonstrate the corrective exercise strategy specifically for foot and ankle impairment.

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7 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment Corrective Exercise Strategy for Foot and Ankle Impairment Corrective exercise strategies are solutions to identify neuromusculoskeletal dysfunctions within the Human Movement System. Identification of dysfunction is achieved through an integrated assessment process which includes a movement assessment, goniometric measurements, and manual muscle testing (for those licensed to do so). The integrated assessment process allows the Health and Fitness Professional to identify the overactive and underactive myofascial tissues. Once the overactive and underactive tissues are known, the corrective exercise strategy can be developed. The specific movement impairment that will be discussed in this text is external rotation and/or eversion of the feet (also known as feet turn out and feet flatten), seen in Figure 1. Figure 1.

8 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment Table 2 details the probable overactive and underactive muscles seen with this impairment. Probable Overactive and Underactive Muscles Accompanying Foot and Ankle Impairment Region Compensation Overactive Underactive Feet Externally Rotate (Turn Out) Soleus Lat. Gastrocnemius Biceps Femoris (short head) Tensor Fascia Lata (TFL) Med. Gastrocnemius Med. Hamstring Gracilis / Sartorius (Pes Anserine) Popliteus Gluteus Medius/Maximus Evert (Flatten) Peroneal Complex Lat. Gastrocnemius Biceps Femoris TFL Anterior Tibialis Posterior Tibialis Med. Gastrocnemius Gluteus Medius Table 2. Probable Overactive & Underactive Muscles Accompanying Foot and Ankle Impairment To ensure clarity and maximal retention of the information, the following section will provide a simplistic overview of functional anatomy for the pertinent muscles, bones, and joints. Review of Foot and Ankle Functional Anatomy As previously stated, the foot and ankle is a complex structure with a great deal of influence on the rest of the kinetic chain. There are many bones, joints, and muscles that affect dysfunction in the foot and ankle, however, this section seeks only to provide a general review of the most pertinent structures. This is not intended to be an exhaustive and detailed review.

9 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment Bones and Joints Looking at the foot and ankle region specifically (Figure 2), the phalanges and metatarsals make up the metatarsophalangeal and tarsometatarsal joints. The tarsal bones, consisting of the navicular, medial, intermediate, and lateral cuneiforms (transverse arch), and cuboid, along with the talus and calcaneus, make up the subtalar (talus and calcaneus), talonavicular & calcaneocuboid joints. Moving up to the lower leg, the tibia and fibula bones form the proximal and distal tibiofibular joints as well as the talocrural joint (tibia, fibula, and talus), typically collectively called the “ankle” joint. Figure 2. Bones of the foot, ankle and lower leg. A=Phalanges; B=Metatarsals; C=Navicular; D=Medial, Intermediate, & Lateral Cuneiform; E=Cuboid; F=Talus; G=Calcaneus; H=Tibia; I=Fibula More proximally (Figure 3), the patella, femur, and the pelvis, in conjunction with the aforementioned bones, comprise the tibiofemoral (tibia, femur), patellofemoral (patella, femur) iliofemoral (femur, pelvis) joints that anchor proximal myofascial tissues. These structures are important in terms of corrective exercise because they will also have a functional impact on the arthrokinematics of the foot and ankle. A B C D E F G H I

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10 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment Figure 3. Proximal bones affecting the foot and ankle. A=Tibia & Fibula; B=Patella; C=Femur; D=Pelvis Muscles With all Human Movement System impairments, there are over- and underactive muscles which create an imbalance and lead to injury. The pertinent muscles of the lower leg which are overactive with this impairment are discussed in Table 3 and pictured in Figure 4. A B C D

11 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment Overactive Muscles of the Lower Leg Accompanying Foot and Ankle Impairment Muscle Concentric Isometric – Stabilization Eccentric Lateral Gastrocnemius Plantarflex ankle, evert calcaneus, externally rotate lower leg, and flex knee Foot, ankle, and knee Decelerates ankle dorsiflexion, internal rotation of lower leg, and knee extension Soleus Plantarflex ankle, externally rotate (supinate) lower leg, and assists in knee extension Foot and ankle Decelerates ankle dorsiflexion, internal rotation of lower leg and eversion of subtalar joint, and knee flexion Peroneus Longus Evert ankle, plantarflex ankle 1 st Metatarsophalangeal joint (MTP) Decelerates ankle inversion, and dorsiflexion Table 3. Overactive Muscles of the Lower Leg Accompanying Foot and Ankle Impairment

12 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment Figure 4. Lateral Gastrocnemius Soleus Peroneus Longus

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13 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment The pertinent muscles of the lower leg which are underactive with this impairment are discussed in Table 4 and pictured in Figure 5. Underactive Muscles of the Lower Leg Accompanying Foot and Ankle Impairment Muscle Concentric Isometric – Stabilization Eccentric Medial Gastrocnemius Plantarflex ankle, invert calcaneus, internally rotate lower leg, and flex knee Foot, ankle, and knee Decelerates ankle dorsiflexion, external rotation of lower leg, and knee extension Posterior Tibialis Plantarflex ankle, externally rotate (supinate) lower leg, invert foot/ankle Foot and ankle Decelerates ankle eversion, dorsiflexion, and internal rotation of lower leg Anterior Tibialis Invert ankle, dorsiflex ankle Foot and ankle Decelerates ankle plantarflexion, and eversion Table 4. Underactive Muscles of the Lower Leg Accompanying Foot and Ankle Impairment.

14 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment Medial Gastrocnemius Posterior Tibialis Anterior Tibialis Figure 5.

15 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment The overactive muscles of the LPHC affecting the foot and ankle are discussed in Table 5 and pictured in Figure 6 Overactive Muscles of the LPHC Accompanying Foot and Ankle Impairment Muscle Concentric Isometric – Stabilization Eccentric Biceps Femoris (short head) Externally rotate lower leg, and flex knee Knee Decelerates internal rotation of lower leg, and knee extension TFL Flex, abduct, and internally rotate femur (hip), externally rotate lower leg, and extend knee LPHC and knee Decelerates femoral extension, adduction and external rotation of LPHC, and internal rotation of lower leg Table 4. Overactive Muscles of the LPC Accompanying Foot and Ankle Impairment

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16 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment Biceps Femoris (short head) TFL (and IT Band) Figure 6.

17 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment The overactive muscles of the LPHC affecting the foot and ankle are discussed in Table 6 and pictured in Figure 7. Underactive Muscles of the LPHC Accompanying Foot and Ankle Impairment Muscle Concentric Isometric – Stabilization Eccentric Medial Hamstrings Flex knee, extend hip, and internally rotate lower leg LPHC and knee Decelerates knee extension, hip flexion, and external rotation of lower leg Gracilis Adduct, internally rotate, and weak flexion of femur, and internally rotate lower leg LPHC and knee Decelerates femoral abduction, and external rotation of lower leg Sartorius Abduct, internally rotate tibia, knee & hip flexion & hip external rotation LPHC and knee Adduct, externally rotate tibia, knee & hip extension & hip internal rotation Popliteus Internally rotate lower leg (open chain), externally rotate femur (closed chain), and weak flexion of knee Knee Decelerates external rotation of lower leg (open chain), and internal rotation of femur (closed chain) Gluteus Medius (posterior fibers) & Gluteus Maximus Abduct, externally rotate, and extend femur (hip) LPHC and knee Decelerates femoral (hip) adduction, internal rotation, and flexion Table 6. Underactive Muscles of the LPHC Accompanying Foot and Ankle Impairment

18 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment Medial Hamstrings Gracilis Sartorius Popliteus Gluteus Medius Gluteus Maximus Figure 7.

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19 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment Assessment for Foot and Ankle The first step in developing a corrective exercise strategy is an integrated assessment process. NASM uses three primary assessments including a movement assessment (Overhead Squat and Single-leg Squat), goniometric measurements, and, for the licensed professional, manual muscle testing. Based upon the collective information obtained from these assessments, the over- and underactive muscles can be identified. Table 7 shows the probable observations for these assessments relative to foot and ankle impairment. Probable Assessment Observations for Foot and Ankle Impairment Assessment Observation Overhead Squat Feet turn out (externally rotate) and flatten (evert) Single-leg Squat Feet flatten (evert) Goniometric Measurement Decreased dorsiflexion (less than 15 degrees) and/or secondary decrease in the hip flexion 90/90 position (hamstring–short head of biceps femoris) and/or hip extension (TFL) Manual Muscle Testing One or more of the following muscles tested “weak”: Anterior tibialis, posterior tibialis, medial gastrocnemius and/or medial hamstring; Proximally, the gluteus medius and/or maximus Table 7. Probable Assessment Observations for Foot and Ankle Impairment

20 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment Corrective Strategies Program Design Once the over- and underactive muscles have been identified, the corrective exercise strategy can be developed. Figure 8 shows the NASM Corrective Exercise Continuum. This is a systematic process designed to provide the Health and Fitness Professional with a structured plan to safely and effectively develop the appropriate corrective exercise strategy. There are essentially four steps in the Corrective Exercise Continuum. Step one is to inhibit the overactive muscles. This procedure reduces unwanted tension in the neuromyofascial tissues to better prepare them for lengthening. Step two is to lengthen the overactive and shortened muscles. Lengthening shortened neuromyofascial tissues increases the extensibility and length- tension relationships of muscles at each respective joint. It is important to note that this technique is only used on the muscles that are overactive and shortened, not on all muscles as some may already be in a lengthened position. The third step is to activate the underactive muscles. This helps re-educate the underactive tissues and increase intramuscular coordination. The fourth step is to integrate the muscles and neuromyofascial tissues back into their functional synergies. This helps to ensure that the integrated function of all muscles involved are re-trained collectively, establishes intermuscular coordination and increase neuromuscular efficiency.

21 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment Figure 8. The Corrective Exercise Continuum C ORRECTIVE E XERCISE C ONTINUUM I NHIBIT A CTIVATE I NTEGRATE Inhibitory Techniques Self-Myofascial Release Activation Techniques Positional Isometrics Isolated Strengthening Integration Techniques Integrated Dynamic Movement L ENGTHEN Lengthening Techniques Static Stretching Neuromuscular Stretching

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22 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment Table 8 shows a sample programming strategy using the Corrective Exercise Continuum for foot and ankle impairment. Sample Corrective Exercise Program for Foot and Ankle Impairment Phase Modality Muscle(s) / Exercise Acute Variables Inhibit Lengthen Activate Integrate* SMR Static Stretching OR NMS Positional Isometrics AND/OR Isolated Strengthening Integrated Dynamic Movement Lateral gastrocnemius and peroneals Biceps femoris (short head) Gastrocnemius/soleus Biceps femoris (short head) Posterior tibialis Anterior tibialis Medial hamstrings Medial Gastrocnemius Single Leg Balance Reach Hold on tender area for 30 sec. 30-sec. hold OR 7- 10 sec. isometric contract, 30-sec. hold 4 reps of increasing intensity 25, 50, 75, 100% OR 10-15 reps with 2-sec. isometric hold and 4- sec. eccentric 10-15 reps under control *NOTE: If client is not initially capable of performing the Integrated Dynamic Movement exercise listed they may need to be regressed to a more suitable exercise. Table 8. Sample Corrective Exercise Program for Foot and Ankle Impairment

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23 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment Inhibit Lateral Gastrocnemius and Peroneals Bicep Femoris (short head) Lengthen Gastrocnemius / Soleus Stretch Bicep Femoris (short head) Stretch

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24 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment A CTIVATE Posterior Tibialis Medial Hamstrings Anterior Tibialis Medial Gastrocnemius I NTEGRATE Single Leg Balance Single Leg Balance START FINISH

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25 Goniometric Assessments Corrective Exercise for Foot and Ankle Impairment R EFERENCES 1 Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: A theoretical perspective. J Orthop Sports Phys Ther. 2003;33(11):639-46. 2 Sahrmann SA. Diagnosis and treatment of movement impairment syndromes. St. Louis: Mosby; 2002. 3 Vasilyeva LF, Lewit K. Diagnosis of muscular dysfunction by inspection. In: Liebenson C, editor. Rehabilitation of the spine. Baltimore: Williams & Wilkins; 1996. p. 113-42. 4 Neumann DA. Kinesiology of the musculoskeletal system: Foundations for physical rehabilitation. St. Louis: Mosby; 2002.

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