We will see over the next few weeks, that by following the joint by joint approach, there are ways that we can absolutely improve out joint health and orthopedic longevity, via intelligent considerations. Let’s get started.
This week we focused on the implications of ankle joint mobility/great toe mobility, as well as the implications of stability through the joints down stream. Let’s get a little more nerdy and understand further some of the anatomy as a foundation.
Ankle (Talo-Crurual) joint: This is a joint that craves mobility. It is essentially a mortise that is formed by the talus (bottom part) going into the tibia/fibula “socket.” In its purest form the TC jt performs dorsiflexion and plantarflexion. What folks generally tend to lack is ability to dorsiflex (ability to flex upwards/point your ankle up towards ceiling), and there is a lot of literature that supports that decreased ankle dorsiflexion is associated with increased chance of injuries, such as:
- -Plantar Fasciitis
- -Achilles tendinopathy
- -Patello-Femoral pain syndrome (PFPS)
- -Patellar Tendinopathy
Let Us Try and Understand Why
In its simplest form, we have a desirable amount of range of motion at each joint. For the ankle, we want roughly 10-20 degrees of dorsiflexion.
When we have this amount accessible, our kinetic chain is able to appropriately absorb ground reaction force (GRF) and dissipate it accordingly.
When we do not have this ROM accessible, the GRF has to go somewhere. What we end up seeing is an inappropriate use of other joints and muscles to compensate and hence potential increase in risk of injury. We will dive further into this when we discuss pronation and supination later on.
(*Side note: In the clinical setting we are taught in school to measure ankle dorsiflexion ROM in open chain, however, I have found closed chain measurements such as the 1/2 kneel test to be not only more reliable, but also more valid, with better carry over to function.*)
WHAT CAN WE DO ABOUT IT?
One thing we can do which is extremely effective and simple is dose daily bouts of ankle mobility through the 1/2 kneeling ankle mobilization. See post below for further instructions on how to do so.
First up, the ankle. Let's start this post by exploring WHY it is desirable to have adequate dorsiflexion range of motion. ••• The ankle is essentially the first critical joint (besides the humble big toe) that is constantly asked to express range of motion on a daily basis (ie walking, running, jumping, and squatting). . When the ankle lacks mobility, the body tends to do a few things. One thing it might do is steal it away from another joint. An easy example to paint this picture would be the knee compensating for lack of ankle mobility during a squat. Another way this happens is when all of the little joints in the foot might be compensating for lack of range of motion at the ankle. . When we lack proper ankle mobility we now can see how range of motion might be inappropriately used above and below that link in the chain. What comes along with this is also an inappropriate use of soft tissues to absorb force. ••• This is really a key point: Every time your foot hits the ground, you are absorbing an equal and opposite force (what up physics). When the ankle lacks mobility, the body tends to absorb force into the chain in a sub-optimal fashion that might lead us down the road to ankle/foot and knee pathologies. Here are few of the most prominent: -Plantar Fasciitis -Achilles Tendonopathy -Patellar Tendonopathy -Patello-Femoral Pain Syndrome (PFPS) ••• So, what can we do about it? Well for starters try this classic: The half kneeling, SELF, ankle mobilization. Find the distance from the wall in which you can glide your shin forward without the heel coming off the ground/forefoot collapse. Try dosing yourself x10 reps a day. (*5 inches is considered optimal for distance from wall). Let's keep those ankles supple and healthy! Stay tuned for @joegambinodpt and @strengthcoachtherapy posts this week, and a summary blog on @strong_by_science next Sunday! #KineticHygiene #BrushYourJoints ________________________________________________________ #simplestrengthphysio #physicaltherapy #PT #DPT #DPTstudent #physio #fitness #workout #health #training #exercise #crossfit #strength #sports #wellness #weightlifting #powerlifting #athlete #recovery #performance #movem
Great Toe Joint
Moving forward, and continuing to discuss joints that crave mobility, lets talk about the big toe or the Metatarsal Phalangeal joint (MTP jt). This joint to me is essentially a “mini ankle” and has very similar properties, expressing both dorsiflexion and plantarflexion as its main movements, however much more ROM is available. For normal gait, we want about 65 degrees of dorsiflexion, for running we need upwards of 90 degrees! You can imagine that similar to the ankle, when we lack ROM of this joint into dorsiflexion, we inappropriately absorb GRF and these forces have to go somewhere!
(*Side note: most common pathology we see associated with lack of great toe dorsiflexion is plantar fasciitis because of its intricate association with the Windlass Mechanism. For more on that, see contributor Tom Walters recent post @RehabScience Instagram page.)
One thing we can do to mobilize and improve our great toe dorsiflexion (extension) is to perform a self mobilization and follow it up with range of motion into extension, see below for further details.
Special guest appearance from my clinical student Amanda (@alynpaquin) who is showing the big toe some love for this #KineticHygiene series and getting some reps on the social medias. She does a great job of explaining the WHY and HOW 👇🏼 _____________________________________________ Looking ALL the way down the kinetic chain… ••• The big toe, although small when compared to the hip or knee, and has important roles that can influence our overall functional mobility. The big toe’s main function is to provide MOBILITY. Pain, instability or hypo mobility (decreased mobility) at the 1st big toe joint (MTP joint) can have an impact on how we walk, run, lunge, jump, squat…etc. . The 1st metatarsophalangeal joint (MTP) is comprised of the 1st metatarsal and base of the proximal phalanx and mainly produces the movements of plantarflexion & dorsiflexion. This joint is surprisingly complex especially when it comes to its main function of hallux dorsiflexion during the push-off phase of gait. (for any nerds out there article at bottom goes into greater detail of great toe anatomy). ••• Key Takeaway: Without getting into too much nitty gritty anatomy let’s appreciate this: we need roughly 65-75 degrees of great toe MTP dorsiflexion during gait and upwards of 90 degrees for running! When we don't have enough range at the big toe joint, the kinetic chain will steal it, or inappropriately use soft tissues to absorb force up the chain. ••• What can we do about it? . In the video above, I am demonstrating a very simple and effective way to perform a self mobilization of the big toe. . 1)Slightly pull the bone right above the “knuckle” of your big toe as to separate the joint. 2)Gently glide the bone upwards as if directing towards the top side of your foot (dorsal glide) x10 3)Range the big toe into its new range for x10 reps ••• This a great self mobilization technique because we can grade it for each individual, as some will not be able to tolerate an aggressive big toe stretch such as in a lunge. Try it out daily and let us know how it goes! *Wearing avocado socks improves great toe mobility by 10 degrees ••• @joegambinodpt @strengthcoachtherapy @strong_by_science
Now we have covered the two primary joints in the foot/ankle that crave mobility, let us take a look at the intricate mid-foot, and understand why we need stability through these joints, as well as discussing the implications of pronation and supination, and whats probably overkill in certain instances.
Joe Gambino did a great job of covering “tripod foot” or the popularized Janda’s “Short Foot.” Basically, imagine three landmarks on the bottom of your foot: ball of your 1st toe, ball of your 5th toe, and the ball of your heel. Now imagine sucking up, or “doming.” at these points to create a muscle contraction. This is in essence, creating a short foot, or a “stable foot.”
One important concept I want you to understand is that we often times need a stable base to have a more potent ability to express mobility or power up the chain. For example a stable scapula thoracic region for improved pressing strength. Similar concept here. If we can apply a stable foot, we can create a much more powerful position to propel from. Could you build a house on quick sand? Check out Joe’s contribution below as he demonstrates on video how to create this “short foot.”
Kinetic Hygiene – Ankle part 2 ________________________________ In our last post, Zak ( @simplestrengthphysio ) spoke about why it is important to have mobile ankles using the joint by joint approach. . But this model is not absolute. A mobile joint still needs aspects of stability, just not as much. ••• Many of the issues I see with hip, knee and ankle pain usually present with foot instability and weakness. . Enter the short foot exercise. This exercise is designed to help strengthen the muscles that help maintain our arches. The arches of the foot are important for it's structural stability allowing our foot to mold to the environment and maintain its base of support. This helps Give us better balance and the ability to produce force. ••• Technique: 1️⃣Start seated. As you get better you can progress to standing, in your squat position, single leg standing etc… 2️⃣Without letting your toes come off the floor or without pressing them into the floor, try and retract your foot. 3️⃣You want to be able to see the toes getting pulled towards your heels while your arch gets slightly higher. ••• Questions, comments, concerns? Let me know down below and stay tuned for Teddy's ( @strengthcoachtherapy ) post later this week.
Teddy Willsey did an excellent job covering the difference between pronation and supination. Essentially, these movements are a combination of all three planes of motion and are very important for gait. Yet can be quite complex. See post below for excellent picture as well as explanation.
Kinetic Hygiene: pronation and supination 👣🤓 . ——– Pronation (the product of dorsiflexion, eversion, abduction) occurs as the foot rolls inwards and the arch of the foot flattens. Someone who over pronates is often times known as having 'flat feet'. Pronation is a normal part of gait, as it provides shock absorption at the foot. Pronation can become a problem when it is excessive and leads to internal rotation of the knee and hip. . —— Supination (the product of plantarflexion, inversion, adduction) occurs as the foot rolls outwards and the arch of the foot raises. In gait, supination occurs during toe off. Heavy supinators tend to toe off early and rely more on their ankle plantarflexors (calf muscles). Their stiffer feet may be well suited for minimalist running and forefoot striking. This same mechanism can be be a slight hindrance in a squat, as it might limit ankle dorsiflexion. —– In everyday life, we manipulate pronation and supination through shoe wear and custom inserts (orthotics). In weightlifting, we use cues like "screw the feet into the ground" or "grip the ground" or "tripod foot" to signify creating an arch and increasing supination of the foot. It is thought that lifting from a stable base allows the lifter to generate more power and engage their powerful hips and external rotators more. Whether this is true or not, depends on the individual lifter and their anatomy. One thing we do know is not one kind of footwear or cue works for everyone, as both feet and humans are incredibly individual. . ——- Next week we hit the knee for #KineticHygiene week 2: 👉🏼@simplestrengthphysio 👉🏼@joegambinodpt ▪️▪️▪️▪️ . . . . . #physicaltherapy #PT #DPT #DPTstudent #physio #fitness #workout #health #training #exercise #crossfit #strength #sports #footpain #feet #shoes #ankle #footwear #physicaltherapist #physiotherapy #sportsmed #running #runningshoes #insoles #orthotics #asics #nike
To reiterate: pronation is a combination of abduction, dorsiflexion, and eversion. Pronation plays a big role in absorption of GRF but can be a problem when we over pronate and don’t properly absorb and see stress going up through the kinetic chain. Remember above how we discussed lack of ankle dorsiflexion with decreased absorption efficiency? Well here is one potential mechanism. If we lack ankle dorsiflexion, we will ultimately get more forefoot collapse via more foot abduction paired with eversion, creating a lot of stress for foot intrinsics and sub optimal forces entering the kinetic chain.
(*Side note: We tend to see more MEDIAL stress associated with over pronation such as: medial tibial stress syndrome, posterior tib muscle pathology, shin splints, etc.)
Often times you will here how MDs or healthcare pros call out patients for having “flat feet.” I tend to think this is an over stated and a “fear mongering” expression that leaves patients/athletes constantly confused about what is right or wrong in terms of orthotics, etc. In my humble opinion, train the intrinsic muscles of your feet and learn how to control your pronation, there your built in orthotics right there.
Supination is a combination of adduction, plantarflexion, and inversion. This is used for pushing off during gait and propelling. This is associated with a rigid foot and STABILITY. This “supination” is essentially what we are going for when we create a short foot, or try to prevent the valgus collapse of the kinetic chain (lower extremity). We do not generally see as many over supinators as we do over pronators, but they do exist. Expect to see limited ankle dorsiflexion, and potentially some over use injuries associated with great toe as well as calf complex.
(*Side note: We tend to see more LATERAL stress associated with over supinators such as: Cuboid pain syndromes, peroneal/fibular tendon pathologies, IT Band syndrome.)
If you have made it through this article, congratulations, we got pretty nerdy there. However lets summarize the KEY TAKEAWAYS from this weeks posts on daily things we can do to improve ankle/foot health.
-Check your ankles and see their ability to dorsiflex, apply 1/2 kneel self mobilization as needed.
-Check your great toe for ability to dorsiflex (extend), apply self mobilization as needed.
-Do you over pronate? Learn how to create a more stable foot through isometric “short foot” contractions
-Do you over supinate? Well for the few people out there who this might be the case: if it problematic seek a skilled health care provider to help you
As always, thanks for reading!