Subtle Clues to Ankle Rocker Pathology: How good are your powers of observation ?
There are clues showing you there is motor pathology to ankle dorsiflexion, if you are paying close enough attention.
When we see motor pathology in ankle dorsiflexion we immediately begin to think about impairment to hip extension range of motion, gluteal strength, motor coordination and many other issues.
Here is a simple case. Observation skills are your greatest superpower when it comes to figuring out many gait and movement problems. But, you have to know what to look for and know what they mean before you can even hope to know how to fix things.
This is a simple video. It shows active ankle dorsiflexion in supination. We asked the client (a runner with right heel and persistent sesamoid pain following a healed sesamoid fracture) to perform simple ankle dorsiflexion. This is what we saw.
It should be clear to the observer that the end of the video shows attempted right dorsiflexion pulls the 2-5 toe extensors into the pattern quite aggressively and as a dominating faction. One can see toe abduction and extension with surprisingly little help from the long hallux toe extensor (EHL). Dorsiflexion also fatigued early on the right. There is only one reason that the lesser toe extensors (EDL & EDB) are being over recruited, it’s because the EHL and tibialis anterior are weak and/or inhibited or have been pattern corrupted for one reason or another. Depending on this smallest of anterior compartment muscles over the EHL and tib anterior will mean that ankle rocker (dorsiflexion) is impaired. It also means that abnormal forefoot valgus posturing is expected (we could make a case for valgus or varus depending on other variables present). Passive ROM assessment confirmed the impaired ankle rocker with barely greater than 90 degrees ankle dorsiflexion ROM. This impairment will possibly do many things including:
- premature heel rise
- premature gastrocsoleus engagement
- accentuated rear foot eversion (Rearfoot pronation)
- midfoot pronation
- strain of plantar fascia
- premature forefoot loading response (strong clue for clients sesamoid fracture and persistent pain)
- anterior/ posterior shin splints
- hallux VALgus /bunion formation
- long toe flexor dominance and many other things.
This clinical find plays nicely into the clients multiple symptoms (plantar pain and sesamoid problems) and functional gait pathology.
Restoring proper motor hierarchy and synchrony to the ankle dorsiflexion team (tib anterior, peroneus tertius, EDL, EHL) will reduce the need for solitary group overuse and impart forces where they should be when they need to be present. Impair the synchrony and problems ensue.
Help your client achieve the motion at the ankle mortise and they do not have to pass the buck into the foot. Always test for skill, endurance and strength. Endurance is the most often forgotten assessment. If endurance is lost early, the brain will begin to block out that end range of motion because it cannot be trusted, and thus posterior compartment tightness will be detected. This is an often common source of regional achilles and para-achilles tendonopathy. If your clients symptoms take time during activity to develop looking at the endurance of motor patterns may give the clue to your solution.
Simple case, but you have to know your normal gait parameters, know functional anatomy and know how impaired mechanics factor into injury.
Shawn and Ivo
The gait guys
