Assessing and Correcting Foot and Ankle Problems

Foot and ankle pain is a prevalent problem that fitness professionals encounter frequently when working with clients. This article illustrates the anatomy of the major structures of the foot and ankle, explains the most common musculoskeletal imbalances of these areas, teaches trainers how to assess a client’s feet and ankles, and provides four corrective exercise techniques that can be used to eliminate pain and improve function.

ABOUT THE FEET AND ANKLES
The feet and ankles are key parts of the body that act as shock absorbers when a person interacts with a contact surface such as the ground. They also help the body adapt to varied surfaces via side-to-side movement. Understanding the anatomy of these important body parts can help you know how to assess them for imbalances.

Anatomy
The ankle can be divided into two parts; the true ankle joint and the subtalar joint. The true ankle joint is immediately below the shin bones and is responsible for up and down movement of the foot. The subtalar joint is located below the true ankle joint between the talus bone and the heel bone. This joint helps transfer weight from side to side.

Figure 1: Anatomy of the Foot and Ankle

The foot consists of three parts; the hindfoot, the midfoot and the forefoot. The hindfoot (talus and heel bone) acts to absorb shock and displace it forward and from side to side. The midfoot (small bones in the foot between the heel and the toes) helps continue dissipating force, while the forefoot (toes) adapts further to the terrain and aids propulsion during gait (see Fig. 1).

Deviations of the Feet and Ankles
The most common imbalances found in the feet and ankles are:

1. Overpronation
2. Lack of dorsiflexion.

Pronation is a necessary function of the foot. It is needed to help transfer weight forward and toward the midline of the body. Overpronation is when the foot collapses too much. This can affect the correct function of the entire kinetic chain.

Dorsiflexion happens when the foot moves toward the shin and vice versa. The ability to dorsiflex can be impacted as a result of overpronation. Overpronation causes the foot, ankle and leg to roll inward too much which limits the ability of the shin to travel forward over the foot. Limited dorsiflexion impairs all weight bearing activities, from standing to squatting to walking and running.

HOW TO ASSESS THE FEET AND ANKLES
You must be able to see and feel the feet, ankles and knees clearly in order to assess these structures properly. Ask clients to remove their shoes and socks for the assessment.

Assessing Overpronation
This hands-on assessment of your client’s subtalar joint will help you evaluate for overpronation. Locate the two small indentations at the base of your client’s ankle, just below the prominent ankle joint. Place your thumb on the dimple on the inside of the ankle and your forefinger on the dimple on the outside (see Fig. 4). Ask your client to roll their foot and ankle inward (overpronate). You will feel pressure increase on your thumb. Ask them to roll outward (oversupinate) and you will feel pressure increase on your forefinger. This pressure is the talus bone moving in the ankle. Coach your client to pronate and supinate until you feel an even amount of pressure of the talus bone on both your thumb and forefinger. This is the anatomical neutral position for the foot and ankle when standing.

Note: Most people will have to supinate to get to neutral from their dysfunctional overpronated position.

Figure 4: Technique for Assessing Overpronation

Relationship Between the Feet and Ankles and the Knees
While your client is in a neutral foot and ankle position, look at their knees. The center of the kneecap will now likely be in line with the second toe (its anatomical neutral position). When your client relaxes from neutral, observe the movement of the kneecap as they fall back into their more comfortable (likely overpronated) foot position. Notice how their foot, ankle and shin rotate inward. This rotation can lead to problems in their foot and ankle, as well as their knee.

EXERCISE RECOMMENDATIONS
Squats, lunges, running, and walking all involve motion of the foot and ankle. Musculoskeletal imbalances in these areas, such as overpronation and a lack of dorsiflexion, can lead to foot, ankle and leg problems like plantar fasciitis, Achilles tendinitis, bunions and shin splints. Here are four exercises to help your clients correct these structural deviations.

Golf Ball Roll
Overpronation leads to wear and tear of the plantar fascia and degeneration of structures on the underside of the foot. The Golf Ball Roll is a myofascial massage technique which can help your clients regenerate the tissue on the underside of their feet.

Figure 6: Golf Ball Roll

Instruct your client to roll a golf ball daily on the underside of each foot (see Fig. 6) for 30 seconds to 1 min on the sore spots they find at least once a day.

Big Toe Pushdowns
When people overpronate, the arch of their foot becomes weak. A strong flexor hallucis muscle, which passes under the foot, can help maintain the structure of the arch of the foot.

Instruct your client to find a neutral foot and ankle position (se: Figure 4: Technique for Assessing Foot and Ankle Position). Ask them maintain this position as they push their big toe down without collapsing the arch of their foot. As they get stronger, they will feel the flexor hallucis muscle contract under the arch of their foot. You can coach your client to activate this muscle in all weight bearing exercises to prevent overpronation and help them perform better.

Tennis Ball Under Calf
One of the most common deviations of the foot and ankle is a lack of dorsiflexion. This musculoskeletal imbalance can be caused by tightness and restrictions of the calf muscles. Using a tennis ball to self-massage the calves is a great way to help rejuvenate and restore health to these muscles so that the ankle and foot can dorsiflex more effectively. This will not only improve foot and ankle function, but also help align the rest of the body.

Instruct your client to sit with their back against the wall or couch and place a tennis ball (or harder ball like a baseball if they need more pressure) under their calf. Ask them to raise the ball up slightly by placing it on top of a book to take pressure off their knee. They should massage each sore spot they find for 20-30 seconds and then move the ball to another spot doing both sides.

Calf Stretch
After performing the self-massage technique above you should instruct your client to perform a calf stretch to further help facilitate dorsiflexion. Increasing the ability of the foot and ankle to dorsiflex will help lessen the effects of overpronation and decrease the associated pain and dysfunction.

Instruct your client to stand in a split lunge stance (make sure their feet are aligned straight front to back) and ask them to push the heel of their back foot into the ground. Coach them to hold this stretch for 30 seconds each side at least once per day.

CONCLUSION

Structural assessments and corrective exercises to eliminate foot and ankle pain can be integrated into any fitness program. Simply incorporate exercise strategies that address any musculoskeletal imbalances you identify during the assessment process to help your clients feel better and function more effectively.

RECOMMENDED READING
Abelson, Dr. Brain and Abelson, Kamali. Release Your Pain. Calgary: Rowan Tree Books, 2003.
Golding, Lawrence A. and Golding, Scott M. Fitness Professionals’ Guide to Musculoskeletal Anatomy and Human Movement. Monterey, CA: Healthy Learning, 2003.
Gray, Henry. Gray’s Anatomy. New York: Barnes & Noble Books, 1995.
Petty, Nicola and Moore, Ann, P. Neuromusculoskeletal Examination and Assessment: A Handbook for Therapists. Edinburgh: Churchill Livingstone, 2002.
Price, Justin. The Biomechanics Method Corrective Exercise Educational Program. San Diego: The Biomechanics Books, 2010.
Whiting, William C. and Zernicke, Ronald F. Biomechanics of Musculoskeletal Injury. Champaign, IL: Human Kinetics, 1998.

ABOUT THE AUTHOR
Justin Price, MA, is the creator of The BioMechanics Method – the world’s fastest growing corrective exercise educational course for health and fitness professionals. He is an IDEA Personal Trainer of the Year and the corrective exercise subject matter expert for The American Council on Exercise, PTontheNet, BOSU, TRX and PTA Global. For more information go to: www.thebiomechanicsmethod.com.

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Justin Price

Justin Price is the creator of The BioMechanics Method® - the world's fastest growing corrective exercise education program for health and fitness professionals. He is an IDEA International Personal Trainer of the Year, subject matter expert on corrective exercise for the American Council on Exercise and BOSU, founding author of PTA Global, Director of Content and featured author on corrective exercise for PTontheNet and an education provider for TRX and the National Strength and Conditioning Association.

Latest posts by Justin Price

• Assessing and Correcting Foot and Ankle Problems - October 10, 2013
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