NASM CES Chapter 11: Corrective Strategies for the Foot and Ankle
NASM CES Chapter 11: Corrective Strategies for the Foot and Ankle 1

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Chapter Goals:

  • Find the basic functional anatomy of the foot and ankle complex.
  • Know the mechanisms for common foot and ankle injuries.
  • E can describe the influence of foot and ankle movement and the rest of the kinetic chain.
  • Determine the right strategies for systematic assessment of the foot and ankle.
  • Use the appropriate corrective exercise strategies for the foot and ankle. 

Introduction

Human movement is a very complex balance of biomechanical stabilization, neuromuscular control, and sensory stimulation.

All closed chain movements start with the connection between the foot and the ground. The human foot, therefore, must take on a significant amount of repetitive stress in the form of the reaction forces with our steps. 

The body functions as an interconnected chain where compensations in one area, such as the foot and ankle in this case, may lead to more dysfunctions throughout the rest of the body. 

Review of Foot and Ankle Functional Anatomy

The foot and ankle structure is complex and greatly influences the rest of the body because it is the first part of the kinetic chain.

The most important things will be covered through this review, not everything regarding the foot and ankle.

Bones and Joints

These structures can be broken down into three areas of the foot.

We have the rearfoot, the midfoot, and the forefoot.

It is important to know the bones that make up each section and their look based on the pictures provided throughout this chapter. 

Talocrural or Ankle Joint

This is the first joint in the rear foot, and it is used for sagittal plane dorsiflexion and plantar flexion during open chain movements.

In the open chain movements, dorsiflexion is shown in the top of the foot, moving closer to the anterior tibia.

For closed chain dorsiflexion, we have the foot in contact with the ground so that the anterior tibia approximates the dorsal part of the foot. 

Subtalar Joint

The talus and the calcaneus make the second joint in the rear foot, which we call the subtalar joint.

It Is a frontal plane joint and the movements are inversions and eversions. 

Relationship Between Ankle Joint and Subtalar Joint

Every action in the ankle joint influences the STJ and vice versa. 

Tibial Rotation

The last step for us to understand the rearfoot function and influence in movement compensations is to appreciate the influences of the rearfoot on the tibia in the transverse plane.

Due to the relationship between the talus and tibia in closed chain moves, every action in the STJ and the ankle joint will have some influence on the tibia and low leg.

When doing closed chain movements, all frontal plane motions of the STJ will create a transverse plane rotation in the leg. 

Pronation and Supination

Due to the STJ and ankle coupling, the rearfoot’s motion will be in three planes.

This is referred to as pronation and supination.

Pronation is the movements of ankle dorsiflexion, foot abduction, and eversion.

This pronation often happens when decelerating and presents an unlocked rearfoot that is best for absorbing force when lowered into a squat like position.

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Supination is the movements of ankle plantar flexion, foot adduction, and inversion.

This occurs most when we are accelerating. 

Muscles

There are two main muscles in the foot and ankle complex.

These are the extrinsic and intrinsic muscles.

Extrinsic muscles are the ones that come from the lower leg and are then inserted into the foot as tendons, and the intrinsic muscles are the ones that originate in and also insert somewhere in the foot.

Their relationship is important for the dynamic movements that we go through. 

We consider the intrinsic muscles to be more stabilizers and the extrinsic ones to be more of mobilizers. 

The main muscles of the invertors and evertors that are extrinsic are these:

The invertors of the foot and ankle complex are the anterior tibialis, posterior tibialis, and soleus.

The evertors will be our gastrocnemius, peroneus longus, and peroneus brevis. These will work together to bring mobility and motion to the foot and ankle complex. 

Altered Foot and Ankle Movement

The ankle is by far the most injured joint in all sports and daily life.

It is the start of the kinetic chain, and thus it receives a lot of stress as we go through the day.

The hip is seen to be vital for maintaining the control of our ankles.

Some other factors that have been related have been the LPHC muscle weakness, especially in the transverse and frontal planes, and this contributes to the altered alignment of the lower body and increases in pronation of the foot. 

Static Malalignments

Common static malalignments in the foot and ankle complex are things like the pes planus of the foot, which results from overactive peroneal and the lateral gastrocnemius, underactive anterior and posterior tibialis, and decreases that have been seen in the joint motion, specifically in the MTP joint and talus. 

Abnormal Muscle Activation Patterns

It has been shown that people with unilateral chronic sprains of their ankle have weaker ipsilateral hip strength during abduction and increases in postural sway.

People with this increase in postural sway have been seen to have 7 times more ankle sprains than those without.

Fatigue of the knees and hips creates this greater sway in posture. 

Dynamic Malalignments

Excessively pronating the foot when doing weight bearing activity has been shown to cause alterations in the alignment of the tibia, femur, and pelvic girdle. This leads to stress from internal rotation in the lower body and pelvis.

This can cause strain on the soft tissues exposed.

Foot and Ankle Dysfunction and the Regional Interdependence Model

Ankle and foot dysfunction can have serious problems in the human movement system.

The motion of your foot and ankle will affect the structures close in proximity by disrupting the natural couples as they exist in the ankle, foot, tibia, femur, and hip.

There are very direct relations between ankle problems and problems showing up next in the knee.

This is because they are so close and affect one another. 

Over Pronation

When the foot abducts too much and/or everts when doing closed chain exercise of the dynamic variety, there will be an associated break in the functional stability of the client’s foundation.

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Over pronation leas to internal rotation of the tibia, adduction in the femoral area, and knee valgus alignment.

Many muscular imbalances are associated with over pronated positions. 

Over Supination

When we do the opposite and over supinate the foot, we will see increases in the plantar flexion and inversion when doing our closed chain exercises of the dynamic kind.

Plantar flexion and inversion couple with tibial external rotation, and this leads to tightness of the foot, ankle, and hip and a restriction in overall mobility. 

Assessment Results for the Foot and Ankle

Doing the lower body assessments barefoot will allow us better to see the function of the foot and ankle complex.

For some people, the assessments can be done in footwear if needed. 

We review all of the assessments we have in our CES flow discussed in the last few chapters. 

Static Foot and Ankle Posture

The first step for making a strategy for corrective exercise is to do a static postural assessment.

We should look for something related to pes planus syndrome, characterized by having flat feet and knee valgus present.

This position will have excessive stress on the muscles and connective tissues associated with ankle joint movement in dynamic moves. 

Another thing to look for is ankle plantar flexion, which is seen by knee hyperextension.

The positions of the knee and ankle are looked at using the posture classifications in Kendall’s classifications. 

Transitional Movement Assessments

The transitional movements follow the static assessments.

This is the next step toward finding the possible imbalances present in the body.

The overhead squat assessment should be done and then modifications can be made to get more details into any dysfunctions. 

Overhead Squat Assessment

Due to the squat needing optimal ankle mobility, many common compensations seen in the overhead squat will be associated with this lack of ankle dorsiflexion.

Pronation and knee valgus may be due to these restrictions due to the relation the ankle has to the knee.

Pay attention to the various ways we see the ankle affecting our overhead squat in the pictures. 

Single-leg squat

This is also a vital assessment for finding possible foot and ankle compensation.

Having to squat on one leg may show dysfunctions not found when squatting with two feet.

The main thing to look for is excessive foot and heel rise pronation. 

Loaded Movement Assessment

If someone can do the overhead squat and the single leg squat assessments with very little to no compensation, then there can be benefits to assessing their performance in the squat under loaded conditions.

The loaded squat assessment looks at dynamic posture, core stability, and overall neuromuscular control in regular conditions of exercise. 

Dynamic Movement Assessment

These can help to find whether foot and ankle deficiencies exist while doing more dynamic things like walking.

When doing a gait assessment, look at the person’s feet for external rotation or pronation.

Like the overhead squat, this may be seen along with knee valgus. 

Mobility Assessments

If the client has shown impairments of the foot and ankle when in a static posture, movement assessment, or both of these, then it is time to do a mobility assessment to pinpoint the cause of these imbalances even more. 

Corrective Strategy for the Foot and Ankle

The integrated assessment process will show patterns of compensation that may require the implementation of the corrective exercise programming in the foot and ankle complex, with the most common thing found being overpronation.

When static, movement, and mobility assessments are done and the impairments are found, the corrective exercise strategy can be made using the NASM’s corrective exercise continuum.

Prevention and rehab programs are effective at decreasing foot and ankle injuries in those who are physically active and improving their ankle function. 

Common corrective programming selections for the foot in the ankle include:

  • Inhibit the use of SMR. The main muscles or exercises will be the gastrocnemius, soleus, peroneals, biceps femoris, and TFL. You should follow the guidelines for inhibiting the muscles with myofascial rolling. 
  • The lengthening phase is next, and this involves the use of static stretching or NMA. The main muscles that will be stretched are the gastrocnemius, soleus, biceps femoris, and the TFL. Use the previous guidelines that were set for lengthening.
  • Activation is the third part and it makes use of isolated strengthening. Here we will target the short foot, posterior tibialis, anterior tibialis, medial hamstrings, and gluteus medius. Follow the aforementioned guidelines from the activation chapter.
  • Integration is the last part of the plan. This involves integrated dynamic movement, and the main exercises will be the step up balance and the single leg balance reach. Follow the 10 – 15 reps recommendations. 
  • Look over the example program set up for over pronation in this chapter section. 

Common Issues Associated with the Foot and Ankle

Due to the great amount of repeated stress put on the ankle and foot daily, the structures themselves are susceptible to being overused and having many impact related injuries.

We will now discuss the four most common injuries to the foot and ankle. 

Plantar Fasciitis

The plantar fascia is a thick and fibrous band of connective tissue that runs from the calcaneus to the base of our digits.

Inflammation of the plantar fascia is caused by irritation.

This is from micro tears that occur in the tissue.

This is common to see with pain in your first steps when waking up in the morning or after resting. 

Achilles Tendinopathy

The Achilles tendon is the largest and strongest in the human body.

It is made up of the tendon fibers from the gastrocnemius and soleus. The Achilles tendon rotates on itself toward the insertion point.

It works to reduce the friction between someone’s muscle fibers and allows for increasing transfer of energy.

Achilles tendinopathy was also known as Achilles tendonitis once.

It is an injury that results from overuse and is considered along a continuum.

It presents itself as pain in the middle of the tendon. 

Medial Tibial Stress Syndrome

This is also known as shin splints.

It is also an overuse injury that is seen with improper loading of impact forces and a more rigid type of foot.

Impact forces are seen as vibrations, absorbed and damped through a stiffening response in the myofascial system.

People with it will often have pain and tenderness in the lower third of their medial tibia, even more so when they are running and walking. 

Ankle Sprains and Chronic Ankle Instability

Ankle sprains are one of the most common sports injuries seen, and they are over 50 percent of all basketball injuries.

73 percent of all sprains occur on the lateral aspect of the joint. 

Chronic ankle instability is seen as repetitive episodes of the ankle giving wat and having feelings of instability.

Many factors contribute to this.

NASM CES Chapter 11: Corrective Strategies for the Foot and Ankle 2
NASM CES Chapter 11: Corrective Strategies for the Foot and Ankle 3
NASM CES Chapter 11: Corrective Strategies for the Foot and Ankle 4

 

Tyler Read

Tyler Read, BSc, CPT. Tyler holds a B.S. in Kinesiology from Sonoma State University and is a certified personal trainer (CPT) with NASM (National Academy of sports medicine), and has over 15 years of experience working as a personal trainer. He is a published author of running start, and a frequent contributing author on Healthline and Eat this, not that.

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