Ankle pain is a common and frustrating problem that many people experience at one time or another.2,8 It can negatively affect almost every move one makes, from standing, to walking to working out. Pain in the ankle joint is often the result of a common musculoskeletal imbalance caused by a number of structures and/or muscles in the body working not working correctly.
Basic Anatomy of the Ankle
The ankle joint (i.e., talocrural joint) is a hinge joint formed in the area where the shin bones (i.e., tibia and fibula) sit on top of the talus bone (see Figure 1).
This joint has up and down movement capabilities which enable the shin to move forward over the foot, the foot to be pulled up toward the shin (i.e., dorsiflex) and the foot to push down away from the shin (i.e., plantar flex). These movements are extremely important during all weight bearing activities like walking and running because they allow the body to first accept weight over the foot and then push the foot down to transfer weight from one side of the body to the other (see Figure 2).3
When the ankle cannot perform these movements effectively and efficiently, pain and dysfunction inevitably result.
What Causes Ankle Pain?
The most common musculoskeletal imbalance that causes pain to the ankle is a lack of dorsiflexion.7 This lack of motion in the ankle joint causes joints above and below to compensate and overly stresses the soft tissue structures (i.e., muscles, tendons, ligaments and fascia) surrounding not only the ankle, but the foot, knee, hip and back as well.
Past injuries/surgeries, arthritis, diabetes, gout, activity choice, footwear and underlying muscle and movement imbalances can result in a lack of dorsiflexion in the ankle joint.7 As a responsible fitness professional it is your duty to refer out to a licensed medical professional if you suspect (or have been informed by your client) that a diagnosed condition beyond your scope of practice is contributing to your client’s ankle pain.1 However, it is also your job to understand the underlying movement/muscle dysfunctions that can cause ankle pain and recommend corrective exercises/strategies to help your clients overcome these imbalances.
What Causes a Lack of Dorsiflexion?
There are four common movement dysfunctions that can factor into a lack of dorsiflexion in the ankle joint. They are overpronation, lack of hip extension, lack of knee flexion and hip flexion.
Overpronation
One of the most common causes of a lack of dorsiflexion is overpronation. Overpronation is characterized by a collapsing inward of the foot toward the midline of the body.4 As previously discussed, the ankle joint (i.e., talocrural joint) can only move up and down (i.e., dorsiflex and plantar flex). Therefore, when overpronation (or excessive motion toward the midline of the body) occurs, it happens in the structures below the ankle (i.e., subtalar joint just below the ankle, the heel bone and the foot). The collapse of these foot/ankle structures sideways impedes the ability of the ankle joint to move up and down and limits dorsiflexion as a result.5
The functioning of the gastrocnemius and soleus muscles is also disrupted by overpronation. These muscles attach to the heel (via the Achilles tendon) and are pulled out of alignment when the heel collapses (i.e., during overpronation). The dysfunction of these muscles further restricts ankle motion as the loading of these muscles (i.e., stretching while the foot is on the ground) is essential to promoting dorsiflexion.
Lack of Hip Extension
When a person is walking or running, one leg must travel behind the body as the other comes forward. As the leg travels behind the body (i.e., goes into hip extension), the shin bones should travel forward over the foot (i.e., dorsiflex) (see Figure 3). If a person is unable to take the leg behind the body effectively, this can inhibit dorsiflexion of the ankle.7
Musculoskeletal imbalances in the lumbo-pelvic hip region (e.g., an anterior pelvic tilt), the position of the hip socket, and the health of the surrounding structures (e.g., if they are dysfunctional and/or inflexible) are all issues that can limit the ability of the hip to extend and the ankle to dorsiflex. A lack of hip extension can also be caused by chronic shortening of the hip flexors, the rectus femoris (a quadriceps muscle that originates from the pelvis) and/or the adductor muscles. As such, the health and flexibility of these specific muscles must be assessed and addressed as part of any corrective exercise program designed to improve dorsiflexion and decrease ankle pain.
Lack of Knee Flexion and Hip Flexion
Movements such as squatting and lunging are closed chain movements of the lower body (i.e., when the foot is in contact with the ground) that require the ankle, knee and hip to bend together in a coordinated fashion (see Figure 4). If the knees are unable to bend (i.e., knee flexion) and/or the hips are unable to bend (i.e., hip flexion) effectively as the ankle bends, a lack of dorsiflexion can result.7
Tightness, restrictions and adhesions in the soleus muscle and quadriceps can limit knee flexion. Similarly, inflexibility of the gluteal complex, erector spinae group and hamstrings can restrict hip flexion. As such, all of these muscles must be targeted as part of an ankle rehab/prehab program because when these muscles are working correctly to enable knee and hip flexion, they will ultimately promote better dorsiflexion (and function) of the ankle.
Ways to Improve Dorsiflexion
The body adapts and responds to its environment and the stresses that are placed upon it. Therefore, you should look to both exercise and non-exercise related strategies for helping decrease ankle pain and improving dorsiflexion.
Corrective Exercise Recommendations
Muscles and dysfunctional movement patterns throughout the body need to be addressed as part of your efforts to improve a client’s ability to dorsiflex. Imbalances including overpronation, lack of knee flexion, lack of hip flexion and lack of hip extension all contribute to a lack of dorsiflexion and must be considered as part of your corrective exercise program design. The use of corrective exercise strategies (i.e., self-myofascial release, stretches and strengthening exercises) to improve the health and function of the major muscles that contribute to the above imbalances (i.e., soleus, gastrocnemius, quadriceps, hamstrings, hip-flexors, gluteals and erector spinae group) should also be included.
Footwear
Discussing footwear choices with clients is another way to help address problems with dorsiflexion. Popular shoe choices, such as running shoes, high heels, dress shoes and work boots often exacerbate the musculoskeletal imbalances discussed above and further limit dorsiflexion. Shoes such as these with an increased heel height (i.e., the typical running shoe) (see Figure 5) actually put the ankle into plantar flexion (i.e., tip the foot downward) and restrict dorsiflexion. More neutral soled shoes (i.e., a similar sole height from front to back) are a better choice for promoting dorsiflexion and restoring ankle function.
Similarly, shoes with a narrow toe box limit dorsiflexion because they do not allow the toes to spread out (see Figure 6). Compression of the toes decreases the overall surface area of the forefoot, and subsequently, the ability of the foot to accept the weight of the body from above. As such, the foot and ankle collapses inward (i.e., overpronates) rather than transferring forward over the foot (i.e., into dorsiflexion).
Therefore, appropriate footwear recommendations to increase dorsiflexion include shoes with a more neutral sole and a wide toe box.6 However, always consider the first rule of any exercise program when recommending a change in shoe type (i.e., gradual progression) to make sure that the modifications you suggest are introduced slowly into your client’s program.
Conclusion
Ankle pain is a common problem that affects almost all of us at one time or another. Understanding that the underlying causes of ankle pain can result from dysfunction almost anywhere in the kinetic chain (and knowing how to address these problems) will not only help you and your clients alleviate their symptoms of ankle pain, but improve the function of their entire body.
To learn more from Justin Price about the causes and cures for both your own and your clients’ aches and pains, check out The BioMechanics Method Corrective Exercise Specialist course available through NETA.
Contributed By:
Justin Price is one of the world’s foremost experts in musculoskeletal assessment and 
corrective exercise and creator of The BioMechanics Method Corrective Exercise Specialist certification (TBMM-CES) available through NETA. The BioMechanics Method is the fitness industry’s highest-rated CES credential with trained professionals in over 70 countries. Justin is also the author of several books including The BioMechanics Method for Corrective Exercise academic textbook, a former IDEA Personal Trainer of the Year, and a subject matter expert for The American Council on Exercise, Human Kinetics, PTA Global, PTontheNET, TRX, BOSU, Arthritis Today, BBC, Discovery Health, Los Angeles Times, Men’s Health, MSNBC, New York Times, Newsweek, Time, Wall Street Journal, WebMD and Tennis Magazine.
References
1American Council on Exercise. 2010. ACE personal trainer manual, 4th ed. San Diego, CA: American Council on Exercise.
2Doherty, C., et al. 2014. The incidence and prevalence of ankle sprain injury: A systematic review and meta-analysis of prospective epidemiological studies. Sports Medicine. Jan: 44(1):123-40.
3Kelikian, A. S. (ed.). 2011. Sarrafian’s anatomy of the foot and ankle: Descriptive, topographic, functional, 3rd ed. Philadelphia: Lippincott, Williams and Wilkins.
4Kendall, F.P., et al. 2005. Muscles testing and function with posture and pain, 5th ed. Baltimore, MD: Lippincott Williams and Wilkins.
5Lynch, S. 2002. Assessment of the injured ankle in the athlete. Journal of Athletic Training. October-December; 37 (4): 406-412.
6Price, J. 2014. How to choose the right training shoe. Australian Fitness Network. www.fitnessnetwork.com.au.
7Price, J., and Bratcher, M. 2010. The BioMechanics Method corrective exercise specialist certification program. San Diego, CA: The BioMechanics Press.
8Thomas, M.J., et al. 2011. The population prevalence of foot and ankle pain in middle and old age: A systematic review. Journal of Pain. Dec; 152 (12): 2870-80.
