In the first part of “Alleviating Ailing Ankles,” I discussed the function of
the ankle joint and demonstrated a few exercises to help achieve additional
range of motion in dorsiflexion. While on the surface it seemed to be a very
extensive article, lucky for you and me, the foot and ankle are extremely
complicated. Thus, true ankle health and “mobility” are multifactor issues, and
often just training “dorsiflexion” isn’t sufficient.
In this article, I will further discuss the structure, function, and
pathomechanics of the ankle in another critical motion to foot and ankle
health—subtalar inversion and eversion—and also give you a few practical
solutions for restoring mobility.
Why do we want eversion?
While dorsiflexion is often trumpeted as critically important for ankle health
(and it is), we often forget the importance of the “red-headed step child” of
movements—eversion. Like most things in the body, rarely does a joint move one
way without there being other accessory joint movements. With regards to the
ankle, pure dorsiflexion is nice, but in gait, dorsiflexion occurs with eversion
and also abduction. The sum of the three create “pronation.”
Unless the joint is adequately mobile in all three planes of motion, we are
doing our athletes a disservice, as they will eventually seek and find mobility
in places where they shouldn’t. Those familiar with the concept of joint by
joint training can certainly appreciate this idea. Our body is composed of
relatively mobile joints connected via relatively stable segments.
Understanding the mechanics
As you will remember from part 1, pronation or supination at the subtalar joint
can help the ankle achieve additional dorsiflexion or plantar flexion range of
motion, respectively. But what exactly is the subtalar joint?
The subtalar joint is composed of three articulating facets—anterior, middle,
and posterior—between the talus and the calcaneus. The flat, calcaneal anterior
and middle facets offer a gliding motion whereas the posterior facet is saddle
shaped, which permits triaxial movement. The joint is reinforced by a joint
capsule surrounding the anterior and middle facets and a capsule surrounding the
posterior facet. It seems that the collateral ligaments of the ankle play a role
in the position of the subtalar joint, including the often injured anterior
talofibular ligament (ATFL).
The subtalar joint serves many important movements in human gait including
inversion and eversion of the rear foot about the long axis of the foot in
addition to abduction and adduction relative to the vertical axis of the tibia.
Additionally, the subtalar joint allows both pronation and supination to occur
(remember the triaxial posterior facet). The subtalar joint also serves the
critical role of translating rotation of the foot to the tibia or vice versa.
This function is absolutely critical in locomotion over unstable surfaces and
can also lead to havoc higher up the chain.
Ankle injury and subtalar alterations
It is well established that ankle injuries are extremely common in sport. An
ankle injury can disrupt the proper mechanics of the bones that make up the
subtalar and talocrural joints. The most common injury to the ankle is the
lateral sprain resulting from high velocity plantar flexion and inversion. Of
lateral ankle sprains, in 66 percent of the occurrences, there is an injury to
the ATFL. In an additional 20 percent of occurrences, injury to the
calcaneofibular ligament is demonstrated. This is no surprise because the ATFL
limits inversion best while plantar flexed, and the CFL is a strong opponent to
inversion throughout the range of motion. Unfortunately, the ATFL is also the
weakest of all of the lateral collateral ligaments.
Following ankle injury, a positional fault is often observed in subtalar
joint position, which is locked into inversion known as rear foot or subtalar
vars Rear foot vars is when the position of the foot is inverted relative to
the ground in subtalar neutral.
Given the body’s remarkable ability to adapt, it can attempt to shift the
position of the talus to compensate for an inverted calcaneus. In observing the
rear foot, a compensated rear foot vars will appear perpendicular in subtalar
neutral but averted in standing (left). Uncompensated, it will appear inverted
in both ranges of motion (right).
With the subtalar joint in inversion, the foot must pronate more to clear the
heel from the ground. Once clear, the foot is forced to rapidly supinate to be
effective in propulsion, creating a whip-like effect, which has been implicated
in Achilles’ tendonopathies. Additionally, the first ray of metatarsals becomes
an inadequately stable base for propulsion (remember the joint by joint
approach) and the big toe begins to lose mobility.
Finally, remember that the subtalar joint translates this rotation
(pronation) to the tibia and the tibia translates rotation higher in the body.
Excessive relative internal rotation of the foot, tibia, and subsequently femur
can cause femoral head position changes and scarring of the deep hip rotators.
This can ultimately lead to a grab bag of pain and pathology of the knee, hip,
and low back.
Do I have you convinced of the importance of addressing the mobility of the
subtalar joint yet? Good!
Mobilization of the subtalar joint
It is worthy of noting first and foremost that in the acute stages of injury, we
strength coaches have no business performing therapy. However, with properly
sequenced rehabilitation in late stage injuries, the performance specialist can
and should consider maintaining or even improving results achieved in therapy
with smart use of mobilization and self-soft tissue prescriptions.
At Boddicker Performance, we use a series of soft tissue exercises and
dynamic mobility drills to address the subtalar joint. You’ve probably seen many
of these as mobility drills but probably not in the light of ankle mobilization.
Lateral leg swings
While classically viewed as a “hip mobility” exercise, the knee drives do an
excellent job at taking a grounded foot through a great mobility exercise in
inversion and eversion. These also have some effect on abduction and adduction
range of motion.
Pivots
These are a great first progression for mobilizing the subtalar joint in
eversion and inversion. Be sure the heel stays in contact with the floor.
Drop lunges
These are much like pivots, but they also give the hips more work and create
more overall warmth. I often include them in the dynamic mobility warm up.
Wedge wall drill
By using a wedge on the lateral half of an inverted talus, the goal is to open
up the joint in eversion with each knee drive. With this exercise, the same
rules still apply as in traditional wall drills. Wedge Romanian deadlift
The same concept as above is used here, but it’s done with a different exercise.
We'll challenge eversion range of motion and dynamic stability and get a lot of
tissues active with this one.
Whether you’re working with athletes or with the elderly, you will often see
restrictions that limit ankle mobility. Though these articles, I hope you’ve
left with a better understanding of the “what,” “why,” and “how” of training the
ankle for optimal performance. While dorsiflexion range of motion is critical to
performance, coaches must not forget that the “ankle” is a triaxial joint that
functions in integrated movement and should be addressed as such.
Works referenced
Boardman and Liu (1997) Contribution of the anterolateral joint capsule
to the mechanical stability of the ankle. Clinical Orthopedics 341:224–32.
Boyle Michael (2009) Joint by Joint Approach to Training. T-Muscle.
Accessed: Dec. 29, 2009. At:
http://www.1500t.com.
Greenman Philip E (2003) Principles of Manual Medicine. Philadelphia:
Lippincott Williams & Wilkins.
Houglum Peggy A (2005) Therapeutic Exercise for Musculoskeletal Injuries
(Athletic Training Education). New York: Human Kinetics.
Hubbard (2008) Anterior positional fault of the fibula after subacute
lateral ankle sprains. Manual Therapy 13:63–7.
Lundberg, Goldie, Slevik, Kalin (1989) Kinematics of the foot and ankle
complex-part 1: plantarflexion and dorsiflexion. Foot and Ankle
9:194–200.
Lundberg, Svensson, Bylund (1989) Kinematics of the foot and ankle
complex-part 2: pronation and supination. Foot and Ankle 9:248–53.
Lundberg, Svensson, Bylund, Selvik (1989) Kinematics of the foot and
ankle complex-part 3: influence of leg rotation. Foot and Ankle 9:304–9.
Maxx (2007) Five Most Common Pathomechanical Foot Types. 1–6.
Oatis Carol A (2008) Kinesiology: The Mechanics and Pathomechanics of
Human Movement. Philadelphia: Lippincott Williams & Wilkins.
Carson Boddicker is owner of Boddicker Performance, a Flagstaff, Arizona
based company with a focus on improving athletic performance using an integrated
training model to help each athlete reach an optimal level of competitive
preparedness. Learn more at
www.BoddickerPerformance.com.
Elite Fitness Systems strives to be a recognized leader in the strength
training industry by providing the highest quality strength training products
and services while providing the highest level of customer service in the
industry. For the best training equipment, information, and accessories, visit
us at www.EliteFTS.com.
