Summer is a carefree transition for feet, going from the confines of boots and high heels to flip-flops or the complete freedom of going barefoot. To make this transition comfortable and safe for your clients, consider it an opportunity for re-assessment and updated corrective exercise programming. Be on the lookout for pronation distortion syndrome, characterized by excessive foot pronation, knee flexion, internal rotation, and adduction. Clients with pronation distortion syndrome have altered joint mechanics at the foot, ankle and knee, and also develop predictable patterns of injury including low back pain, patellar tendonitis, posterior tibialis tendonitis, and plantar fasciitis.
High heels aren’t just a fashion statement for women. Men’s dress shoes and most work boots are also designed with an elevated heel. This elevation places the foot in an unnaturally plantar flexed position that, overtime, can shorten the posterior muscles of the leg (e.g., calves, hamstrings) and elongate those of the anterior leg (e.g., anterior tibialis, posterior tibialis) leading to a decrease in normal ankle dorsiflexion range of motion and increased pronation (1-2). This alteration can impact the function of other muscles and joints throughout the entire kinetic chain, so it is vital to restore and maintain normal range of motion and strength.
Plantar fasciitis, Achilles’ tendinopathy, posterior tibialis tendinitis (shin splints), and ankle sprains are some of the more common complaints and injuries linked to the ankle’s limited range of dorsiflexion (2). The hallmark complaint of those with plantar fasciitis is the pain felt in the heel during those first steps when getting out of bed or after sitting for an extended amount of time (2). A study by Bolivar, et al., indicated that those with tight hamstrings were 8.7 times more likely to suffer plantar fasciitis (1). Based on this research, stretching the hamstrings in addition to the standard approach of stretching the calves and plantar fascia may provide further relief (1).
Additionally, the shortened gastrocnemius can be particularly susceptible to injury because it crosses multiple joints across the knee and ankle (and also the subtalar joint that converts the midfoot to a rigid lever for push off during walking) (3). Plantar flexion torque is greatest when it is in full dorsiflexion, such as walking up stairs with the heel hanging over the edge or stepping backwards and planting the heel flat on the ground (which now goes even further without the rigid support or lift of a heeled shoe)(3). When the ankle plantar flexes for takeoff, the gastrocnemius elongates as the knee extends (3). During the time when the gastrocnemius is eccentrically loaded is likely when a strain will occur. Another way to consider this is that when the ankle is in full dorsiflexion and the knee in extension, the gastrocnemius is stretched and more susceptible to tearing when it contracts (4-5).
Ankle sprains are one of the most common sports-related injuries. Clients who have had ankle sprains may not only have decreased ankle dorsiflexion range of motion, but may also have hip weakness (2). This is yet another indicator of pronation distortion syndrome, under-activity of the gluteus medius/maximus and hip external rotators that can be identified in postural assessments (2).
Using assessments, both static and dynamic, can guide the development of a corrective exercise strategy. Evaluate all kinetic chain checkpoints, paying particular attention to the responses of the feet, ankles, knees and lumbo-pelvic-hip complex to discover what muscles may be over- or underactive. For example, during the overhead squat assessment, if flattening of the feet is observed, the overactive muscles most likely will be the lateral gastrocnemius, biceps femoris, peroneal complex, and tensor fascia latae (TFL) (2). If the knees move inward it could be a compensation for restricted ankle dorsiflexion.
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- Bolivar Y., Munuera P., Padillo J., Relationship between tightness of the posterior muscles of the lower limb and plantar fasciitis. Foot Ankle Int 2013:34(1):42-48.
- Clark, M., Lucett S., Sutton, B., NASM Essentials of Corrective Exercise Training, 1st ed. rev. Burlington, MA. Jones & Bartlett Learning. 2014 .
- Neumann D., Kinesiology of the Musculoskeletal System, 2nd ed. St Louis, MO:Mosby Elsevier. 2010.
- Physionpedia- Calf Strain Lynn Leemans editor, http://www.physio-pedia.com/Calf_Strain
- Foot Education - Calf Muscle Tear, 2011 http://www.footeducation.com/calf-muscle-tear-gastrocnemius-tear