The Foot, Ankle and Knee

PFT 101 BY JUSTIN PRICE, MA The Foot, Ankle and Knee

The first of two articles presenting and fibula, functions as a shock absorber. ceps tendon, and to the tibia below the a structural assess- Just below the true ankle joint and above knee via the patella ligament. Correct ment of the lower the heel bone is the talus bone, and below alignment of the femur and tibia ensures kinetic chain. that bone is the subtalar joint. This joint that the patella moves smoothly during helps displace force from side to side. flexion and extension. Between the femur The lower kinetic chain consists of the and tibia lie two shock absorbers: the foot, ankle, knee and lumbopelvic hip gir- COMMON DEVIATIONS OF medial and lateral menisci. On either side dle. In the first article of this two-part THE FOOT AND ANKLE of the knee are two ligaments—the series, you will learn how to assess the The two most common deviations found medial and lateral collateral ligaments, structures of the foot, ankle and knee; in the foot and ankle are overpronation which give side-to-side support to the how the alignment of these parts affects and lack of dorsiflexion. knee. Inside the knee between the tibia the alignment of other body parts in the Pronation, a function of the foot and femur lie the anterior cruciate liga- lower kinetic chain; and some possible wherein the foot collapses and the heel ment (ACL) and the posterior cruciate lig- exercises to help correct deviations. rolls inward, is necessary to help transfer ament (PCL), which help stabilize the forces forward and toward the midline of knee from front to back. ANATOMY OF THE FOOT the body. Overpronation, however— AND ANKLE wherein the tibia, femur and knee rotate COMMON DEVIATIONS The foot and ankle form the foundation inward along with the heel—causes a dis- OF THE KNEE for the entire body and act as shock ruption in the transfer of force. The two most common deviations absorbers when the body interacts with Dorsiflexion is also a normal function found in the knee are problems with a contact surface. They also help the of the foot and ankle. It involves flexing, or side-to-side alignment (the side-to-side body adapt to terrain via side-to-side pulling the foot and toes up and back position of the knee in relation to the movement. toward the shin to maintain alignment femur and tibia) and tracking prob- The Foot. The foot consists of three throughout the body. Overpronation lim- lems of the patella during flexion and parts: the hindfoot, the midfoot and the its dorsiflexion, causing the foot to push extension. These two problems are forefoot. The hindfoot (talus and heel down and forward (plantarflex) rather than closely related. If the knee has side-to- bone) absorbs shock and displaces it for- up and back. Limited dorsiflexion impairs side alignment problems, the patella ward and from side to side. The midfoot all weight-bearing activities from standing will not move freely over the end of the (comprising the small bones in the foot to squatting, walking and running. femur (femoral groove) when the knee between the heel and toes) also helps dis- bends or straightens, and the joint can sipate force from side to side. The forefoot ANATOMY OF THE KNEE become irritated. (consisting of the toes) adapts further to The primary function of the knee is to link the terrain and pushes the foot off for the the upper and lower leg by way of a hinge ASSESSMENT OF THE next step during walking. joint. The knee allows a small degree of FOOT, ANKLE AND KNEE The Ankle. The ankle can be divided movement from side to side; however, its In order to assess a client for problems into two parts: the true ankle joint and main functions are flexion and extension. with the foot, ankle and knee, you must the subtalar joint. The true ankle joint, The kneecap (patella) attaches to the be able to see these structures clearly. which lies immediately below the tibia quadriceps above the knee via the quadri- Instruct the client to wear shorts for the

November–December 2006 IDEA Fitness Journal assessment, and make sure he removes his overpronated, with the arch dropped—or on either side of the knee. Note any shoes and socks. The assessment process absent—and a bulge of flesh sticking out irregularities in both a seated and stand- is verbal, visual and hands-on. on the inside of the foot. Most people will ing position. be overpronated, and there are a num- Side-to-Side Alignment. Ask your Verbal Assessment ber of strategies you can use to address client to stand on one leg and bend the A verbal assessment can provide some this imbalance—for example, choosing knee of the standing leg to about 20–30 insight into your client’s condition. Ask exercises that strengthen the gluteus max- degrees three or four times. Watch the the following questions: imus (which functions to outwardly center of the knee. Make a note of any 1. Do you ever experience pain in your rotate the leg), thereby improving align- movement either inward or away from feet, ankles or knees? ment of the leg and helping to prevent the center line of the body. 2. Have you ever been diagnosed with inward rotation. Patella Tracking During Flexion and arthritis in the feet, ankles or knees? Supination. If all the weight appears to Extension. Ask your client to lie supine. 3. What is your occupation? How much be on the outside of the foot, your client Help him bend one leg toward the chest. physical activity do you get? (This probably suffers from oversupination. Place your hand on his kneecap and ask helps you gauge the daily stress the Movement Patterns. While your client him to bend and straighten the knee. joint experiences.) is in a neutral foot and ankle position, Make a note of whether the kneecap 4. If you are experiencing pain, what look at her knees. (See “Finding Neutral glides smoothly or if there is excessive aggravates the condition? What makes Foot and Ankle Position” sidebar.) For popping, grinding or crunching. it feel better? Does the pain coincide most people, the center of the kneecap Movement Patterns. If your client’s with other pains in the body? will be in line with the second toe (its kneecap moves toward the midline of the Remember to stay within your scope of anatomical neutral position). When your body during the assessment for side-to- practice; only a physician can diagnose a client relaxes from neutral, she will likely side alignment, the foot and ankle are medical condition. Rather than attempting fall back into an overpronated position, probably overpronated as well. This over- to make a diagnosis, use your client’s and the tibia and femur will rotate inward pronation causes the lower and upper leg responses to your questions to choose with the foot. This rotation will cause the to inwardly rotate, which adds further exercises that strengthen or balance weak knee to rotate inward and subsequently stress to the knee. areas. If the imbalances are severe, avoid be out of alignment. exercises that might be contraindicated. When the knee shifts toward the EXERCISE For example, if the client’s patella does middle of the body, many people turn CONSIDERATIONS not track effectively, flexing and extend- the foot outward so the knee can be Full squats, single-leg squats, leg presses, ing the knee under a load, as during a bar- aligned pointing forward. This com- lunges, elliptical training and running all bell squat, would be contraindicated. You pensation places further stress on the involve ankle and knee flexion. If the foot could address the issue by using exercises foot, as forces no longer pass over all the overpronates during these activities, the to strengthen the gluteals and muscles of toes during walking. This can lead to knee joint cannot function optimally. the calf and foot, since these muscles help calluses on the inside of the big toe Similarly, if the knee moves toward the control alignment of the femur and tibia and/or bunions, and can place undue midline of the body, the foot will over- and, subsequently, alignment of the knee. stress on the underside of the foot. pronate, which will limit dorsiflexion. Overpronation also causes the foot and These structural malalignments can cause Visual and Hands-On Assess- toes to move laterally (abduct). Over foot and leg problems like plantar fasci- ment: The Foot and Ankle time, this affects the calf muscle, creat- itis, bunions and shin pain. They can also A visual and hands-on assessment is used ing an imbalance in the lower leg and cause both medial and lateral knee con- to further assess the structures of the body. ultimately preventing the foot from ditions such as iliotibial (IT) band pain, General Appearance. With the client dorsiflexing. chrondomalacia and ligament irritation. standing in front of you, look for any [Editor’s note: See “The Scoop on Run- swelling, calluses or irregularities between Visual and Hands-On ning Injuries” in this issue for more infor- the two feet and ankles. Assessment: The Knee mation on IT pain.] Therefore, it is Pronation. Check to see if the foot is General Appearance. Look for swelling imperative to carefully assess your client’s ability to maintain correct form and opti- mal alignment during complex move- finding neutral foot and ankle position ments of the ankle, foot, knee and hips. There are small indentations at the base of the ankle just below the ankle bones. Place your Make sure that the client’s foot is in neu- thumb on the dimple on the inside of the ankle and your forefinger on the dimple on the tral, the patella is in line with the second outside. When your client rolls the foot and ankle inward (overpronate), you will feel pres- toe, and the center of the front of the hip sure on your thumb. When the foot is rolled outward (oversupinated), you will feel pressure is in line with both the patella and the sec- on your forefinger. This pressure is the talus bone moving in the ankle. Coach your client to ond toe. If there is a deviation, choose pronate and supinate until you feel even pressure of the talus bone on both your thumb and exercises that strengthen and balance the forefinger. This is the anatomical neutral position for the foot and ankle. Most people will supporting structures, and if the devia- have to supinate to get to neutral from their usual dysfunctional overpronated position. tion is severe, avoid contraindicated exer- cises, such as squats under a load.

November–December 2006 IDEA Fitness Journal INCORPORATING suggested exercises THE INFORMATION These three exercises will help your The process of structural assessment clients overcome the structural devia- and corrective exercise does not need to tions associated with the foot, ankle and be a laborious one. Simply assess struc- knee. tures and think about what muscles might be affected by any deviations. GOLF BALL ROLL Then incorporate strategies such as Overpronation leads to wear and tear on the stretching and strengthening exercises plantar fascia and degeneration of other struc- and myofascial release to address the tures of the foot. The golf ball roll is a myofascial massage technique that can help regenerate the musculoskeletal imbalances you have tissue on the underside of the foot. identified, while you get on with your Each day, roll golf ball along bottom of foot for regular exercise program. (See “Sug- 30 seconds to 1 minute, focusing on any sore gested Exercises” sidebar.) spots. In the next installment of this series, you will learn how to assess the lum- CALF STRETCH bopelvic hip girdle, how it relates to The lack of dorsiflexion that accompanies over- pronation is usually caused in part by tight calf other structures of the body and some muscles. sample exercises to correct or alleviate In standing position, place one foot behind body deviations. and push heel of that foot into ground. To avoid overpronation, maintain neutral position in foot and ankle. Hold for 30 seconds. Perform at least Justin Price, MA, is a corrective exercise spe- once a day on each side. cialist, personal trainer and co-owner of The BioMechanics. He is the 2006 IDEA Personal SINGLE-LEG STAND Trainer of the Year and IDEA’s national Strengthening the structures of the lower legs and hips helps maintain a neutral foot, ankle and spokesperson on personal training issues. knee position. Stand on one leg, using balance aid if needed. © 2006 by IDEA Health & Fitness Inc. All rights reserved. Repro- Rotate tibia and femur of standing leg outward duction without permission is strictly prohibited. by rolling foot out and raising arch. Feel gluteal muscles contracting and pulling both lower and upper leg outward. Keep pelvis rotated under so that abdominals contract. This will help align leg in hip joint. Perform 2–3 sets of 10–12 reps three times a week.

November–December 2006 IDEA Fitness Journal