*In case you missed it- Check out part 1 of our foot-ankle series discussing essential foot anatomy
Foot and ankle limitations are shockingly common, especially within sport performance. Foot-ankle deficits can range from minor irritants like ankle instability, weak intrinsic foot muscles, or chronic arch or calf cramping to more significant ailments such as turf toe, plantar fasciitis, and Achilles tendinopathy. While there are several potential contributing variables, we do need to recognize the rise of lower limb and foot injuries over the last decade, particularly among younger athletes. Potential contributing factors include early sport specialization, playing surface, footwear, mismanagement and/or misguided programming that does not adequately prepare the foot-ankle complex for demands of sport. But irrespective of the contributing factors, what coaches and practitioners should emphasize is the variables they can control, while understanding the significance of the interrelated dynamics of foot function.
Throughout the last year of working with athletes I have noticed some consistent trends across a variety of sports and levels/ages. What I find most commonly is a lack of intrinsic foot strength, chronically tight calves, poor foot compliance (i.e., pronation-supination), and poor force coupling around the ankle joint (i.e., Windlass mechanism). While most of these athletes have minor or no symptoms and generally can perform up to their ability, these foot-ankle limitations can become a quiet but significant weak link in the chain. The trouble with foot deficiencies is that they materialize in a cascade fashion, or in other words, one small problem leads to another, which then accumulates into other, or much bigger issues. If these seemingly minor things go unaddressed, athletes can become vulnerable to more significant injuries such as turf toe, chronic ankle sprains, shin splints, or even worse, plantar arch tears or Achilles tears.
A Quick Note of Footwear
Over the years I’ve become more and more adamant that to get the most out of foot-ankle specific work we need to have athletes perform certain portions of their training without shoes. The first reason speaks to the points on stimulating proprioceptive acuity. When athletes are training in shoes, the demand for proprioception is significantly reduced as the cushioning of the midsole and tread create interference for the feet to be stimulated. The second reason is the influence of compliance and ability to pressurize across the foot. The presence of shoes disrupts the foot’s ability to create compliance and stability as we are unable to fully bend and articulate the foot with shoes on. Barefoot training shouldn’t be applied all the time or for everyone blindly, but it should be considered and included for most.
When the athlete can’t bend and manipulate the foot to accommodate different positions and vectors, it disrupts the ability to pressurize across various aspects of the foot. Foot pressurization is a critical aspect of foot function and sets the foundation for total body kinetic sequencing. Another restriction of shoes is limiting the athletes ability to bend through the forefoot, which, importantly, compromises extension of the toes and therefore the windlass mechanism. When the forefoot cannot appropriately bend, the plantar arches are unable to be fully tensed which reduces the potential for storing and releasing mechanical energy. As simple as it seems, getting athletes out of their shoes, without changing any other aspects of training, is covering a lot of ground for improving foot and ankle strength.
Addressing Foot Deficiencies
The heuristic I’ve always used for the foot-ankle complex is that it represents our origin for force excursions. Adding to this, if we have a weak foundation, it’s difficult to develop a stable structure. The foot-ankle complex should be seen as a foundational construct to how the body tolerates, disperses, and transmits forces throughout the body. The ability to be stable and compliant across the foot-ankle complex is essential for how the body moves and performs. Improving foot-ankle strength and function should not be seen as an arduous task, and it does not require much additional input in training. We can develop this model around the four central pillars of improving foot proprioception, developing intrinsic foot strength, improving foot compliance, and increasing the mechanical spring of the foot.
This starts with addressing foot proprioception and intrinsic foot strength first. These two traits are essentially the gatekeepers for all other foot functions and therefore should be a preliminary focal point. Thereafter, I look to develop the athlete’s ability to pressurize and stabilize across multiple aspects of the foot. Rather than emphasizing a single mechanical action (i.e., foot pronation) I take a general approach of being able to pressurize across all aspects of the foot. Being able to transition fluidly between the outside border of the foot (supination) to the medial aspect of the foot (pronation) is a fundamental demand for sport.
Segmental function, coupling and de-coupling the three segments of the foot is significant for foot compliance and stabilization. This interaction between the forefoot, midfoot, and hindfoot is another factor that is essential for kinetic chain sequencing pattern. Finally, developing the Windlass mechanism of the foot is critical for foot-ankle force coupling and mechanical force transmission. This involves being able to extend at the big toe while suspending the heel creating full mechanical tensioning of the plantar arches. When this function is lost or impaired, adjacent and surrounding structures become vulnerable to overload due to a loss of mechanical foot stiffness, which impairs propulsion in movement. I look at this simply as athletes “working harder to achieve less” when they can’t mechanically load the foot.
Where the intrinsic foot muscles act as the gatekeeper for foot function, tibial internal and external rotation can be seen as the “master lock & key” for foot actions. When athletes are compromised in tibial IR-ER, the foot will invariably compensate to create the desired or demanded actions. For instance, if tibial internal rotation is compromised, the midfoot will excessively pronate to achieve the toe off mechanics. There is essentially a give and take relationship between the structures above and below the ankle joint. When one side of the tandem is compromised in function or capacity, the opposing side will “find a way” to achieve the desired outcome. Therefore, when, for example, we lose tibial internal-external rotation, the foot independent overworks and often performs actions the structures are not designed to do. This is a perfect scenario for chronic injuries (“itis’s”) to develop.
Speaking in a general sense, when athletes have compromised foot function or have a history of lower leg-foot injuries, I refer back to the four key components of foot function outlined above- proprioception, intrinsic strength, compliance, and elasticity. Ultimately our programming and exercise selection should be developed from these four traits, and emphasis simply placed on the areas most compromised. As shown below, for the case of injuries and return to play I organize the timeline by tolerance, function, and capacity. Meaning, we want to reduce pain levels and inflammation, restore basic functionality, and then add to the reestablished function. This process involves some combination of therapeutic modalities (manual work, dry needling, cupping) and conventional strength and stability/mobility concepts that is organized based on individual needs.
Foot Health & Restoration
Foot health and restorative concepts should not just be relegated for athletes coming off an injury but seen as a key supporting component for all other training applications. I develop this around three central pillars- mechanical, fluid, and pain restrictions. While there are an abundance of specific options and applications, I tend to get the most value from using some combination of manual/massage work, compression-decompression mechanisms, and isolated strength/mobility applications. The ultimate goal with foot-ankle restoration is re-establishing proper viscoelasticity in the tissues, and this process often requires a wider range of inputs than conventional training alone.
Check out our full restoration playlist here: Foot-Ankle Series
The most important realization for coaches is to not be reactive with restorative options, this is something we want to stay ahead of and see very much as a part of the regular training process. From a physiological standpoint, the circulation and fluid dynamics are significant, as the foot is predisposed to compromised blood flow due to the poor venous return. Compromised fluid dynamics becomes amplified with bigger athletes or those who have poor health/nutritional habits. Addressing foot-ankle circulation is essential for several reasons, but namely driving oxygen and nutrient rich blood to tissues that biologically have poor vascularity. Moreover, proper fluid dynamics (i.e., lymphatic fluid, synovial joint fluid, hyaluronic acid within fascial layers) is also critical for promoting proper joint motion and tissue glide. For improving fluid dynamics and circulation compression mechanisms such as NormaTec’s or Voodoo Floss, and decompression mechanisms such as cupping have been very valuable for me.
The soft tissue modulation is another critical modality for foot-ankle health, and one that again we cannot see as a reactionary intervention following pain or injury. Maintaining proper soft tissue care helps to keep athletes feeling fresh while also promoting a better opportunity for stress (load) to be applied. I see the manual concepts as primarily “creating a transient optimal window for load to be applied” by stimulating local mechanoreceptors which “alert” tissues of preparing for stress. This is obviously somewhat limited for coaches depending on your credentialling and support staff, but there are several ways this can be incorporated. Novelty certifications such as RPR and BeActivated have been tremendously beneficial for me and offer ways to apply soft tissue modulation that isn’t violating scope of practice. While these types of certifications are valuable, they are not a necessity. Alternatively, coaches should always do what they can to develop a strong professional network, so you have the ability to refer out to when necessary.
·Understand the anatomy and mechanics of the foot-ankle complex
·Athletes should have portions of their training performed barefoot. Warm-up and accessory blocks are easiest for implementation.
·Foot strength should be developed from four foundations- proprioception, intrinsic strength, compliance, elasticity.
·Foot injuries can often be the result of a “cascade effect” in which several small problems create one big problem.
·Foot restoration should be developed around pain, mechanical, and circulatory restrictions. Restoration should also not be applied retroactively but rather built into the standard process.
·Foot and ankle injuries and deficits should not be taken lightly and addressed with multiple modalities/applications.