The first day out of a brace, cast, or ankle foot orthosis or off crutches following lower extremity injury is an exciting but sometimes stressful time for a recovering athlete. Whether immobilized for a single day, weeks, or even months, there are usually at least subtle gait alterations for the individual to overcome. This can be challenging for both the clinician and the athlete because the seemingly basic goal of returning to normal walking can result in frustration, pain, stiffness, and further altered gait. Walking represents the foundation for most functional activities related to physical activity and sport participation. Without the ability to walk normally, restoration of more advanced functional activities is difficult.
One of the challenges to this early return to normal gait is overcoming the many compensations that are made due to prolonged immobilization. There are several determinants of normal gait, but the most important are related to motion at the foot and ankle. Foot and ankle motions have been divided functionally into the heel, ankle, and forefoot rockers during the stance phase.1 These plantar and dorsiflexion arcs are responsible for both force absorption (heel and ankle rocker) in the early part of stance and propulsion (fore-foot rocker) in the latter (Table 1). When immobilized for prolonged periods of time, dorsiflexion at the talocrural joint (ankle rocker) is typically decreased. Dorsiflexion deficits have been linked to decreased functional performance and increased risk of injury.2,3
Description of Gait Rockers
Although decreased dorsiflexion is a commonly described gait alteration related to prolonged immobilization, a critical alteration we have seen clinically is the avoidance of the forefoot rocker in late stance phase in individuals who have been immobilized. The typical presentation is a stiff first metatarsophalangeal (MTP) joint, which limits the patient's MTP extension. While immobilized, the foot cannot move through the normal pattern of rockers during the gait cycle into toe off. If the forefoot rocker becomes stiff, two issues commonly occur: (1) a decrease in propulsion force and/or (2) an increase in the forces driven toward the lateral aspect of the forefoot during propulsion.1 In our experience, fore-foot dysfunction has been related to decreased performance and has been linked to the development of metatarsalgia, plantar fasciitis, medial longitudinal arch collapse, stress fractures, and a host of other foot problems.
When evaluating an athlete who is recovering from lower extremity immobilization, we recommend evaluating not only the extent of weight-bearing dorsiflexion available (using outcome measures such as the weight-bearing lunge test3), but also assessing the arthrokinematics and osteokinematics of the first MTP joint. During this early return to function, analyzing gait is essential and understanding the role of the forefoot rocker, especially in relation to the windlass mechanism,4,5 is critical.
During the forefoot rocker, the MTP joints extend as the heel rises. MTP extension places tension in the plantar aponeurosis and the foot forms a rigid lever that facilitates proper push off.4–6 A loss of normal extension range of motion at the great toe due to stiffness reduces the windlass mechanism's ability to create a rigid foot during push off. Consequently, this can affect the rest of the lower kinetic chain during functional movement. To maintain proper forefoot rocker function, one effective strategy in dealing with this issue is to assess great toe flexibility and begin manual therapy to increase extension range of motion almost immediately after immobilization.
The manual therapy technique to enhance great toe range of motion that we have found to be most effective is posterior to anterior MTP joint mobilization. One article cited the benefit of joint mobilization of the ankle following injury,7 but no mention was made about the benefits of mobilizing the great toe for improvements in gait. It is essential to assess not only the joint motion of the knee and ankle following immobilization but also the MTP joints. Performing joint mobilizations to the MTP joints, particularly the first MTP joint, helped restore normal motion and decrease foot pain and stiffness.
As described in Table 2 using Kaltenborn's grading system,8 we mobilized the first MTP joint by applying two sets of 20 Grade III (stretching) dorsal glides. Frequency of mobilization depended on the severity of the restriction/stiffness. Typically, mobilizations were done twice per day, usually prior to activity (eg, practice or rehabilitation). In addition, we evaluated the joint play between the distal ends of MTP II–V, and if any restriction or stiffness was noted, we mobilized those segments using the same technique as we applied for the first MTP joint. The optimal outcome desired is for the patient to report that the stiffness and/or pain experienced prior to the treatment is either substantially decreased or completely eliminated during gait and functional activities.
Grades of Joint Mobilization
When treating an athlete returning from a period of lower extremity immobilization, MTP joint mobilizations during the early stages of rehabilitation will help to reestablish normal gait. Including MTP joint mobilization might just be the key to efficient restoration of normal foot and ankle kinematics, culminating in a successful return to play.
- Perry J, Burnfield J. Gait Analysis: Normal and Pathological Function, 2nd ed. Thorofare, NJ: SLACK Incorporated; 2010.
- de Noronha M, Refshauge KM, Herbert RD, Kilbreath SL, Hertel J. Do voluntary strength, proprioception, range of motion, or postural sway predict occurrence of lateral ankle sprain?Br J Sports Med. 2006;40:824–828. doi:10.1136/bjsm.2006.029645 [CrossRef]
- Hoch MC, Staton GS, Medina McKeon JM, Mattacola CG, McKeon PO. Dorsiflexion and dynamic postural control deficits are present in those with chronic ankle instability. J Sci Med Sport. 2012;15:574–579. doi:10.1016/j.jsams.2012.02.009 [CrossRef]
- Hicks JH. The mechanics of the foot II: the plantar aponeurosis and the arch. J Anat. 1954;88:25–30.
- Bolgla LA, Malone TR. Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice. J Athl Train. 2004;39:77–82.
- Van Beek C, Greisberg J. Mobility of the first ray. Foot Ankle Int. 2011;32:917–922. doi:10.3113/FAI.2011.0917 [CrossRef]
- Hoch MC, Andreatta RD, Mullineaux DR, et al. Two-week joint mobilization intervention improves self-reported function, range of motion, and dynamic balance in those with chronic ankle instability. J Orthop Res. 2012;30:1798–1804. doi:10.1002/jor.22150 [CrossRef]
- Kaltenborn FM. Manual mobilization of the joints. In: Kaltenborn FM. The Kaltenborn Method of Joint Examination and Treatment: Volume I: The Extremities, 5th ed. Oslo, Norway: Olaf Norlis Bokhandel; 1999:192–193, 201–202.
Description of Gait Rockers
||Lasts from initial contact (start of Stance phase) to the time of total ground contact of foot
||Begins at time of total ground contact of foot to initiation of heel rise
||From Heel Rise to end of Stance phase; this is the rocker most affected by MTP joint restrictions
Grades of Joint Mobilization
||No stress on the joint capsule by sustained distracting or gliding force. Goal: Pain relief
||Slack in joint capsule is reduced through a sustained distraction or gliding force. Goal: Maintain integrity of joint play
||Joint capsule is stretched by applied force. This is the grade we typically use when restoring MTP range of motion.