What’s causing your client’s foot pain?
Assessing a client’s ability to dorsiflex effectively, and knowing which exercises will correct their limitations, is the key to reducing foot pain says Justin Price.
Foot pain is an extremely common problem encountered by fitness professionals. It will affect at least a quarter of your clients at one time or another and can severely restrict their ability to exercise regularly and reach their health and fitness goals (Thomas, et. al., 2011, Hill, C. et al. 2008). The key to tackling this problem effectively lies in understanding the possible musculoskeletal causes of a client’s foot pain and integrating corrective exercise strategies into their program that swiftly and successfully alleviate their pain (Price and Bratcher, 2010).
Common causes of foot pain
Two of the most common musculoskeletal imbalances that can lead to foot pain are overpronation and a lack of dorsiflexion (Price and Bratcher, 2010, Kendall, et al. 2005). Overpronation is characterised by a collapsing inward of the foot and ankle toward the midline of the body (i.e. a flattening of the foot and rolling in of the ankle). This deviation causes excessive stress to the structures toward the midline of the foot (e.g. medial longitudinal arch) and can lead to pain and/or injury. A lack of dorsiflexion refers to the inability of the lower leg to come forward over the foot and/or the foot to move toward the shins (i.e. failure of the ankle to bend/flex correctly). When the structures that run across and on the outside of the foot (e.g. lateral longitudinal and transverse arches) are unable to do their jobs correctly because of a lack of dorsiflexion, it can also lead to foot pain (Bryant and Green, 2010; Price and Bratcher, 2010).
Overpronation and a lack of dorsiflexion are inherently linked because when the foot/ankle are unable to bend/flex forward effectively (dorsiflex) during weight bearing activities, these structures collapse inward toward the midline of the body (overpronate) in order to displace the weight of the body. Therefore, one of the easiest ways to alleviate a client’s foot pain is to remedy their overpronation issues by assessing and improving their ability to dorsiflex (Houglum, 2016).
Assessments for lack of dorsiflexion
The ability of the ankle to bend/flex forward (dorsiflex) so that weight can displace evenly over the entire foot is necessary both when the knee is bent, when squatting for example, and straight, such as when walking (see Figures 1 and 2).
As such, evaluating your client’s ability to dorsiflex requires two assessments – one with their knee bent and one with their knee straight.
1. Bent knee assessment
To assess dorsiflexion when the knee is bent, instruct your client to place themselves in a split-kneeling position with their hands on the wall in front of them for balance (see Figure 3). Coach them to align their hips so that they are parallel to the wall and push their front knee forward so it travels forward over that foot. Have them perform this movement with each foot/leg and evaluate which side is tighter, or feels more difficult to bend their ankle forward (dorsiflex). Watch that the client does not ‘cheat’ during this assessment by letting their ankle and knee collapse inward toward the midline (overpronating), and/or twisting their hips (i.e. not keeping them parallel to the wall) (Price and Bratcher, 2010; Cook, 2010). Make a note of any discrepancies or imbalances you, or your client, discover about their ability to dorsiflex with their knee bent.
2. Straight knee assessment
To assess dorsiflexion when the knee is straight, instruct your client to stand in a split-stance standing posture with their hands on a wall in front of them for balance (see Figure 4). Coach them to align their hips so that they are parallel to the wall and straighten both feet so that they are pointing forward. Once in this position, instruct them to ‘stretch’ the calf muscle of the back leg by allowing their lower leg to travel forward over the foot (dorsiflex). Watch that the client does not raise their heel off the floor, collapse their ankle (overpronate) or rotate their hips during this movement. Ask them to assess both sides and evaluate which side feels more difficult to dorsiflex (i.e. bend their ankle forward without ‘cheating’ at their ankle or hips) (Price and Bratcher, 2010). Make a note of any discrepancies or imbalances you, or your client, discover about their ability to dorsiflex with their knee straight.
Foot pain relief exercises
The results you gather from these two assessments will provide you with valuable clues about the origin of your client’s foot pain – specifically, whether they lack the ability to dorsiflex. Once you know whether, and to what extent, they lack dorsiflexion, you can use this information to direct the client’s corrective exercise program. If a client does lack dorsiflexion, begin the program by selecting self-myofascial release (SMR) techniques that promote dorsiflexion of their feet/ankles (on one or both sides, as needed). Have them use a tennis ball or golf ball to massage under their foot (i.e. plantar fascia) while standing (see Figure 5) and a tennis ball or cricket ball (or similar) to massage their calf muscles (i.e. gastrocnemius and soleus) while seated (see Figure 6). Instruct them to massage all sore spots on both feet/calves for a total of two to three minutes each leg (Price, 2013).
Once you have increased blood supply to the plantar fascia and posterior calf muscles (and released any adhesions that may restrict range of motion/dorsiflexion) with the SMR techniques, it will be appropriate to introduce stretching exercises for the soleus and gastrocnemius muscles. Use the assessments for dorsiflexion (see Figures 3 and 4 above) as isolated stretching techniques. Instruct the client to hold each stretch for 10 to 15 seconds and repeat two to three times.
Once the SMR and stretching techniques are completed, incorporate exercises that lengthen the calf muscles under load (i.e. eccentric strengthening) and mimic the way the foot and ankle move during real-life weight-bearing activities (e.g. walking, running and squatting). Movements such as stepping and walking backward (see Figure 7) and squatting (all while ensuring the feet stay pointing forward) will strengthen the soleus and gastrocnemius muscles eccentrically, helping promote dorsiflexion and reducing the effects of overpronation. Because eccentric strengthening exercises can be difficult for clients to perform correctly and are easily overdone, introduce these types of exercises carefully, beginning with only a few repetitions and progressing over time to 10 to 12 repetitions for two to three sets (LaBella, et al. 2011).
Assessing a client’s ability to dorsiflex effectively, and addressing any limitations you find with corrective exercises, is the key to reducing foot pain. Enabling the feet and ankles to move more efficiently will not only alleviate painful symptoms in these areas, but will also reduce the effects of overpronation. The correction of these two common imbalances ultimately assists the entire kinetic chain in functioning and performing optimally as clients work hard toward achieving their goals.
- Bryant, C.X., and Green, D.J., eds. 2010. ACE personal trainer manual: The ultimate resource for fitness professionals, 4th ed. San Diego, CA: American Council on Exercise.
- Cook, Gray. 2010. Movement: Functional Movement Systems: Screening, assessment and corrective strategies. Aptos, CA: On Target Publications.
- Hill, C., Gill, T.K., Menz, H.B., and Taylor, A.W. 2008. Prevalence and correlates of foot pain in a population-based study. Journal of Foot and Ankle Research, July 1: 2.
- Houglum, P. 2016. Therapeutic exercise for musculoskeletal injuries. (Fourth edition). Champaign, Illinois: Human Kinetics.
- Kendall, F.P., McCreary, E.K., and Provance, P.G. 2005. Muscles testing and function with posture and pain (5th ed.). Baltimore, MD: Lippincott Williams & Wilkins.
- LaBella, C.R., Huxford, M.R., Grissom, J., Kim, K.Y., Peng, J., and Christoffel, K.K. Effect of neuromuscular warm-up on injuries in female soccer and basketball athletes in urban public high schools. Pediatric Adolescence Medicine. 165: 1033-40.
- Price, J., and Bratcher, M. 2010. The BioMechanics Method corrective exercise specialist certification program. San Diego, CA: The BioMechanics Press.
- Price, J. 2013. The amazing tennis ball back pain cure. San Diego: The BioMechanics Press.
- Thomas, M.J., Roddy, E., Zhang, W., Menz, H.B., Hannan, M.T., and Peat, G.M. 2011. The population prevalence of foot and ankle pain in middle and old age: a systematic review. Journal of Pain. Dec 152(12):2870-80.