Now that you understand how the muscles and soft tissue structures of the feet and ankles are affected by the most common deviations of the foot/ankle complex, you are in a good position to select and design corrective exercise programs for your clients. However, there are many elements that must be taken into consideration when designing successful corrective exercise programs to alleviate foot and ankle pain. Knowing how to select and implement safe and effective exercises is important, but you must also incorporate the particular needs and capabilities of every client to promote adherence and minimize potential for discomfort. You must also structure programs in a logical sequence so clients can achieve the greatest benefits in the least amount of time and know when to progress and regress programs to maximize success. Before specific exercises are provided to address the most common musculoskeletal imbalances of the foot and ankle, some basic corrective exercise program design information is outlined below to make sure the exercises you select are appropriate for both you and your client’s needs.
Consider Your Client’s Needs
When a client discusses their foot and ankle problems with you in hopes of finding a solution, remember that this person may have been feeling a lot of fear and anxiety regarding their pain, injury, and/or dysfunction – probably for quite some time. They may have lost confidence in their ability to perform certain tasks and generally lack the self-assurance needed to perform complex motor tasks, especially those that require the use of their feet/ankles. To help boost client confidence at the outset of a corrective exercise program, choose easy-to-perform exercises that address the clients' imbalances and increase their own belief in the ability to perform the exercises/movements successfully. When a person attempts a new exercise and is able to perform it correctly, it increases their self-confidence. This increased confidence will motivate them to repeat the action and also increase the likelihood they will be open to trying additional corrective exercises (Price & Bratcher, 2010).
The guiding principle of corrective exercise programming is the same as that of traditional fitness programs - gradual progression. Introducing concepts and exercises at a manageable pace for clients increases confidence, adherence and the client’s belief in their own abilities.
The Role of Orthotics in a Corrective Exercise Program
Many clients may ask you for advice or guidance with regard to the use of orthotics in order to alleviate their foot and ankle pain and to resolve other musculoskeletal imbalances/problems. In the early stages of a corrective exercise program orthotics may be beneficial in helping to realign the joint structures of the foot and ankle (and the rest of the body), particularly if a person has chronically overpronated for many years. An orthotic is designed to hold up the arch of a person’s foot, thereby reducing the amount the foot pronates and the ankle collapses inward. The general theory is that by preventing overpronation, orthotics can positively affect the alignment of the feet and ankles and consequently the entire body. Indeed, many people find temporary relief from their painful symptoms through the use of these devices.
As helpful as orthotics can be, however, it should be noted that problems can arise if the arch of the foot is artificially supported with an orthotic for too long or too much. The muscles and soft tissue structures whose job it is to hold up the arches of the feet can become weak because they are no longer able to engage due to the forced limitation of foot movement. Therefore, the use of orthotics is usually only recommended at the outset of some corrective exercise programs or when assisted alignment of the body may help alleviate some of the symptoms of pain or dysfunction. However, the long term strategy to help correct malalignment of the feet and ankles should be to retrain the naturally occurring elements in the feet and ankles (and the rest of the body) such as the muscles, fascia and soft tissue structures that can control the amount of force to the feet and ankles and, therefore, the degree of pronation and dorsiflexion.
The more you understand how the soft tissue structures of the body work to prevent overpronation and lack of dorsiflexion, the better you will become at designing effective corrective exercise strategies to strengthen these important muscles. Consequently, the need to recommend orthotics or other foot support devices for your clients and the overall length of time they need to utilize them will lessen (Price, 2014).
Corrective Exercise Types and Sequencing
The negative impact of musculoskeletal imbalances and deviations on the soft tissue structures and joints of the feet and ankles can be significant and wide ranging. Therefore, corrective exercise programs must be designed in a way that addresses imbalances and deviations in a logical format. Damaged and stressed tissue structures must be reconditioned and rejuvenated before attempts at stretching or strengthening movements can be made.
As such, when designing a corrective exercise program for foot and ankle pain, incorporate activities that accomplish the following goals in the order listed below:
- Regenerate and release the fascia, muscles and tendons,
- Realign and increase blood flow and range of movement to structures, and
- Strengthen the muscles and challenge the nervous system.
In other words, begin your foot and ankle corrective exercise programming with the introduction of self-myofascial release (self-massage) techniques, progress to stretching, and then to strengthening exercises (Price & Bratcher, 2010).
Self-Myofascial Release Techniques
The first types of exercises you should recommend for clients with foot/ankle pain are self-myofascial release techniques (i.e., self-massage). These types of exercises regenerate and rejuvenate soft tissues that have become adversely affected by chronic malalignments (Abelson, 2003). Self-myofascial release exercises are usually easier for clients to perform than more complex, movement-based exercises. Moreover, self-massage not only promptly reduces painful symptoms, but clients can also be successful when doing these techniques which helps build their confidence.
Two popular kinds of self-massage are:
1. Self-Myofascial Release (SMR)
Self-myofascial release is a massage technique of applying continual pressure to an area of the fascia that contains restrictions or lacks movement. The sustained pressure stimulates circulation to the area, reduces pressure build-up from sluggish blood flow, and restores suppleness to the myofascial tissue (see “Calf Massage” exercise in the next section of this course) (Barnes, 1999).
2. Trigger-Point Massage
Trigger point massage differs slightly from SMR in that it is intended to target a very specific area of a muscle (or the surrounding fascia). Trigger points are so-called because they trigger a painful response to the surrounding area when stretched, moved, or touched. Both techniques are very effective methods for preparing the soft tissue structures of the body for movement at the beginning of any corrective exercise program or exercise session (see “Golf Ball Roll” exercise in the next section of this course).
Teach clients how to utilize tennis balls, golf balls, lacrosse balls, baseballs, racquetball balls and their hands and fingers to perform self-massage of the feet and the soft tissue structures that surround their ankles. Recommend techniques that clients can replicate at home, the office, or anywhere they feel completely comfortable.
When to Progress/Regress Between Self-Massage and Stretching
If a client is uncomfortable, experiences any type of pain, or finds a self-myofascial exercise too difficult, regress the self-massage technique being used. You can regress self-massage techniques by using a softer tool for applying pressure (e.g., a softer ball) or instructing clients to apply heat to the affected area instead.
When a client no longer feels any tenderness when applying pressure to the target area or if the appropriate tissues have released enough to perform the desired progression (i.e., a stretch) with correct technique, it is time to progress the client’s program from SMR to stretching.
As deconditioned soft tissue structures become more fluid and healthy, the new focus of the client’s corrective exercise program should be to increase the comfortable range of motion for the muscles, fascia, tendons, ligaments and joints. Stretching involves elongating and lengthening muscle fibers (and their accompanying soft tissues and fascia) in order to restore blood flow and elasticity to those structures (Walker, 2007). Many different types of stretching exercises can help facilitate flexibility/mobility and retrain movement in those parts of the body that have become dysfunctional as a result of chronic malalignment (Alter, 1996). Stretching also involves retraining the nervous system by moving the body in directions that mimic the way the body should move when it is working properly.
Three common stretching techniques are:
- passive stretching
- active stretching
- dynamic stretching
Each technique should be utilized in the order listed above and offers a unique benefit to clients as they prepare for the next stage of their corrective exercise program.
1. Passive Stretching
Passive stretching involves holding a static position for a predetermined amount of time to achieve an increased range of movement around a joint or number of joints. Other muscles in the body are not being stimulated to a great extent to contract in a passive stretch and are, therefore, in a relatively passive state. Passive stretches are a good choice to use at the beginning of a stretching program (see “Foot and Toe Stretch” in the next section of this course).
2. Active stretching
Active stretching involves a concept known as reciprocal inhibition. This is based around the notion that in order for one muscle group to relax, its antagonist muscle or muscle group must contract
(e.g., contracting the quadriceps to enable the hamstrings to relax). Active stretching is a great way to begin integrating different functions of muscles or muscle groups to work together in a lengthening/contracting fashion. A passive stretch, such as a standing calf stretch (see next section of this course), can be turned into an active stretch by activating the tibialis anterior (i.e., pulling the toes up toward the shin).
3. Dynamic stretching
Dynamic stretching mimics functional movements. It involves the use of concentric activation (i.e., contraction) of certain muscles to move bones while other muscles eccentrically load (i.e., lengthen with tension like a bungee cord) to allow joint motion to occur with minimal stress to the joint. This type of stretching helps clients learn to perform a desired range of movement in a controlled and coordinated manner (see “Calf Stretch on BOSU®” exercise in the next section of this course). These types of stretches assist clients in progressing from the stretching to the strengthening components of their programs more successfully.
When to Progress/Regress Between Stretching and Strengthening
If a client is in pain or discomfort, or has difficulty performing a stretch or remaining in control of the movement, you should regress the exercise. You can regress stretching exercises by applying a self- massage technique instead of a stretch or utilizing a less dynamic/more controlled stretch.
Progress from stretching to strengthening when you are confident that the muscles and soft tissue structures in the area(s) your client is stretching are working correctly. It may also be appropriate to add a strengthening exercise as a client gains control of greater ranges of movement during a stretch.
Once progress has been made toward improving the overall condition of a client’s dysfunctional soft tissue structures, begin incorporating strengthening exercises into the corrective exercise program.
There are many different kinds of strengthening exercises that can be used in a corrective exercise program. Following are four effective corrective exercise strengthening strategies:
- kinetic chain multi-planar/dimensional
Follow the order detailed above to ensure your clients' benefit from each type of strengthening exercise as they progress through their corrective exercise program.
Isometric contraction occurs when a muscle becomes activated, but stays the same length (i.e., it does not shorten or lengthen). This is the easiest type of movement for the nervous system to coordinate. Once the nervous system has generated an isometric muscle contraction, it is able to continually keep motor units firing to the muscle(s) involved in that contraction to maintain a state of activation (e.g., activating the tibialis anterior muscle when performing the “Calf Stretch” - see next section of this course). When a client’s muscles cannot activate correctly, or have shut down as a result of chronic musculoskeletal imbalances, it is important to get those muscles firing again before attempting to engage them in dynamic movements.
Concentric muscle action involves shortening a muscle to bring the origin and insertion points of that muscle closer together and results in the movement of a joint (e.g., contracting your flexor hallucis longus will pull your big toe down toward the ground and contract the muscle that helps support the medial longitudinal arch of your foot) (see “Big Toe Pushdown” exercise in the next section of this course).
Eccentric muscle action involves the lengthening of a muscle to slow down parts of the body as they move (e.g., the gastrocnemius muscle lengthens to slow down dorsiflexion of the ankle joint as the shin comes over the foot during gait). Clients unable to perform an eccentric contraction correctly may experience more stress to a joint and/or pain if they attempt an eccentric movement. Therefore, concentric exercises are usually better choices when initially progressing corrective strengthening exercises from isometric to concentric/eccentric.
4. Kinetic Chain and Multi-Planar/Dimensional Movements
Progress to multi-joint strengthening exercises that coordinate movements of the foot and ankle (and, in time, the rest of the kinetic chain) when you feel confident your client has control over each joint involved in the sequence. For example, combining activation of the flexor hallucis longus muscle (i.e., the “Big Toe Pushdown” exercise in the next section of this course) with the “Calf Stretch on BOSU®” is a good way to coordinate multiple joints and muscles in all three planes of motion.
When groups of muscles are working efficiently as part of a kinetic chain, progress to whole-body, multi-planar exercises that move the feet and ankles in all different directions such as forward and backward (i.e., the sagittal plane), side-to-side (i.e., the frontal plane) and in rotation (i.e., the transverse plane) as part of full body movements. Performance of these types of exercises correctly and efficiently is the ultimate goal of corrective exercise programs. Clients that have progressed to this highest level should be free from pain, highly functional, and able to perform coordinated, full-body dynamic movements that involve weight-bearing activities of the whole body with their feet and ankles in contact with the ground.