4 Non Negotiables for Foot and Ankle Rehab ⎸ Ep 138

If you are rehabbing a foot and ankle injury, there are 4 things you want to make sure you address, especially as you start thinking about returning to run. The big 4 are focusing on movement patterns and how the biomechanics of your foot and ankle are affected when one is missing.

• Runners Complete Program: 12 week strength and mobility program that helps runners prevent injuries and run stronger. Receive 3 full body strength workouts that take 45 minutes and 3 post run mobility routines each week. Has helped over 2,000 runners take the guesswork out of what they should be doing outside of running
• Hip Program: At home rehab program for hip injuries including hip impingement, gluteal tendinopathy, low back soreness/pain, SIJ pain, psoas/hip flexor pain, piriformis syndrome and ITB syndrome
• Runners Knee Program: At home rehab program for pain around the kneecap, under the knee cap or around the joint line
• Foot and Ankle Program: At home rehab program for injuries including plantar fasciitis, shin splints, achilles tendinopathy, ankle sprains, posterior tibialis pain and big toe pain
• Toe Spacers (use discount code DRLISA10)
• Mobo Board (use discount code DRLISAMITRO10)

Transcript

SPEAKER_00 0:00

Welcome back to the Rehab for Runners podcast. I'm your host, Dr. Lisa, and I'm officially in the return to run phase in postpartum. So I'm 11 weeks postpartum. I've run maybe three or four times. And even though it's extremely humbling to be running and getting fatigued after like a minute of running and feeling like at the end of the day your legs are tired, like you just ran a race. I'm very excited to be back. And with return to run, you know, I tell my injured runners this all the time, but it's always different when you're experiencing it versus you being the one teaching it. But really, return to run tests are not a test for endurance, even though sometimes it can feel like it. Just like I said, like I'm running one minute at a time, and sometimes it can feel like a test for endurance. And while that minute has felt a little bit easier and a little less clunky, it's not a test. Run those return to run intervals are not a test of endurance, they're a test of the injury or the recovery. So for me, when I'm doing these intervals, I'm taking note of how I'm feeling during the run, right after the run, and then into the next day. So just to give you some context, because I think this is really important. And if you've ever, you know, taken some time off of running from an injury, then you know that if you if things don't go as planned, it can be really disappointing and really frustrating. And that's basically what happened for me the first two runs that I did. I went maybe a little bit too aggressive in terms of the amount of times that I did my run walk intervals. And because of that, I experienced some pelvic floor heaviness, and I really want to make sure I'm doing this correctly because I'm just gonna continue building my endurance. So I took that sensation of pelvic floor heaviness, even though I wasn't having pain, it wasn't anything extreme. I still took that sensation and saw it as a yellow flag. And because of that, I pivoted and I was thinking to myself, you know, I'm it's funny how I'm obviously a physical therapist, but when you're going through it, you feel like the patient, and sometimes it's hard to coach yourself. But when I was going through it, I was thinking, okay, because of this sensation, I may have gotten back into running too quickly. Maybe I should have waited a couple more weeks. And basically my mindset went to, well, this didn't go as planned, so I'm just gonna stop running for another two weeks and then come back to it and see how it goes. But the reality is after I talked to a pelvic floor PT, which is always nice, it's always nice to have a PT when you're going through something instead of trying to be your own PT. But, anyways, she said just keep pivoting. Basically, like just bring your intervals down a notch and see how it feels. So I think that's just an important lesson of like one, when you are returning to run, do not think of it as a test of your endurance, it's a test of the injury. And two, if things don't go as planned, keep pivoting until you can't pivot anymore, and then you are forced to take a break. Because for me, I was very excited when I realized, oh, I can just actually. So I was basically doing a one-minute on run, one minute on walk 10 times, and that was probably a little too aggressive. So I did a one minute on run and then a four-minute walk, and I did that five times, and I felt a hundred times better. So I'm just gonna keep progressing from there, but I think it's just an important lesson of like keep pivoting and modifying before you quit. And this is also just important for like any sort of exercise, too, to modify before you call it quits. But today we're actually talking, I just want to give you a recap of that because that's such an important lesson. And like I said, like it's so different when I'm the patient versus being the PT. But today I really want to talk about, you know, I I treat so many foot and ankle injuries, and I was thinking about these common themes that I see when I'm treating these injuries, whether it's shin splints, plantar fasciitis pain, posterior tip pain, achilles tendenitis, um, all of those, even like bunions, like even injuries that don't necessarily have a diagnosis, but it's like it hurts here when I do this. I think there's four main non-negotiables that need to be included with foot and ankle rehab. And unfortunately, a lot of PTs that maybe you know are seeing these runners don't include these. I see this all the time with plantar fasciitis rehab, where it's almost like we're forgetting like half of these things that we're we should be working on, especially as you want to progress back into the load and like the demands that come with running. So let's today walk through these four things. These are non-negotiables, these are common themes, and these are also big, you know. The main idea is that you're focusing on a movement pattern, you're not focusing on just like isolated strength. Because at the end of the day, if we want to get back into running without pain, we have to focus on that movement pattern. Our muscles don't work in isolation, our joints don't move in isolation when we're running. Same with walking, same idea. So we have to focus on how the body is moving instead of thinking of you know the entire rehab process as just like isolated movements, or else it's gonna be really hard to progress back into such a high intensity activity. Movement pattern number one is to focus on ankle dorsiflexion. Now, ankle dorsiflexion, there's two different ways that we could look at this. The first is let's say you're just like laying in your bed, you know, on your back, and you bring your toes up to, you bring your toes up. That is ankle dorsiflexion. Another way of looking at ankle dorsiflexion is if you are doing a squat or you are going down the stairs where your knee is translating over your toes, or it's translating forward. That is what we call closed chain ankle dorsiflexion, and that's really what we want to be focusing on with rehab. Now, when I was in clinic and how I was taught to measure ankle dorsiflexion is so different than how I measure it now, because when I was taught in PT school to measure it, it was really like okay, bring your toes up as far as you can, and you know, bring your foot up as far as you can, and then you measure it while someone's on the table. But and while that's all fine and dandy, we really want to focus on functional dorsiflexion. So, how much dorsiflexion do you have when you're going into a squat, when you're running, when you're going down the stairs, when you're doing these activities? Is your ankle dorsiflexion limited? If it's limited, it's gonna affect the way your foot and ankle can pronate, it's gonna affect how much load is going through your calf, it's gonna affect the entire way your foot and ankle moves. We have to be able to get into ankle dorsiflexion. And it's common for this movement to be very stiff if you've had a history of foot and ankle injuries. More specifically, chronic ankle sprains are really, you know, yes, you have a lot of medial lateral instability, but you also see uh stiffness into the ankle joint, into dorsiflexion. So being able to bring your knee forward with your foot on the ground without lifting your heel up, that's really what I'm looking at. So, you know, if I'm asking someone to do a squat and I see them lift their heel up as they do a squat, then that might trigger me into thinking, okay, their ankle is very tight, and therefore we really need to address it. Because what happens if your ankle's tight, let's say you're doing a squat or you're running, you're a lot of your load, as you can imagine, if you're lifting your heel up, a lot of your load is now going very anterior. Versus if you get your butt back, you're doing a squat, you're able to keep your heel on the ground. Now you have a lot better of a balance between that anterior and posterior load. So a lot of these things can address how that foot and ankle is moving. Pronation is a combined movement that includes dorsiflexion. So being able to have that good dorsiflexion mobility is important. Now, it's important to note too that just because you can feel calf tightness does not mean that your ankle is stiff into dorsiflexion. Ankle dorsiflexion is really measured from the ankle joint itself. Not necessarily, you know, yes, calf tightness can affect it, but just because you have the sensation of calf tightness doesn't necessarily mean you have a stiff ankle joint itself. Moving on to movement pattern number two, big toe extension. Now, this is really important. You need 50 to 60 degrees of big toe extension when you're walking, and more along the 60 degrees when you're running. And I want you to think of big toe extension as the push-off part of your foot leaving the ground. So when you think about your heel lifting off the ground, and then your toes are in this bent position as they're pushing off the ground. That is big toe extension. Now, this is very common for it to be stiff if someone has a bunion, if somebody has plantar fasciitis, if somebody even has shin splints. That is super common for the big toe to be tight. I know for me, I had was not dealing with any of those injuries, but after a long run, it would just feel so good to stretch out my big toe. I would always stretch it out. Like it was like it just felt amazing because my it was like your foot is locked in the shoe for hours, and just being able to really stretch out your plantar fascia and the muscles that sit under your plantar fascia by stretching out your big toe into extension, that just felt really good as a side note. But when you go into big toe extension, if you don't have the proper mobility or you don't have enough mobility, it can it could cause plantar fascia, like on the flip side, it could cause plantar fasciitis, it could cause a bunion. And say you're walking and you don't have as much or running and you are lacking big toe extension, it's going to affect how much power you have with your stride as you're pushing off the ground. It's going to affect how stable your foot and ankle are, how much you're using your calf as you're pushing off the ground, because all of these things are connected. It's very much, I like to think of the foot and ankle. You know, the foot and ankle is extremely complicated, especially throughout the gait cycle of what is happening, because there's a million things happening because there's so many joints in the foot and ankle. But I like to think of it as there's a lot of cause and effects. Because you're going into big toe extension, the calf is able to elongate and the calf is able to push you off the ground with a lot of power. Because you're going into big toe extension, your arch is able to stabilize and stiffen as it pushes you off the ground. There's a lot of these because this happens, these things happen that should be happening. So on the flip side, if you're not getting into enough big toe extension, maybe now the weight is going very much medial into your big toe, causing a bunion, it's going to affect how other things are contracting. You know, other tissues are contracting, how much power you have, what's happening at the joint biomechanics. So all of those things can cascade and create this ripple effect because of lack of big toe extension. Moving on to number three, and that is single leg calf strength. So I always say all runners should be able to do 20 single-legg calf raises in a row without a lot of fatigue and without pain, obviously, and being able to really go through that full range of motion from your heel on the ground to your heel all the way up with control. Now, a lot of runners cannot do this. A lot of runners, you know, they tend to one, fatigue out, two, they tend to use momentum at their hip. They almost like hike their hip up, or they do this thing where they bend and straighten their knee as momentum because the calf is weak. So it's something that I always say, like, if it's if you test it and you're like, say you have shin splints on the right side, you're dealing with shin splints right now, you try to do 20 single-legged phrases on the right side, and say you get to like 12. Then you're like, I feel this muscle burn. I literally cannot go any further. My calf feels so weak and it's tightening up. Then you do it on the left side and you're able to get to 18 before you really feel that calf fatigue. So, because of that difference between side to side, I would say, and the side that's a little bit weaker has that, has those shin splints. It's something that you can continue to work on in order to reduce those shin splints. So then you start taking this test and basically creating an exercise out of it where you're like, okay, I'm gonna do two to three sets of 10 single leg heel raises or two to three sets of eight single leg heel raises and continue to build up my calf strength so I can balance out my calves between the right and left side. That brings us to number four, and this is calf endurance, and it's really also about how the Achilles tendon is rebounding. Think of the Achilles tendon as a spring, it's the strongest tendon in your body. I mean, you can see how thick it is just from your skin. So when you are when you are planting your foot on the ground and pushing off the ground, it's almost like it's collecting all this energy as your foot's on the ground and then it's pushing you off the ground. It's storing that elastic energy and pushing you off. So, in order to have a strong Achilles, we need to also work on our calf endurance. With calf endurance, I want you to think of that as how long can your calf sustain a load? So this is where double leg pogo hops or double leg jumps in place can be extremely effective for increasing your speed and extremely effective with reducing Achilles injuries too. And then you progress them into single-leg calf or single leg hops in place. 30 seconds, 20 to 30 seconds, it's a great place to start. I always recommend being able to do that three times before you think about returning to run, just as a side note of what is expected from someone who's injured. So, in order to, you know, knowing that is a return to run test, you kind of want to take that reverse engineer and be like, all right, this is something I need to eventually work on. But if you're having pain with a single-egged calf raise, do not try double-ake hops, do not try single-egged hops, it is going to be painful. So try to focus on, you know, the single egg calf raise first. And then as that feels better, then you work on the impact. But being able to have that calf endurance, especially if you run marathons, you run these longer distance races, or just you enjoy running longer distances, that is kind of like the last part of the rehab process that needs to be addressed. And then again, you progress from double egg and you progress into single egg. All right, that wraps up today's session. These are really like four general non-negotiables. Obviously, it's gonna get a little more specific depending on what injury you are focusing on and what injury you're rehabbing. But these are four things that you either need to address or you need to be able to prove that you can do as you're rehabbing, especially as you're returning to run, in order to one, reduce your pain and two, prevent that pain from coming back on. So if you do need a rehab plan, go through the foot and ankle program. It's used by thousands of runners, it's very specific to running and it progresses you each week and it's a one-time fee. So it's actually cheaper than one visit with me, and that's pretty incredible because it's also lifetime access. So I will link that below, and I hope you have a great run as it's the weather starts to heat up and we start to get into a little bit more humidity. And if you have any questions at all, you can always message me or email me.