NASM Essentials of
NASM Essentials of
Corrective Exercise
Corrective Exercise
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EDITORS
Micheal A. Clark
Scott C. Lucett
1.800.460.NASM
www.nasm.org/ces
1.800.460.NASM
www.nasm.org/ces
National Academy of Sports Medicine
Chapter 8
Corrective Exercise
Strategy for Foot and Ankle
Impairments
Corrective Exercise Strategy for
Foot and Ankle Impairments
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Corrective Exercise Strategy for
Foot and Ankle Impairments
Introduction
The human body is susceptible to movement dysfunctions and neuromusculoskeletal imbalances. The reasons for this include repetitive movement, overuse, sedentary living, and improper movement techniques.
These dysfunctions, in turn, lead to many of the common injuries seen today.
The foot and ankle complex is a region of the body with great influence on the entire Human Movement
System. This region represents the platform from which our base of support is derived and is the main
contact point between the ground and the body. As such, it must withstand the highest amount of contact
force (ground reaction force) with each step taken, as it is closest to the impact site (heel strike).
If there is movement impairment centralized within the foot and ankle region, it can lead to various symptomatic responses, as seen in Table 8-1. These include plantar fasciitis, Achilles tendonitis, and posterior
tibialis tendonitis (shin splints). As the body is an interconnected chain (kinetic chain), compensation or
dysfunction in one region such as the foot and ankle can and will lead to dysfunctions in other areas of
the body. (1, 2) More proximally, dysfunction for the foot and ankle can also lead to patellar tendonitis
(jumper’s knee), iliotibial band (IT-band) tendonitis (runner’s knee), low back pain, hamstring, quadriceps,
and groin strains, as well as many shoulder and upper-extremity injuries. (Table 8-1)
Table 8-1. Common Injuries Associated with Foot and Ankle Impairment
Local Injuries
Proximal Injuries
Plantar fasciitis
Patellar tendonitis (jumper’s knee)
Achilles tendonitis
IT-band tendonitis (runner’s knee)
Posterior tibialis tendonitis (shin splints)
Low back pain
Hamstring, quad, and groin strains
For example, if the foot externally rotates and/or everts during movement, it is generally the collective
motion of the foot/ankle and lower leg. Therefore, the displacement of the foot will likely result in altered
lower leg motion/alignment, which is indicative of overactivity of the lateral gastrocnemius, peroneals,
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Corrective Exercise Strategy for
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short head of the biceps femoris, and/or the tensor fascia lata (TFL), and underactivity of the medial
gastrocnemius, posterior tibialis, medial hamstrings, gracilis, sartorius, popliteus, and/or gluteus medius
and maximus.
Locally, the lateral gastrocnemius, when activated, can externally rotate the lower leg as well as cause
eversion of the calcaneus. The peroneals (longus and brevis), when activated, will evert the foot. The
peroneus longus can cause external rotation as well. Proximally, the short head of the biceps femoris
and the TFL can externally rotate the lower leg because of their attachments to the fibula and tibia,
respectively. When the medial gastrocnemius, posterior tibialis, medial hamstrings, gracilis, sartorius,
popliteus, and/or gluteus medius and maximus cannot be sufficiently activated to counter these actions,
compensation occurs.
This combination of over and underactive muscles can also cause the knee (tibiofemoral joint) to adduct
and internally rotate. The lateral gastrocnemius and biceps femoris each externally rotate the lower leg
relative to the femur and flex the knee. When the knee is flexed and the lower leg is externally rotated
relative to the femur, it produces a lateral displacement (abduction) of the lower leg causing the femur
to internally rotate and adduct. (3) This can be further perpetuated by the TFL, which specifically produces internal rotation of the femur and external rotation of the lower leg. (3) Collectively, this places
disproportional stress on the patellofemoral and tibiofemoral joints (i.e., patellar tendonitis and general
knee pain). (1, 4)
Overactivity of the TFL can lead to underactivity of the gluteus medius. The flexion and internal rotation
of the hip/femur caused by the TFL places the posterior fibers of the gluteus medius as well as the gluteus
maximus in a lengthened position, which alters the length-tension relationship and decreases recruitment due to altered reciprocal inhibition. (2) In turn, this creates a destabilized lumbo-pelvic-hip complex
(LPHC), which can lead to low back pain, hamstring, quadriceps, and groin strains. (2, 4)
Any alterations in pelvic positioning and stability will directly affect the latissimus dorsi, which attaches
to the pelvis via the thoracolumbar fascia network. (4) The latissimus dorsi has direct influence on the
shoulder region through its attachment to the scapula and humerus and this can lead to many shoulder
and/or cervical injuries.
Each of the typical injuries listed can be problematic for any individual and the reduction in pain or severity is the focus of many exercise programs. However, these injuries are primarily symptoms representing
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Foot and Ankle Impairments
a problem in the Human Movement System. The National Academy of Sports Medicine (NASM) has
developed a systematic corrective exercise strategy to identify and address the problem rather than the
symptoms. This allows the Health and Fitness Professional to develop a safe and effective solution for any
client. The purpose of this text is to demonstrate the corrective exercise strategy specifically for foot
and ankle impairment.
Corrective Exercise Strategy for Foot and Ankle Impairment
Corrective exercise strategies are solutions to identify neuromusculoskeletal dysfunctions within the
Human Movement System. Identification of dysfunction is achieved through an integrated assessment
process, which includes a movement assessment, goniometric measurements, and manual muscle testing
(for those licensed to do so). The integrated assessment process allows the Health and Fitness Professional
to identify the overactive and underactive myofascial tissues. Once the overactive and underactive tissues
are known, the corrective exercise strategy can be developed.
The specific movement impairment that will be discussed in this text is external rotation and/or eversion
of the feet (also known as feet turn out and feet flatten), seen in Figure 8-1.
Figure 8-1. Example of feet turn out and flatten
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Table 8-2. Probable Overactive & Underactive Muscles Accompanying Foot and Ankle
Region
Feet
Compensation
Overactive
Underactive
Externally Rotate
Soleus
Med. Gastrocnemius
(turn out)
Lat. Gastrocnemius
Med. Hamstring
Biceps Femoris
(short head)
Gracilis / Sartorius
(Pes Anserine)
Tensor Fascia Lata (TFL)
Popliteus
Gluteus Medius/Maximus
Evert
Peroneal Complex
Anterior Tibialis
(flatten)
Lat. Gastrocnemius
Posterior Tibialis
Biceps Femoris
Med. Gastrocnemius
TFL
Gluteus Medius
To ensure clarity and maximal retention of the information, the following section will provide a simplistic
overview of functional anatomy for the pertinent muscles, bones, and joints.
Review of Foot and Ankle Functional Anatomy
As previously stated, the foot and ankle is a complex structure with a great deal of influence on the rest
of the kinetic chain. There are many bones, joints, and muscles that affect dysfunction in the foot and
ankle; however, this section seeks only to provide a general review of the most pertinent structures. This
is not intended to be an exhaustive and detailed review.
Bones and Joints
Looking at the foot and ankle region specifically (Figure 8-2), the phalanges and metatarsals make up
the metatarsophalangeal and tarsometatarsal joints. The tarsal bones, consisting of the navicular, medial,
intermediate, and lateral cuneiforms (transverse arch), and cuboid, along with the talus and calcaneus,
make up the subtalar (talus and calcaneus), talonavicular and calcaneocuboid joints.
Moving up to the lower leg, the tibia and fibula bones form the proximal and distal tibiofibular joints as
well as the talocrural joint (tibia, fibula, and talus), typically collectively called the “ankle” joint.
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Figure 8-2. Bones of the Foot, Ankle and Lower Leg
A=Phalanges; B=Metatarsals; C=Navicular; D=Medial, Intermediate, & Lateral Cuneiform;
E=Cuboid; F=Talus; G=Calcaneus; H=Tibia; I=Fibula
More proximally (Figure 8-3), the patella, femur, and the pelvis, in conjunction with the aforementioned
bones, comprise the tibiofemoral (tibia, femur), patellofemoral (patella, femur) iliofemoral (femur, pelvis)
joints that anchor proximal myofascial tissues. These structures are important in terms of corrective
exercise because they will also have a functional impact on the arthrokinematics of the foot and ankle.
Figure 8-3. Proximal Bones Affecting the Foot and Ankle
A=Tibia & Fibula; B=Patella; C=Femur; D=Pelvis
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Muscles
With all Human Movement System impairments, there are over and underactive muscles which create
an imbalance and lead to injury. The pertinent muscles of the lower leg which are overactive with this
impairment are discussed in Table 8-3 and pictured in Figure 8-4.
Table 8-3. Overactive Muscles of the Lower Leg Accompanying Foot and Ankle Impairment
Muscle
Concentric
Isometric –
Stabilization
Eccentric
Lateral
Plantarflex ankle, evert
Gastrocnemius calcaneus, externally
rotate lower leg, and
flex knee
Foot, ankle, and knee
Decelerates ankle
dorsiflexion, internal rotation
of lower leg, and knee
extension
Soleus
Plantarflex ankle,
externally rotate
(supinate) lower leg,
and assists in knee
extension
Foot and ankle
Decelerates ankle
dorsiflexion, internal rotation
of lower leg and eversion
of subtalar joint, and knee
flexion
Peroneus
Longus
Evert ankle, plantarflex
ankle
1st Metatarsophalangeal Decelerates ankle inversion
joint (MTP)
and dorsiflexion
Figure 8-4. Overactive Muscles of the Lower Leg
Lateral Gastrocnemius
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Soleus
Peroneus Longus
Corrective Exercise Strategy for
Foot and Ankle Impairments
The pertinent muscles of the lower leg which are underactive with this impairment are discussed in Table
8-4 and pictured in Figure 8-5.
Table 8-4. Underactive Muscles of the Lower Leg Accompanying Foot and Ankle Impairment.
Muscle
Isometric –
Stabilization
Concentric
Medial
Plantarflex ankle, invert
Gastrocnemius calcaneus, internally rotate
lower leg, and flex knee
Eccentric
Foot, ankle, and knee Decelerates ankle
dorsiflexion, external
rotation of lower leg, and
knee extension
Posterior
Tibialis
Plantarflex ankle, externally Foot and ankle
rotate (supinate) lower leg,
invert foot/ankle
Decelerates ankle eversion,
dorsiflexion, and internal
rotation of lower leg
Anterior
Tibialis
Invert ankle,
dorsiflex ankle
Decelerates ankle
plantarflexion and eversion
Foot and ankle
Figure 8-5. Underactive Muscles of the Lower Leg
Medial Gastrocnemius
Posterior Tibialis
Anterior Tibialis
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The overactive muscles of the LPHC affecting the foot and ankle are discussed in Table 8-5 and pictured
in Figure 8-6.
Table 8-4. Overactive Muscles of the LPHC Accompanying Foot and Ankle Impairment
Muscle
Concentric
Isometric –
Stabilization
Eccentric
Biceps Femoris
(short head)
Externally rotate lower
leg and flex knee
Knee
Decelerates internal rotation of
lower leg and knee extension
TFL
Flex, abduct, and
internally rotate femur
(hip), externally rotate
lower leg, and extend
knee
LPHC and knee
Decelerates femoral extension,
adduction and external rotation
of LPHC, and internal rotation
of lower leg
Figure 8-6. Overactive Muscles of the LPHC
Biceps Femoris (short head)
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TFL (and IT Band)
Corrective Exercise Strategy for
Foot and Ankle Impairments
The overactive muscles of the LPHC affecting the foot and ankle are discussed in Table 8-6 and pictured
in Figure 8-7.
Table 8-6. Underactive Muscles of the LPHC Accompanying Foot and Ankle Impairment
Muscle
Concentric
Isometric –
Stabilization
Eccentric
Medial Hamstrings
Flex knee, extend hip, LPHC and knee
and internally rotate
lower leg
Decelerates knee extension,
hip flexion, and external
rotation of lower leg
Gracilis
Adduct, internally
rotate, weak flexion
of femur, and
internally rotate
lower leg
LPHC and knee
Decelerates femoral
abduction, external rotation
of lower leg
Sartorius
Abduct, internally
rotate tibia, knee and
hip flexion, and hip
external rotation
LPHC and knee
Adduct, externally
rotate tibia, knee and hip
extension, and hip internal
rotation
Popliteus
Internally rotate
lower leg (open
chain), externally
rotate femur (closed
chain), and weak
flexion of knee
Knee
Decelerates external
rotation of lower leg (open
chain) and internal rotation
of femur (closed chain)
Gluteus Medius
(posterior fibers) and
Gluteus Maximus
Abduct, externally
rotate, and extend
femur (hip)
LPHC and knee
Decelerates femoral (hip)
adduction, internal rotation,
and flexion
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Figure 8-7. Underactive Muscles of the LPHC
Medial Hamstrings
Gracilis
Popliteus
Sartorius
Gluteus Medius
Gluteus Maximus
Assessment for Foot and Ankle
The first step in developing a corrective exercise strategy is an integrated assessment process. NASM
uses three primary assessments including a movement assessment (Overhead Squat and Single-Leg Squat),
goniometric measurements, and, for the licensed professional, manual muscle testing. Based upon the collective information obtained from these assessments, the over and underactive muscles can be identified.
Table 8-7 shows the probable observations for these assessments relative to foot and ankle impairment.
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Table 8-7. Probable Assessment Observations for Foot and Ankle Impairment
Assessment
Observation
Overhead Squat
Feet turn out (externally rotate) and flatten (evert)
Single-Leg Squat
Feet flatten (evert)
Goniometric Measurement
Decreased dorsiflexion (less than 15 degrees) and/or
secondary decrease in the hip flexion 90/90 position
(hamstring, short head of biceps femoris) and/or hip
extension (TFL)
Manual Muscle Testing
One or more of the following muscles tested “weak”:
Anterior tibialis, posterior tibialis, medial gastrocnemius,
and/or medial hamstring;
Proximally, the gluteus medius and/or maximus
Corrective Strategies Program Design
Once the over and underactive muscles have been identified, the corrective exercise strategy can be
developed. Table 8-8 shows a sample programming strategy using the corrective exercise continuum for
foot and ankle impairment.
Figure 8-7. Corrective Exercise Continuum
Corrective Exercise Continum
Inhibit
Lengthen
Activate
Inhibitory
Techniques
Lengthening
Techniques
Activation
Techniques
Self-Myofascial
Release
Static Stretching
Positional
Isometrics
Neuromuscular
Stretching
Integrate
Integration
Techniques
Integrated Dynamic
Movement
Isolated
Strengthening
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Table 8-8. Sample Corrective Exercise Program for Foot and Ankle Impairment
Phase
Inhibit
Modality
SMR
Muscle(s)/Exercise
Lateral gastrocnemius and
peroneals
Acute Variables
Hold on tender area for
30 sec.
Biceps femoris (short head)
Lengthen
Static Stretching
or NMS
Gastrocnemius/soleus
Biceps femoris (short head)
30 sec. hold or 7–10 sec.
isometric contract, 30 sec.
hold
Activate
Positional
Isometrics
Posterior tibialis
and/or Isolated
Strengthening
Medial hamstrings
4 reps of increasing
intensity: 25, 50, 75, 100%
or
Integrate
Anterior tibialis
Medial Gastrocnemius
Integrated Dynamic Single-Leg Balance Reach
Movement
10–15 reps with 2 sec.
isometric hold and 4 sec.
eccentric
10–15 reps under control
*NOTE: If client is not initially capable of performing the Integrated Dynamic Movement
exercise listed, they may need to be regressed to a more suitable exercise.
Figure 8-8A. Inhibit
Figure 8-8B. Inhibit
Lateral Gastrocnemius and Peroneals
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Bicep Femoris (short head)
Corrective Exercise Strategy for
Foot and Ankle Impairments
Figure 8-9A. Lengthen
Figure 8-9B. Lengthen
Gastrocnemius/Soleus Stretch
Bicep Femoris (short head) Stretch
Figure 8-10A. Activate
Figure 8-10B. Activate
Posterior Tibialis
Medial Hamstrings
Figure 8-10C. Activate
Figure 8-10D. Activate
Anterior Tibialis
Medial Gastrocnemius
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Corrective Exercise Strategy for
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Figure 8-11A. Integrate
Figure 8-11B. Integrate
Single-Leg Balance
START
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Single-Leg Balance
FINISH
Corrective Exercise Strategy for
Foot and Ankle Impairments
References
1.
Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint
dysfunction: A theoretical perspective. J Orthop Sports Phys Ther. 2003;33(11):639–46.
2.
Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis, MO:
Mosby; 2002.
3.
Vasilyeva LF, Lewit K. Diagnosis of muscular dysfunction by inspection. In: Liebenson C (ed).
Rehabilitation of the Spine. Baltimore: Williams & Wilkins; 1996. p. 113–42.
4.
Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Physical Rehabilitation.
St. Louis, MO: Mosby; 2002.
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