Restoring ankle dorsiflexion range of motion in athletes: an individualized clinical decision-making system

Key points

1. 01The weight-bearing lunge test (WBLT) is the gold-standard assessment for ankle dorsiflexion ROM but is underused in clinical practice.
2. 02Restricted dorsiflexion increases knee valgus, peak ground reaction forces, and risk of lateral ankle sprain, Achilles tendinopathy, patellar tendinopathy, and metatarsal stress fracture.
3. 03The 3-step framework: quantitative and qualitative WBLT assessment, confirmatory diagnostic testing to identify the specific structure, then targeted treatment.
4. 04Five symptom zones guide which structure to investigate: anterior (talocrural or transverse tarsal), anterolateral (inferior tibiofibular), medial retromalleolar (FHL tendon or subtalar), lateral retromalleolar (fibularis tendons), and posterior (triceps surae or tibial nerve).
5. 05Chronic stretching protocols require more than 1,200 seconds of time under stretch per week over at least 5 weeks; joint mobilizations require 2-3 sessions per week at grades III-IV.

How it was conducted

Design

Clinical practice commentary (perspective article) - no original trial data

Population

Athletes with ankle dorsiflexion ROM deficit following foot-ankle injury, applicable in acute or chronic rehabilitation phase

Framework

3-step clinical decision-making system using the weight-bearing lunge test as its foundation

Interventions covered

Antero-posterior talar mobilization (Maitland), mobilization with movement (Mulligan MWM), chronic stretching for triceps surae, FHL, and fibularis tendons, and tibial nerve neurodynamics

Evidence base

Synthesis of existing literature including meta-analyses on manual therapy for chronic ankle instability and stretching for dorsiflexion ROM

What they found

• Posterior talar glide test ICC = 0.94, indicating high reliability for assessing posterior talar glide restriction.
• Normative ankle dorsiflexion ROM suggested as greater than 9-10 cm (toe-to-wall) or greater than 40-42 degrees (tibial inclination).
• Modified SLR asymmetry greater than 7.0 degrees (above MDC) indicates tibial nerve mechanosensitivity.
• One RCT using individualized (pragmatic) manual therapy demonstrated a large effect size in improving dorsiflexion ROM.
• Distal tibiofibular joint mobilizations over multiple sessions improve dorsiflexion ROM; a single session yields limited benefit.
• Tibial nerve neurodynamics protocol: 80-100 seconds total time under stretch per session (2 sets of 10 repetitions with 5-second holds), 3 sessions per week.

Limitations

• The authors explicitly state there are no interventional data showing the individualized system produces superior outcomes over a generalized protocol.
• This is a perspective article based on literature synthesis and clinical experience, not an original randomized controlled trial.
• The confirmatory tests and symptom zones are based on clinical reasoning and limited individual studies, not validated diagnostic accuracy studies for this specific decision pathway.
• Normative WBLT values (greater than 9-10 cm, greater than 40-42 degrees) are described as derived from clinical experience, not large normative datasets.

Why it matters

For patients

Athletes with ankle stiffness or recurrent lower-limb injuries may benefit from a clinician who uses a structured test to find the specific cause of their restricted ankle motion rather than applying the same generic stretching to everyone.

For clinicians

This framework offers a practical decision tree - symptom zone during WBLT, a confirmatory test, then a matched intervention - that can guide more targeted rehabilitation when generic protocols have failed or when individualized care is preferred.

For readers

The article highlights that most clinicians do not use the WBLT despite it being the gold-standard, and that restricting dorsiflexion is linked to a wide range of lower-limb injuries, making this a relevant clinical gap in sports physiotherapy.