ReviewThe effect of reduced ankle dorsiflexion on lower extremity mechanics during landing: A systematic review
Introduction
Many lower-limb injuries are associated with restricted ankle dorsiflexion (DF) range of motion (ROM)1, 2, 3, 4, 5, 6, 7, 8 such as ACL,7 Achilles,4 and patellar tendon injuries.1, 8 In New Zealand from July 2012−June 2013, the Accident Compensation Corporation (ACC) received 172,461 new claims for lower-extremity injuries incurred during sport with costs exceeding $15 million NZD.9 Ankle injury sustained during sports participation may contribute to injury risk as reduced DF ROM has been reported following ankle sprain,10 ankle ligament reconstruction,11 chronic ankle instability,12, 13 and with ankle bracing.12, 13
There are a number of theories as to the mechanics behind the association between DF restriction and injury. Reduced DF may restrict the ability to pass the leg forwards over the foot6, 14, 15, 16 and to lower the centre of mass during squat-type movements.17 This may be compensated for via subtalar and midfoot pronation6, 14, 15 or knee valgus6, 18 both of which have been linked to chronic and acute injury.19, 20, 21, 22, 23 This theory is supported by studies reporting increased knee valgus during squat movements in participants with reduced DF ROM.16, 18
DF restriction may also increase injury risk by altering lower-extremity stiffness and landing forces. Decreased stiffness on landing results in greater lower-extremity joint-excursion and thereby reduces loading-rate (LR) and ground-reaction forces (GRFs).24, 25 Restricted DF and the associated reduction in hip and knee flexion24, 26 could therefore increase GRFs or LRs as the reduced joint excursion causes increased stiffness.26, 27 Increased injury risk has been reported with both higher GRFs28, 29, 30 and higher LRs.27, 31, 32 A further possibility is that DF loss is linked to injury via one of a number of compensatory mechanical patterns rather than through a single compensatory movement at a particular joint. Dynamical Systems theory approaches goal-directed movement from the perspective that there are multiple biomechanical degrees of freedom (DOF), which work in different patterns to achieve a consistent outcome.33, 34 This variation in biomechanical patterns is termed ‘coordinative variability’ and the pattern used for a given task can vary widely both within and between individuals.33, 34 Restricted DF may represent a loss of DOF and force individuals into one of a number of alternative movement patterns that may be associated with various injuries. A measure such as stiffness which captures a number of variables into a single measure may be more beneficial for identifying changes in movement patterns than individual mechanical variables.
Identifying predisposing factors to injury and the mechanical factors linked to increased injury risk will assist clinicians in prevention and treatment of injury. Given the above variation in rationale for a link between reduced dorsiflexion and injury incidence, the purpose of this review is to examine the evidence for the effect of DF ROM on peak DF angle, ankle, knee, and hip kinematics, peak vGRF, LR, time-to-peak (TTP) vGRF, and stiffness during landing.
Section snippets
Methods
A preliminary database search (keywords: ankle, dorsiflex*, land*, mechanic*) was conducted on EBSCO Health Databases to identify keywords (see supplementary search strategy table online). A comprehensive search of the literature was then conducted on EBSCO Health Databases on 17/09/2014 using the following search strategy: (dorsiflex* OR ankle OR talocrural) N8 (range OR ROM OR flex*) AND mechanic* OR biomechanic* OR kinetic* OR kinematic* OR move* OR “ground-reaction force*” OR GRF* OR
Results
The database search yielded 268 articles of which six met the inclusion criteria (see supplementary search results flow chart online). Scores ranged from 17−21/28 on the Downs and Black checklist (Table 3). The major quality issues were a lack of power calculations, not stating source populations, not stating the percentage of those approached who agreed to participate, and a lack of researcher and participant blinding.
Overall, there is strong evidence that restricted DF ROM alters landing
Discussion
Although five of the six reviewed studies found a significant association between DF range of motion and landing mechanics, results for each measured variable were inconsistent. This inconsistency may be due in part to variations in landing tasks investigated in each study and to variability in landing strategy within and between participants.
Studies by Whitting et al.,46 Fong et al.,26 Dill et al.,43 and Malloy et al.45 found that peak DF angle on landing was unaffected by DF ROM. Although
Conclusion
Restricted DF ROM may alter landing mechanics in a manner that predisposes athletes to injury. There is some support for increased frontal plane ankle motion, knee valgus, and frontal plane excursion, reduced knee and hip sagittal excursion, and increased peak vGRF, but results are inconsistent between studies. DF restriction does not appear to reduce peak DF angle on landing or TTP vGRF. Further studies are needed to investigate the effect of DF restriction on mechanical patterns rather than
Practical implications
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Reduced ankle flexibility may alter movement patterns during landing and increase landing forces.
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Altered movement patterns and greater forces may predispose athletes to injury.
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Screening athletes for ankle flexibility may assist in identifying those at an increased risk of injury.
Acknowledgements
No funding was provided for this review.
Nil.
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