Quick Case: Runner with Chronic Ankle Pain | Modern Manual Therapy Blog

Quick Case: Runner with Chronic Ankle Pain

Here are two Quick Cases from The Eclectic Approach to UQ and LQ Assessment and Treatment in Vancouver, BC just a few weeks ago.

Physio with Hx of 10 years Ankle Pain and loss of Dorsiflexion
  • sprained 20 years ago
  • 10 years ago, onset of pain and loss of motion with dorsiflexion
  • has been stretching into dorsiflexion since with little carry over
  • limited and painful with running, squatting

I brought this case up first, explaining that the Directional Preference of a Reset had to be novel. Since this physio/runner was constantly working on his dorsiflexion, with dorsiflexion stretches. In addition to having severe ankle dorsiflexion limitation in the ankle half kneel dorsiflexion test, he also had limited and painful squat, plus loss of passive end range ankle plantarflexion.

The Directional Preference chosen was repeated end range loading into plantarflexion and inversion, as he was able to attain end range with a yellow light initially, that rapidly changed into a green light. After about 30 reps or so, ankle dorsiflexion was significantly less painful in both squatting and the dorsiflexion test. He was instructed to perform 10 reps or more hourly the rest of the day.

The next morning, his dorsiflexion was improved and felt much better. Since we had moved onto lower quarter assessment that day, I also checked him for a loss of ipsilateral SGIS. As expected, he had a loss of SGIS to left (same side as involved ankle). Pre-test, his squat was still limited and looked like this. As you can see, his left knee did not travel as far anteriorly as his tibia was not able to translate anteriorly over his talus due to mild end range pain and loss of ankle dorsiflexion.

The chosen reset this time, since he was limited in SGIS to the same side, was shift correction in standing to the left to restore ability to load the involved side lumbar spine. After about 30 reps, he regained full motion. A quick demo of me performing the SGIS is seen below.


After re-test, his squat was pain free, and ankle, knee, hip ROM was all symmetrical bilaterally. The physio was very happy and faithfully perfomed ankle plantarflexion/inversion and SGIS against the wall to the left repeatedly throughout the day. He just had to wrap his head around forgetting arthrokinematics and focusing on two simple solutions to eliminate his chronic 10 years of ankle pain.

The moral of this story is, loss of ability to load the involved side has been shown in the research to lead to running injury. The loading loss in this case was in the lumbar spine and ankle ipsilaterally. Second, and more importantly, a history of 10 years of ankle pain is not really chronic when it is intermittent in nature. Remember, intermittent pain is the best news a patient can give you - and you should make a point to tell them, thus alleviating their anxiety, since it almost guarantees their categorization as a rapid responder.

Keeping it Eclectic...


  1. The Vancouver course was great, and the content immediately applicable! The following week back at clinic I had an evaluation of persisting lateral ankle pain with stairs, running & kneeling (otherwise pain free). Pain with kneeling and running were confirmed with pre-test. The distal tib-fib joint was moving well, and 6 months post inversion sprain the lateral ankle ligaments were pain free with stress testing. A combination of repeated ankle plantar flexion movements that I learned in Erson's live "lower quarter" course & peroneal nerve biased glides from his "neurodynamics" Medbridge course alleviated patient symptoms with running & kneeling 100% at post-test, and were then prescribed as a home program. Patient cancelled follow-up a week later, very pleased that the prescribed home program exercises had kept up the 100% pain free status.

  2. So why plantarflexion an inversion? Trying to understand thought process that took you to those movements.

  3. The best reset and directional preference is often a novel strategy. Since the physio had been using df stretching to improve his painful and limited df, I chose PF and inversion. It worked to get to end range and reset his CNS thus raising his pain and movement thresholds.

  4. So seeing as his pain was intermittent would McKenzie classify him as reducible derangement still?

  5. The classification of derangement syndrome is based upon repeated loading/unloading strategies able to make a rapid change in the patient's presentation. So the answer is yes! Intermittent pain for me is always great news and I relay that to the patient to alleviate their fear avoidance behaviors and beliefs that are often reinforced by thought viruses from family, friends, and other health care providers.