The ankle joint is an important part of the musculoskeletal system necessary for normal ambulation. Reduced range of movement at this joint has been termed as gastrocnemius contracture, limited ankle dorsiflexion and ankle equinus. This condition has been related to various functional lower extremity musculoskeletal conditions.This paper explores and provides an overview of ankle equinus, its effect on the lower extremities and someof the issues involved in the clinical measurement of ankle dorsiflexion.La articulación del tobillo es una parte importante del sistema musculoesquelético necesaria para la deambulación normal. A la reducción del rango de movimiento en esta articulación que se ha denominado como contractura de gemelo, flexión dorsal del tobillo limitado y equino del tobillo. Esta condición se ha relacionado con diversas condiciones patológicas funcionales de las extremidades inferiores musculoesqueléticos.Este artículo explora y proporciona una visión general de equino de tobillo, su efecto en las extremidades inferiores y algunas de las cuestiones relativas a la medición clínica de la flexión dorsal del tobillo

Chockalingam, Nachiappan

Gatt, Alfred

Portal de Revistas Científicas Complutenses

Revista Internacional de Ciencias Podológicas
2012, Vol. 6, Núm. 1, 25-29
25 ISSN: 1887–7249
Assessment of Ankle Joint Dorsiflexion: An Overview
 
Exploración de la flexión dorsal del tobillo: Una revisión
 
Alfred Gatt1, Nachiappan chockalinGam2 
 
1 Podiatrist, Assistant Lecturer
 Faculty of Health Sciences, University of Malta
alfred.gatt@um.edu.mt
2 Professor of Biomechanics
Faculty of Health, Staffordshire University
N.Chockalingam@staffs.ac.uk
 
Correspondencia:
Alfred Gatt 
Podiatry Department
Faculty of Health Sciences
University of Malta
Tal-Qroqq
Malta
Fecha de recepción: 10 de septiembre de 2010
Fecha de aceptación: 25 de octubre de 2010
Los autores declaran no tener ningún tipo de interés económico o comercial.
ABSTRACT
The ankle joint is an important part of the musculoskeletal system necessary for normal ambulation. Reduced 
range of movement at this joint has been termed as gastrocnemius contracture, limited ankle dorsiflexion and 
ankle equinus. This condition has been related to various functional lower extremity musculoskeletal conditions.
This paper explores and provides an overview of ankle equinus, its effect on the lower extremities and some 
of the issues involved in the clinical measurement of ankle dorsiflexion.
Key words: Ankle Equinus; Goniometry.
RESUMEN
La articulación del tobillo es una parte importante del sistema musculoesquelético necesaria para la deambulación 
normal. A la reducción del rango de movimiento en esta articulación que se ha denominado como contractura 
de gemelo, flexión dorsal del tobillo limitado y equino del tobillo. Esta condición se ha relacionado con diversas 
condiciones patológicas funcionales de las extremidades inferiores musculoesqueléticos.
Este artículo explora y proporciona una visión general de equino de tobillo, su efecto en las extremidades 
inferiores y algunas de las cuestiones relativas a la medición clínica de la flexión dorsal del tobillo.
Palabras clave: goniometría; equino del tobillo.
Sumario: 1. Limited Ankle Dorsiflexion. 2. Effects of Ankle Equinus. 3. Examination. 4. Conclusion. References. 
Referencia bibliográfica: Gatt, A., Chockalingam , N. Assessment of Ankle Joint Dorsiflexion: An Overview. 
Rev. Int. Cienc. Podol. 2012; 6(1): 25-29. 
http://dx.doi.org/ 10.5209/rev_RICP.2012.v6.n1.37894
Alfred Gatt, Nachiappan Chockalingam Assessment of Ankle Joint Dorsiflexion: An Overview
26 Revista Internacional de Ciencias Podológicas
2012, Vol. 6, Núm. 1, 25-29
The ankle joint is formed by the articulation be-
tween the mortise of the lower tibia and fibula 
and the trochlear surface of the talus. Actually 
composed of 3 joints – the tibiotalar, tibiofibu-
lar and fibulotalar joints1 – it plays an essential 
role during walking, and is of great importance 
during physical activities2. It is generally be-
lieved that the upward and downward move-
ment of the foot, referred to as dorsiflexion 
and plantarflexion respectively, occurs mainly 
at this joint3,2. This Tibio-talar movement in-
volves the rotation of the talus within the ankle 
mortise4 with unresisted mobility being ob-
tained by the sliding of the articular surfaces 
upon each other5.  
The ankle moves through an average of 20 o 
to 40 o total range of motion during walking6. 
Whilst this is a triplanar joint, the orientation 
of its axis, which runs from the medial to the 
lateral malleolus, facilitates the majority of 
this motion to occur in the sagittal plane. It is 
claimed that during normal locomotion, 10 de-
grees of ankle dorsiflexion is required for the 
forward translation of the centre of gravity of 
the body to occur during single limb support3, 
although this has been challenged by various 
authors6. This forward translation occurs in the 
sagittal plane, and this is said to occur using a 
3 rocker system to permit advancement7. This 
sagittal plane movement at the ankle occurs 
during the 2nd rocker8. 
1. LIMITED ANKLE DORSIFLExION
 
Clinically, lack of ankle joint dorsiflexion is 
known by many terms, including equinus, gas-
trocnemius contracture and limited ankle dor-
siflexion. The classical orthopaedic definition 
of ankle equinus is a plantarflexed foot as is of-
ten seen in neurological conditions such as cer-
ebral palsy. Another definition is <10o of dorsi-
flexion with the subtalar joint placed at neutral 
position. This is thought to lock the midtarsal 
joint and reduce any movement extraneous to 
the ankle joint3. DiGiovanni et al (2002) de-
fined Equinus as <5° of ankle dorsiflexion with 
the knee extended or <10° with the knee flexed 
and used the term ‘gastrocnemius tightness’ 9.  
The most common cause of Equinus is tight-
ening or shortening of the gastocnaemius/soleus 
group (collectively known as the triceps surae), 
causing premature activity of ankle plantarflex-
ors10. In fact, the term muscular ankle equinus 
has been coined . This is thought to result from 
modern lifestyle factors in the daily environ-
ment, which put patients at risk of develop-
ing this condition. These factors include over-
training of muscles, sleeping with the feet in a 
plantarflexed position for long hours and sitting 
for long hours at desks with the knees flexed 
and the feet in an equinus position10. Even dur-
ing standing, the gastrocnaemius is being used 
to maintain the centre of gravity anterior to the 
ankle joint axis11,12 and to oppose the dorsiflex-
ing moment imposed on the foot12. 
2. EFFECTS OF ANKLE EqUINUS
 
Lack of ankle dorsiflexion is compensated for 
by altering gait, including early heel-off in 
mild cases (bouncy gait) or even a total lack of 
heel strike in severe cases (such as in cerebral 
palsy); triplanar rearfoot motion (pronation) 
and an adducted gait pattern.3 Equinus can be 
uncompensated, with the patient walking on 
the toes, or compensated by various methods, 
including foot abduction, significant pronation 
of the mid foot and rearfoot, resulting in the 
loss of the medial longitudinal arch and abduc-
tion of the forefoot13.  
Once the ankle is restricted, the midtarsal 
joint is the next joint through which dorsiflex-
ion may occur. This is achieved by excessive 
pronation of the foot8, which turns it into a 
mobile adaptor to facilitate dorsiflexion at this 
joint. Forces on the midtarsal joint may even-
tually lead to the midfoot break and significant 
structural foot problems14.  
Lack of ankle dorsiflexion is said to pro-
duce a sagittal plane blockage8. This refers to 
a restriction of rotational motion of the foot 
or any part of it – such as the ankle and first 
metatarsophalangeal joint – within the sagittal 
plane. As the forward movement of the foot oc-
curs mainly in the sagittal plane, anything that 
prevents this is likely to cause a change in gait 
and produce compensatory patterns of walking. 
In fact, muscular ankle equinus, or gastrocne-
mius contracture, has been linked to various 
foot conditions. In a study of 209 consecutive 
Alfred Gatt, Nachiappan ChockalingamAssessment of Ankle Joint Dorsiflexion: An Overview
27Revista Internacional de Ciencias Podológicas
2012, Vol. 6, Núm. 1, 25-29
patients with musculoskeletal problems in the 
foot, a prevalence of 96.5% of this condition 
was found and has been linked to foot problems 
including plantar fasciitis and metatarsalgia10. 
Various authors claim that ankle equinus 
may be a significant causative factor of a varie-
ty of lower extremity conditions3, ranging from 
low back pain, hyperextended knees, hallux 
rigidus, calcaneal spurs15, chronic plantar heel 
pain16, foot nerve entrapment17, Achilles tendi-
nopathy, Posterior Tibial Tendon Dysfunction, 
plantar fasciitis10, metatarsalgia18 and forefoot 
callus19. It has been shown that diabetic pa-
tients with equinus have significantly higher 
pressures in the forefoot than those without20. 
Although highly evident equinus may be 
a presentation of neurological conditions, in-
cluding toe walking21 and cerebral palsy22, 
the milder form of equinus does not normally 
become apparent except through a thorough 
lower limb examination. This form of equinus 
can affect anyone, from diabetics20,23, adoles-
cent athletes24 to children25. In individuals with 
neurological conditions, contracture of the tri-
ceps surae is well documented. The impact of 
contracture of the gastrocnemius in the normal 
patient needs to be researched more because it 
can have deleterious effects such as pain in the 
forefoot and/or midfoot9.  
3. ExAMINATION
Thus it is evident that ankle joint assessment, 
including measurement, is an important aspect 
of any musculoskeletal examination. A biome-
chanical evaluation of the foot normally starts 
with passive examination of this joint. Ankle 
joint movement examination may be per-
formed using various methods. The procedures 
mostly used in clinics and research include go-
niometry3,26 and visual estimation27. This may 
be because goniometers can be found easily 
in clinics and are relatively inexpensive. Dur-
ing goniometric examination, one arm of the 
goniometer is placed along a bisection of the 
lateral aspect of the lower leg, and the other 
arm along the lateral margin of the foot3,26. The 
subtalar joint is held in neutral position, with 
the midtarsal joint locked. An upward force is 
applied until the maximum ankle joint range of 
motion is reached. This examination is initially 
done with the knee extended and then with the 
knee flexed in order to differentiate between 
gastrocnaemius (the former) and soleus tight-
ening3,26,28. 
However, there is ample evidence in litera-
ture that goniometer based measurements for 
ankle joint movement are not reliable29,30,31,32. 
Although hand-held goniometers have intro-
duced quantification33 they have major draw-
backs in measuring ROM; goniometric relia-
bility is unproven with reliability studies often 
having major flaws in design or analysis34. In 
fact, goniometry has been shown to be unre-
liable for rearfoot assessment35,36 and the re-
sponsiveness of ankle range of motion meas-
urements is uncertain30. 
These problems with reliability have spurred 
the design of a number of devices and proce-
dures aimed at measuring ankle dorsiflexion. 
These include, among others:
The Equinometer 37,38
The Mechanical Equinometer 39
The Biplane Goniometer 40
The Iowa Ankle Device 41
The Lunge Test 42
4. CONCLUSION
 
There is still a paucity of information in quan-
tifying Ankle Joint dorsiflexion. An inappro-
priate measurement using an in appropriate 
technique could have important repercussions. 
Wrong techniques for measurement and the 
use of poorly-validated instruments may pro-
vide a mis-diagnosis from which wrong treat-
ment modalities could ensue. 
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2012, Vol. 6, Núm. 1, 25-29
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Exploración de la flexión dorsal del tobillo: Una revisión

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Exploración de la flexión dorsal del tobillo: Una revisión

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