Foot and Ankle Strength For Runners

A strong base of support is essential for runners and running based athletes. Having a strong foot and ankle allows can help manage the loads further up the kinetic chain at the knee and hip. Additionally, it may assist in preventing or managing foot and ankle pain.

Running injuries are considered largely multifactorial, meaning that multiple contributing factors play a role in the development of a running injury. There is a large body of evidence that points to numerous factors such as training loads, certain running technique variables (cadence, vertical oscillation), stress, sleep, psychosocial factors, tissue strength and capacity. There is a mix of evidence that points to the role of foot and ankle strength and postures in various running injuries.

Current consensus in running injuries management involves firstly managing loads, education regarding pathology and secondary exercise therapy. The most effective exercise interventions target both above and below the knee. Strengthening below the knee is often neglected, however can be easily added or worked into a strength program to maximise the benefits of strength training.  

Here is just a quick snapshot of evidence for foot and ankle strength:

• Individuals randomised to knee targeted exercises combined with foot targeted exercises and foot orthoses had a significantly larger improvement in pain compared to individuals randomised to knee targeted exercises at 4 months follow-up for patellofemoral pain (small effect size).
• Foot and ankle posture has been identified as a contributing factor to a number of injuries including tibialis posterior tendinopathy, plantar fasciitis/pain/fasciopathy, Achilles tendinopathy, foot stress fractures and Patellofemoral pain.
• 4 weeks of short foot exercise training in healthy individuals reduces arch collapse as assessed by measures of navicular drop and arch height index, and improve balance ability.
• In another study, healthy individuals who completed 4 weeks of short foot exercises demonstrated improved dynamic balance compared to those who performed 4 weeks of towel curl exercises.
• A systematic review identified strong and very limited evidence of small effect that a pronated foot posture is a risk factor for MTSS and patellofemoral pain respectively. Evaluation of static foot posture should be included in a multifactorial assessment for both MTSS and patellofemoral pain, although only as a part of the potential injury risk profile. Whilst the included measures are clinically applicable, further studies are required to determine their relationship with dynamic foot function (Neal et al).
• Calf strength is an important factor in preventing calf injuries and in the management of Achilles tendinopathy.

Exercises:

1. Short Foot Exercise // Foot Doming (Active Arch)

The first exercise is learning how to perform a short foot exercise, also known as foot doming or creating an active arch. The aim of this exercise is to utilise some of the shorter muscles within the foot and big toe. Imagine a tripod with its three points; under your heel, base of your big toe and outside of your foot. Keeping weight balance over these points, draw the big toe backwards towards your heel. Keep the base of your big toe on the ground and try not to scrunch your toes. Your arch should lift slightly higher off the ground and a tightening felt underneath your foot. Aim to perform 5x30sec holds and progress from performing standing on 2 legs, then 1.

Note in the relaxed foot (left) the arch height is lower than the right image. In the contracted position (right), note the change in foot length due to the short foot contraction drawing in the foot ( following the direction of the arrows) from the relaxed condition. The toes should remain in contact with the ground and not scrunch.

2. Weighted Pass/ Single leg squats

The second exercise is a progression from foot doming. Essentially we want an active strong arch under increased load and able to sustain its position during exercises. Here we demonstrate a weighted pass from one hand to another while keeping an active arch and balancing on one leg. Other variations include a single leg squat or deadlift whilst maintaining the foot dome. See the video below for more information.

3. Forward shuffles

The forward shuffle is an exercise to increase strength and endurance through the anterior compartment, notably tibialis anterior. In a squat position, drive your knees forward over your toes as far as you can. As you can see from the picture above, my range is poor and you should be able to move past your toes. Keeping your big toe lifted in the air and knees driving forward over your toes you are going to shuffle forward sliding your feet along the ground. As you do so actively try lift your forefoot off the ground without straightening your knees. It should begin to burn the front of your shins after 20-30sec. Try work up to 4min total in this position, or until anterior shin fatigue.

4. Plantar Fascia Calf Raises

Plantar fascia calf raises place additional stress on the plantar fascia, compared to a typical calf raise. By placing a rolled towel (or Fascia Fighter) under the toes, the arch is placed under greater tension and this greater stress and can be helpful in improving the load tolerance of the arch. It has also been shown to be effective in reducing pain and improving function in clients with plantar fascia pain.

5. Soleus Calf Raises

Seated calf raises target the soleus muscle, one of the calf muscle complex. I have previously discussed the importance of this muscle here. It takes loads 6-8x body weight when running, has a major role in achilles pain/tendinopathy and calf pain (particularly in the aging runner). Sitting on a bench positioned in front of the smith machine. Feet placed on a small step if possible. Perform a calf raise by pushing up into padded bar (extra padding may be needed for some), the smith machine bar will need to be rotated to ‘unrack’ the bar, then lower your heels below the level of the step. Perform repetitions then re-rack the bar at the top of the final repetition. Ensure you don’t try lift up the bar with your arms as the weight necessary to load the calf sufficiently will be quite heavy. Alternative exercises include a standing calf raise with a bent knee or performing a wall sit/wall squat in a calf raise position.

6. Skipping

Progressing to higher level loading for the foot and ankle is important to develop tolerance to higher rates of force such as during running and sprinting. A simple exercise to assist this is performing simple skipping or double leg bouncing. To make this more difficult higher jumps or single leg skips can be utilised.

Lewis Craig (APAM)
POGO Physiotherapist
Masters of Physiotherapy

Featured in the Top 50 Physical Therapy Blog

References

1. Mølgaard, C. M., Rathleff, M. S., Andreasen, J., Christensen, M., Lundbye-Christensen, S., Simonsen, O., & Kaalund, S. (2018). Foot exercises and foot orthoses are more effective than knee focused exercises in individuals with patellofemoral pain. Journal of science and medicine in sport, 21(1), 10-15.
2. Lack, S. (2018). The interaction of hip and foot biomechanics in the presentation and management of patellofemoral pain. Br J Sports Med, 52(8), 544-545.
3. Collins, N. J., Barton, C. J., van Middelkoop, M., Callaghan, M. J., Rathleff, M. S., Vicenzino, B. T., … & de Oliveira Silva, D. (2018). 2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017. Br J Sports Med, bjsports-2018.
4. Rathleff, M., Mølgaard, C., Fredberg, U., Kaalund, S., Andersen, K., & Jensen, T. et al. (2014). High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scandinavian Journal of Medicine & Science in Sports, 25(3), e292-e300. 
5. Huffer, D., Hing, W., Newton, R., & Clair, M. (2017). Strength training for plantar fasciitis and the intrinsic foot musculature: A systematic review. Physical Therapy in Sport, 24, 44–52. doi:10.1016/j.ptsp.2016.08.008
6. Malliaras, P., Barton, C. J., Reeves, N. D., & Langberg, H. (2013). Achilles and patellar tendinopathy loading programmes. Sports Medicine, 43(4): 267-286.
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9. Neal, B. S., Griffiths, I. B., Dowling, G. J., Murley, G. S., Munteanu, S. E., Smith, M. M. F., … & Barton, C. J. (2014). Foot posture as a risk factor for lower limb overuse injury: a systematic review and meta-analysis. Journal of foot and ankle research, 7(1), 55.
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