NASM Essentials of

NASM Essentials of
Corrective Exercise Corrective Exercise

NASM Essentials of Corrective Exercise

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EDITORS
— Jeremy Cheung, NASM CPT, California, Top 10 Trainers in the U.S., Women’s Health Magazine

Micheal A. Clark
Scott C. Lucett

1.800.460.NASM www.nasm.org/ces 1.800.460.NASM www.nasm.org/ces

 National Academy of Sports Medicine

Chapter 8
Corrective Exercise
Strategy for Foot and Ankle
Impairments
 Corrective Exercise Strategy for
Foot and Ankle Impairments

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Introduction
The human body is susceptible to movement dysfunctions and neuromusculoskeletal imbalances. The rea-
sons for this include repetitive movement, overuse, sedentary living, and improper movement techniques.
These dysfunctions, in turn, lead to many of the common injuries seen today.

The foot and ankle complex is a region of the body with great influence on the entire Human Movement
System. This region represents the platform from which our base of support is derived and is the main
contact point between the ground and the body. As such, it must withstand the highest amount of contact
force (ground reaction force) with each step taken, as it is closest to the impact site (heel strike).

If there is movement impairment centralized within the foot and ankle region, it can lead to various symp-
tomatic responses, as seen in Table 8-1. These include plantar fasciitis, Achilles tendonitis, and posterior
tibialis tendonitis (shin splints). As the body is an interconnected chain (kinetic chain), compensation or
dysfunction in one region such as the foot and ankle can and will lead to dysfunctions in other areas of
the body. (1, 2) More proximally, dysfunction for the foot and ankle can also lead to patellar tendonitis
(jumper’s knee), iliotibial band (IT-band) tendonitis (runner’s knee), low back pain, hamstring, quadriceps,
and groin strains, as well as many shoulder and upper-extremity injuries. (Table 8-1)

Table 8-1. Common Injuries Associated with Foot and Ankle Impairment

Local Injuries Proximal Injuries

Plantar fasciitis Patellar tendonitis (jumper’s knee)
Achilles tendonitis IT-band tendonitis (runner’s knee)
Posterior tibialis tendonitis (shin splints) Low back pain
Hamstring, quad, and groin strains

For example, if the foot externally rotates and/or everts during movement, it is generally the collective
motion of the foot/ankle and lower leg. Therefore, the displacement of the foot will likely result in altered
lower leg motion/alignment, which is indicative of overactivity of the lateral gastrocnemius, peroneals,

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short head of the biceps femoris, and/or the tensor fascia lata (TFL), and underactivity of the medial
gastrocnemius, posterior tibialis, medial hamstrings, gracilis, sartorius, popliteus, and/or gluteus medius
and maximus.

Locally, the lateral gastrocnemius, when activated, can externally rotate the lower leg as well as cause
eversion of the calcaneus. The peroneals (longus and brevis), when activated, will evert the foot. The
peroneus longus can cause external rotation as well. Proximally, the short head of the biceps femoris
and the TFL can externally rotate the lower leg because of their attachments to the fibula and tibia,
respectively. When the medial gastrocnemius, posterior tibialis, medial hamstrings, gracilis, sartorius,
popliteus, and/or gluteus medius and maximus cannot be sufficiently activated to counter these actions,
compensation occurs.

This combination of over and underactive muscles can also cause the knee (tibiofemoral joint) to adduct
and internally rotate. The lateral gastrocnemius and biceps femoris each externally rotate the lower leg
relative to the femur and flex the knee. When the knee is flexed and the lower leg is externally rotated
relative to the femur, it produces a lateral displacement (abduction) of the lower leg causing the femur
to internally rotate and adduct. (3) This can be further perpetuated by the TFL, which specifically pro-
duces internal rotation of the femur and external rotation of the lower leg. (3) Collectively, this places
disproportional stress on the patellofemoral and tibiofemoral joints (i.e., patellar tendonitis and general
knee pain). (1, 4)

Overactivity of the TFL can lead to underactivity of the gluteus medius. The flexion and internal rotation
of the hip/femur caused by the TFL places the posterior fibers of the gluteus medius as well as the gluteus
maximus in a lengthened position, which alters the length-tension relationship and decreases recruit-
ment due to altered reciprocal inhibition. (2) In turn, this creates a destabilized lumbo-pelvic-hip complex
(LPHC), which can lead to low back pain, hamstring, quadriceps, and groin strains. (2, 4)

Any alterations in pelvic positioning and stability will directly affect the latissimus dorsi, which attaches
to the pelvis via the thoracolumbar fascia network. (4) The latissimus dorsi has direct influence on the
shoulder region through its attachment to the scapula and humerus and this can lead to many shoulder
and/or cervical injuries.

Each of the typical injuries listed can be problematic for any individual and the reduction in pain or sever-
ity is the focus of many exercise programs. However, these injuries are primarily symptoms representing

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a problem in the Human Movement System. The National Academy of Sports Medicine (NASM) has
developed a systematic corrective exercise strategy to identify and address the problem rather than the
symptoms. This allows the Health and Fitness Professional to develop a safe and effective solution for any
client. The purpose of this text is to demonstrate the corrective exercise strategy specifically for foot
and ankle impairment.

Corrective Exercise Strategy for Foot and Ankle Impairment

Corrective exercise strategies are solutions to identify neuromusculoskeletal dysfunctions within the
Human Movement System. Identification of dysfunction is achieved through an integrated assessment
process, which includes a movement assessment, goniometric measurements, and manual muscle testing
(for those licensed to do so). The integrated assessment process allows the Health and Fitness Professional
to identify the overactive and underactive myofascial tissues. Once the overactive and underactive tissues
are known, the corrective exercise strategy can be developed.

The specific movement impairment that will be discussed in this text is external rotation and/or eversion
of the feet (also known as feet turn out and feet flatten), seen in Figure 8-1.

Figure 8-1. Example of feet turn out and flatten

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Table 8-2. Probable Overactive & Underactive Muscles Accompanying Foot and Ankle

Region Compensation Overactive Underactive

Feet Externally Rotate Soleus Med. Gastrocnemius
(turn out) Lat. Gastrocnemius Med. Hamstring
Biceps Femoris Gracilis / Sartorius
(short head) (Pes Anserine)
Tensor Fascia Lata (TFL) Popliteus
Gluteus Medius/Maximus
Evert Peroneal Complex Anterior Tibialis
(flatten) Lat. Gastrocnemius Posterior Tibialis
Biceps Femoris Med. Gastrocnemius
TFL Gluteus Medius

To ensure clarity and maximal retention of the information, the following section will provide a simplistic
overview of functional anatomy for the pertinent muscles, bones, and joints.

Review of Foot and Ankle Functional Anatomy

As previously stated, the foot and ankle is a complex structure with a great deal of influence on the rest
of the kinetic chain. There are many bones, joints, and muscles that affect dysfunction in the foot and
ankle; however, this section seeks only to provide a general review of the most pertinent structures. This
is not intended to be an exhaustive and detailed review.

Bones and Joints

Looking at the foot and ankle region specifically (Figure 8-2), the phalanges and metatarsals make up
the metatarsophalangeal and tarsometatarsal joints. The tarsal bones, consisting of the navicular, medial,
intermediate, and lateral cuneiforms (transverse arch), and cuboid, along with the talus and calcaneus,
make up the subtalar (talus and calcaneus), talonavicular and calcaneocuboid joints.

Moving up to the lower leg, the tibia and fibula bones form the proximal and distal tibiofibular joints as
well as the talocrural joint (tibia, fibula, and talus), typically collectively called the “ankle” joint.

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Figure 8-2. Bones of the Foot, Ankle and Lower Leg

A=Phalanges; B=Metatarsals; C=Navicular; D=Medial, Intermediate, & Lateral Cuneiform;

E=Cuboid; F=Talus; G=Calcaneus; H=Tibia; I=Fibula

More proximally (Figure 8-3), the patella, femur, and the pelvis, in conjunction with the aforementioned
bones, comprise the tibiofemoral (tibia, femur), patellofemoral (patella, femur) iliofemoral (femur, pelvis)
joints that anchor proximal myofascial tissues. These structures are important in terms of corrective
exercise because they will also have a functional impact on the arthrokinematics of the foot and ankle.

Figure 8-3. Proximal Bones Affecting the Foot and Ankle

A=Tibia & Fibula; B=Patella; C=Femur; D=Pelvis

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Muscles
With all Human Movement System impairments, there are over and underactive muscles which create
an imbalance and lead to injury. The pertinent muscles of the lower leg which are overactive with this
impairment are discussed in Table 8-3 and pictured in Figure 8-4.

Table 8-3. Overactive Muscles of the Lower Leg Accompanying Foot and Ankle Impairment

Isometric –
Muscle Concentric Eccentric
Stabilization
Lateral Plantarflex ankle, evert Foot, ankle, and knee Decelerates ankle
Gastrocnemius calcaneus, externally dorsiflexion, internal rotation
rotate lower leg, and of lower leg, and knee
flex knee extension
Soleus Plantarflex ankle, Foot and ankle Decelerates ankle
externally rotate dorsiflexion, internal rotation
(supinate) lower leg, of lower leg and eversion
and assists in knee of subtalar joint, and knee
extension flexion
Peroneus Evert ankle, plantarflex 1st Metatarsophalangeal Decelerates ankle inversion
Longus ankle joint (MTP) and dorsiflexion

Figure 8-4. Overactive Muscles of the Lower Leg

     
Lateral Gastrocnemius Soleus Peroneus Longus

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The pertinent muscles of the lower leg which are underactive with this impairment are discussed in Table
8-4 and pictured in Figure 8-5.

Table 8-4. Underactive Muscles of the Lower Leg Accompanying Foot and Ankle Impairment.

Isometric – Eccentric
Muscle Concentric
Stabilization
Medial Plantarflex ankle, invert Foot, ankle, and knee Decelerates ankle
Gastrocnemius calcaneus, internally rotate dorsiflexion, external
lower leg, and flex knee rotation of lower leg, and
knee extension
Posterior Plantarflex ankle, externally Foot and ankle Decelerates ankle eversion,
Tibialis rotate (supinate) lower leg, dorsiflexion, and internal
invert foot/ankle rotation of lower leg
Anterior Invert ankle, Foot and ankle Decelerates ankle
Tibialis dorsiflex ankle plantarflexion and eversion

Figure 8-5. Underactive Muscles of the Lower Leg

     
Medial Gastrocnemius Posterior Tibialis Anterior Tibialis

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The overactive muscles of the LPHC affecting the foot and ankle are discussed in Table 8-5 and pictured
in Figure 8-6.

Table 8-4. Overactive Muscles of the LPHC Accompanying Foot and Ankle Impairment

Isometric –
Muscle Concentric Eccentric
Stabilization
Biceps Femoris Externally rotate lower Knee Decelerates internal rotation of
(short head) leg and flex knee lower leg and knee extension
TFL Flex, abduct, and LPHC and knee Decelerates femoral extension,
internally rotate femur adduction and external rotation
(hip), externally rotate of LPHC, and internal rotation
lower leg, and extend of lower leg
knee

Figure 8-6. Overactive Muscles of the LPHC

   
Biceps Femoris (short head) TFL (and IT Band)

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The overactive muscles of the LPHC affecting the foot and ankle are discussed in Table 8-6 and pictured
in Figure 8-7.

Table 8-6. Underactive Muscles of the LPHC Accompanying Foot and Ankle Impairment

Isometric – Eccentric
Muscle Concentric
Stabilization
Medial Hamstrings Flex knee, extend hip, LPHC and knee Decelerates knee extension,
and internally rotate hip flexion, and external
lower leg rotation of lower leg
Gracilis Adduct, internally LPHC and knee Decelerates femoral
rotate, weak flexion abduction, external rotation
of femur, and of lower leg
internally rotate
lower leg
Sartorius Abduct, internally LPHC and knee Adduct, externally
rotate tibia, knee and rotate tibia, knee and hip
hip flexion, and hip extension, and hip internal
external rotation rotation
Popliteus Internally rotate Knee Decelerates external
lower leg (open rotation of lower leg (open
chain), externally chain) and internal rotation
rotate femur (closed of femur (closed chain)
chain), and weak
flexion of knee
Gluteus Medius Abduct, externally LPHC and knee Decelerates femoral (hip)
(posterior fibers) and rotate, and extend adduction, internal rotation,
Gluteus Maximus femur (hip) and flexion

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Figure 8-7. Underactive Muscles of the LPHC

     
Medial Hamstrings Gracilis Sartorius

     
Popliteus Gluteus Medius Gluteus Maximus

Assessment for Foot and Ankle

The first step in developing a corrective exercise strategy is an integrated assessment process. NASM
uses three primary assessments including a movement assessment (Overhead Squat and Single-Leg Squat),
goniometric measurements, and, for the licensed professional, manual muscle testing. Based upon the col-
lective information obtained from these assessments, the over and underactive muscles can be identified.
Table 8-7 shows the probable observations for these assessments relative to foot and ankle impairment.

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Table 8-7. Probable Assessment Observations for Foot and Ankle Impairment

Assessment Observation
Overhead Squat Feet turn out (externally rotate) and flatten (evert)
Single-Leg Squat Feet flatten (evert)
Goniometric Measurement Decreased dorsiflexion (less than 15 degrees) and/or
secondary decrease in the hip flexion 90/90 position
(hamstring, short head of biceps femoris) and/or hip
extension (TFL)
Manual Muscle Testing One or more of the following muscles tested “weak”:
Anterior tibialis, posterior tibialis, medial gastrocnemius,
and/or medial hamstring;
Proximally, the gluteus medius and/or maximus

Corrective Strategies Program Design

Once the over and underactive muscles have been identified, the corrective exercise strategy can be
developed. Table 8-8 shows a sample programming strategy using the corrective exercise continuum for
foot and ankle impairment.

Figure 8-7. Corrective Exercise Continuum

Corrective Exercise Continum

Inhibit Lengthen Activate Integrate

Integration
Inhibitory Lengthening Activation Techniques
Techniques Techniques Techniques
Integrated Dynamic
Self-Myofascial Static Stretching Positional Movement
Release Isometrics
Neuromuscular
Stretching Isolated
Strengthening

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Table 8-8. Sample Corrective Exercise Program for Foot and Ankle Impairment

Phase Modality Muscle(s)/Exercise Acute Variables

Inhibit SMR Lateral gastrocnemius and Hold on tender area for
peroneals 30 sec.
Biceps femoris (short head)

Lengthen Static Stretching Gastrocnemius/soleus 30 sec. hold or 7–10 sec.

or NMS Biceps femoris (short head) isometric contract, 30 sec.
hold

Activate Positional Posterior tibialis 4 reps of increasing

Isometrics Anterior tibialis intensity: 25, 50, 75, 100%
and/or Isolated or
Medial hamstrings
Strengthening 10–15 reps with 2 sec.
Medial Gastrocnemius
isometric hold and 4 sec.
eccentric
Integrate Integrated Dynamic Single-Leg Balance Reach 10–15 reps under control
Movement

*NOTE: If client is not initially capable of performing the Integrated Dynamic Movement
exercise listed, they may need to be regressed to a more suitable exercise.

Figure 8-8A. Inhibit Figure 8-8B. Inhibit

   
Lateral Gastrocnemius and Peroneals Bicep Femoris (short head)

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Figure 8-9A. Lengthen Figure 8-9B. Lengthen

   
Gastrocnemius/Soleus Stretch Bicep Femoris (short head) Stretch

Figure 8-10A. Activate Figure 8-10B. Activate

   
Posterior Tibialis Medial Hamstrings

Figure 8-10C. Activate Figure 8-10D. Activate

   
Anterior Tibialis Medial Gastrocnemius

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Figure 8-11A. Integrate Figure 8-11B. Integrate

   
Single-Leg Balance Single-Leg Balance
START FINISH

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References

1. Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint

dysfunction: A theoretical perspective. J Orthop Sports Phys Ther. 2003;33(11):639–46.

2. Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis, MO:
Mosby; 2002.

3. Vasilyeva LF, Lewit K. Diagnosis of muscular dysfunction by inspection. In: Liebenson C (ed).
Rehabilitation of the Spine. Baltimore: Williams & Wilkins; 1996. p. 113–42.

4. Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Physical Rehabilitation.
St. Louis, MO: Mosby; 2002.

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