What are the causes and treatments of limited dorsal flexion?

Limited Dorsal Flexion: Causes and Treatment

Primary Causes

Limited ankle dorsiflexion is most commonly caused by gastrocnemius/soleus tightness, previous ankle sprains with residual ligament changes, and structural ankle joint restrictions. 1

Intrinsic Risk Factors

• Reduced ankle dorsiflexion range of motion is a documented risk factor for lateral ankle ligament injuries, creating a cycle where limited dorsiflexion predisposes to ankle sprains, which further restricts motion 1
• Proprioceptive deficits frequently accompany limited dorsiflexion and compound injury risk 1
• Previous ankle distortions are the strongest predictor of developing chronic dorsiflexion limitations 1

Biomechanical Consequences

• Every 1° reduction in clinical dorsiflexion ROM produces 1.2° less peak knee flexion and 0.9° less knee flexion excursion during landing, forcing compensatory movement patterns up the kinetic chain 2
• Limited dorsiflexion causes increased knee valgus angles (3.2° increase per 10% underutilization of available ROM) and medial knee displacement during functional activities 2, 3
• Restricted dorsiflexion increases soleus muscle activation by 64% during squatting while decreasing quadriceps activation by 20-33%, altering normal muscle recruitment patterns 3

First-Line Treatment: Supervised Exercise Therapy

Supervised exercise therapy focusing on proprioception, strength, and functional training is the most effective treatment for chronic ankle instability and limited dorsiflexion. 4

Specific Exercise Protocol

• Begin with active dorsiflexion and plantarflexion exercises (3 sets of 10 repetitions), progressing to resistance band exercises in all four directions (dorsiflexion, plantarflexion, inversion, eversion) 4
• Implement ankle disk or wobble board exercises for proprioceptive training, progressing from bilateral to single-leg stance on unstable surfaces 4
• Include strengthening of both ankle and hip muscles, as hip weakness contributes to compensatory movement patterns when dorsiflexion is limited 4
• Continue the full 4-6 week rehabilitation program even after pain subsides, as premature discontinuation increases recurrent injury risk 4

Manual Therapy Adjunct

• Combine manual joint mobilization with exercise therapy for superior outcomes compared to exercise alone, particularly for short-term increases in dorsiflexion ROM and pain reduction 4
• Manual mobilization should target the talocrural joint with posterior glides of the talus to improve dorsiflexion mechanics 4

Functional Support During Rehabilitation

Use semirigid or lace-up ankle supports rather than elastic bandages for 4-6 weeks during activities. 4

• Functional support allows controlled movement while providing stability, unlike rigid immobilization which leads to poorer outcomes when used beyond 10 days 4
• Elastic bandages and compression wraps alone are less effective than structured ankle supports 4

Addressing Functional Neurological Components

When limited dorsiflexion occurs in the context of functional dystonia or movement disorders:

• Encourage optimal postural alignment and even weight distribution in sitting, standing, and walking to normalize movement patterns 1
• Avoid prolonged positioning at end-range ankle flexion, which can exacerbate dystonic posturing 1
• Grade activities to progressively increase affected limb use with normal movement techniques 1
• Implement muscle relaxation strategies and support the limb at rest using pillows or furniture to reduce overactivity 1

Surgical Intervention

Reserve surgical therapy exclusively for patients who have failed comprehensive exercise-based physiotherapy after 4-6 months. 4

• Surgery demonstrates superiority for decreasing recurrent ankle sprain prevalence and improving ankle activity scores compared to conservative treatment alone in refractory cases 4
• Surgical options typically address underlying ligament laxity or structural restrictions that prevent adequate dorsiflexion 4

Critical Pitfalls to Avoid

• Never rely solely on passive stretching without addressing proprioceptive deficits, as reduced proprioception is an independent risk factor that must be corrected 1
• Avoid prolonged immobilization exceeding 10 days, which consistently produces worse functional outcomes than early mobilization 4
• Do not neglect proximal muscle strengthening—limited dorsiflexion creates compensatory hip and knee biomechanics that require targeted intervention 2
• Patients must utilize their available dorsiflexion ROM during functional activities, as underutilization (even with adequate passive ROM) produces high-risk movement patterns including increased knee valgus 2
• Returning to full sports participation before completing 4-6 weeks of structured rehabilitation significantly increases reinjury rates 4

Special Considerations for Incline Activities

• Individuals with limited dorsiflexion require 3.4-12.2° greater tibialis anterior activation during swing phase and significantly increased soleus activation during stance when walking on inclines of 10° or greater 5
• Prolonged incline walking may accelerate muscle fatigue and tissue damage in those with restricted dorsiflexion, necessitating gradual progression of sloped surface training 5