Half Kneeling Closed Kinetic Chain Dorsiflexion Test

By  Phil Plisky, PT, DSc, ATC, OCS, CSCS & Adam Devery, ATC, PTA, CSCS 

Ankle sprains are the most prevalent athletic lower extremity injury and many (75%) become recurrent.^1-7 Limited ankle dorsiflexion is a common sequelae after ankle sprain. Researchers have found that limited ankle dorsiflexion (DF) range of motion (ROM) increases ankle and overall lower extremity injury risk.^8-12 

Ankle DF ROM has conventionally been assessed in the open chain position but the reliability is questionable and does not impose the same ankle motion as athletic movement.¹³

Instructions for Closed Kinetic Chain Ankle Dorsiflexion Testing

1. Instruct the athlete to assume a half-kneeling position with shoes off. The front hip and knee of the forward foot should be placed at a 90-degree angle. Be sure that the down knee is far enough forward so that down leg hip extension does not limit the front ankle excursion.
2. AIign the athlete’s foot straight forward with the medial aspect of the foot aligned with the edge of a board or line. 
3. The top of the phone inclinometer is placed two fingers width below the tibial tuberosity on the crest of the tibia
4. With the athlete’s front leg at a 90-degree angle, zero the inclinometer
5. Ask the athlete to bring the knee forward over their 4th and 5th toes as far as possible while keeping their heel on the ground. It is best to palpate the space between the heel and the floor while the athlete is moving forward and note when the heel begins to lift off ground. If it does come up, the athlete is directed to bring the tibia back to place the heel back down and resume dorsiflexion motion until the heel just starts to lift off the ground.
6. The degree measurement is recorded at the maximum forward excursion of the tibia with the heel down.
7.  Measure ankle dorsiflexion 3 times on each leg

Inclinometer App

We recommend and use the Clinometer app and it can be downloaded here

Android  

iPhone  

Ankle CKCDF Passing Criteria

• The passing criteria for ankle half-kneeling closed kinetic chain dorsiflexion is 40 degrees (this is based on normative data in healthy persons). In addition, having decreased ankle dorsiflexion ( below 34 degrees) was identified as being related to having five times greater risk of an ankle sprain in individuals with poor ankle DROM compared to those with normal ankle flexibility.^8-12
• An asymmetry of >5 degrees compared bilaterally is considered an asymmetry and places the person at increased risk of injury. ^11,12

Half-kneeling closed chain dorsiflexion reliability

Half-kneeling closed chain dorsiflexion has shown high reliability interrater reliability of 0.95 (ICC: 0.92 to 0.97) ¹⁵

Other Methods of Measuring Closed Kinetic Chain Dorsiflexion

Ankle Dorsiflexion can also be measured in standing with the knee straight (gastroc emphasis) as well as bent (talocrural joint and soleus emphasis).^16-19 We prefer starting with the half kneeling measurement as it helps us quickly determine that the ankle joint has full mobility which is a more common and problematic dysfunction than gastroc tightness alone.

Ankle Dorsiflexion Screening

You can also screen closed chain dorsiflexion. This screen involves categorizing how far the knee goes forward in relation to the front foot malleolus (in front, within, an behind).  It is important to note that ankle dorsiflexion screen should not be used as a return to sport test. You will want to measure closed chain dorsiflexion with an inclinometer to be certain that the athlete has at least 40 degrees and less than a 5 degree asymmetry. Dr. Kiesel does an excellent job of describing the development of the dorsiflexion screen in the video below.

Validation Studies of Ankle Dorsiflexion Screen

The Dorsiflexion Range of Motion Screen: A Validation Study

The Reliability and Criterion Validity of a Novel Dorsiflexion Range of Motion Screen

Summary of Research Of Closed Chain Dorsiflexion as a Risk Factor for Injury

• Youth basketball athletes showed that an ankle-dorsiflexion ROM < 36.5° was associated with an increased risk of developing patellar tendinopathy during the season.
• Army recruits: ankle-dorsiflexion ROM < 34° was associated with a five-fold risk of suffering a lateral ankle sprain
• Army Rangers: Dorsiflexion asymmetry > 6.5° greater risk of injury
• General Military: >4.5° asymmetry = increased risk
• General military after return to duty >5° asymmetry = increased risk

References

1. Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42(2):311-319.
2. Dick R, Hootman JM, Agel J, et al. Descriptive epidemiology of collegiate women's field hockey injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2002-2003. J Athl Train. 2007;42(2):211-220.
3. Lemoyne J, Poulin C, Richer N, et al. Analyzing injuries among university-level athletes: prevalence, patterns and risk factors. J Can Chiropr Assoc. 2017;61(2):88-95.
4. Almeida SA, Williams KM, Shaffer RA, et al. Epidemiological patterns of musculoskeletal injuries and physical training. Med Sci Sports Exerc. 1999;31(8):1176-1182.
5. McKay GD, Goldie PA, Payne WR, et al. Ankle injuries in basketball: injury rate and risk factors. Br J Sports Med. 2001;35(2):103-108.
6. Nelson AJ, Collins CL, Yard EE, et al. Ankle injuries among United States high school sports athletes, 2005-2006. J Athl Train. 2007;42(3):381-387.
7. Cloke DJ, Spencer S, Hodson A, et al. The epidemiology of ankle injuries occurring in English Football Association academies. Br J Sports Med. 2009;43(14):1119-1125.
8. Malliaras P, Cook JL, Kent P. Reduced ankle dorsiflexion range may increase the risk of patellar tendon injury among volleyball players. J Sci Med Sport. 2006;9(4):304-309.
9. Pope R, Herbert R, Kirwan J. Effects of ankle dorsiflexion range and pre-exercise calf muscle stretching on injury risk in Army recruits. Aust J Physiother. 1998;44(3):165-172.
10. Gabbe BJ, Finch CF, Wajswelner H, et al. Predictors of lower extremity injuries at the community level of Australian football. Clin J Sport Med. 2004;14(2):56-63.
11. Teyhen DS, Shaffer SW, Butler RJ, Goffar SL, Kiesel KB, Rhon DI, Plisky PJ. Identification of Risk Factors Prospectively Associated with Musculoskeletal Injury in a Warrior Athlete Population. Sports Health. 2020. Nov/Dec;12(6):564-572
12.  Teyhen DS, Shaffer SW, Butler RJ, Goffar SL, Kiesel KB, Rhon DI, Williamson JN, Plisky PJ. What Risk Factors Are Associated With Musculoskeletal Injury in US Army Rangers? A Prospective Prognostic Study. Clin Orthop Relat Res. 2015 Sep;473(9):2948-58. 
13.   Martin RL, McPoil TG. Reliability of ankle goniometric measurements: a literature review. J Am Podiatr Med Assoc. 2005;95(6):564-572.
14. Gourlay J,  Bullock G, Weaver A, Matsel K, Kiesel KB, Plisky PJ. The Reliability and Criterion Validity of a Novel Dorsiflexion Range of Motion Screen. Athletic Training and Sports Health Care. 2019
15. Plisky PJ, Bullock GS, Garner MB, et al. The Dorsiflexion Range of Motion Screen: A Validation Study. IJSPT. 2021;16(2):306-311.
16. Bennell KL, Talbot RC, Wajswelner H, et al. Intra-rater and inter-rater reliability of a weight-bearing lunge measure of ankle dorsiflexion. Aust J Physiother. 1998;44(3):175-180.
17. Munteanu SE, Strawhorn AB, Landorf KB, et al. A weightbearing technique for the measurement of ankle joint dorsiflexion with the knee extended is reliable. J Sci Med Sport. 2009;12(1):54-59.
18. Konor MM, Morton S, Eckerson JM, et al. Reliability of three measures of ankle dorsiflexion range of motion. Int J Sports Phys Ther. 2012;7(3):279-287.
19. O'Shea S, Grafton K. The intra and inter-rater reliability of a modified weight-bearing lunge measure of ankle dorsiflexion. Man Ther. 2013;18(3):264-268.

20. Backman Ludvig J., Danielson Patrik. The American Journal of Sports Medicine. 12. Vol. 39. SAGE Publications; Low range of ankle dorsiflexion predisposes for patellar tendinopathy in junior elite basketball players; pp. 2626–2633

21. Effects of ankle dorsiflexion range and pre-exercise calf muscle stretching on injury risk in Army recruits. Pope Rodney, Herbert Rob, Kirwan John. 1998Australian Journal of Physiotherapy. 44(3):165–172. doi: 10.1016/s0004-9514(14)60376-7. doi: 10.1016/s0004-9514(14)60376-7. 

Co-author Information

Adam Devery, ATC, PTA, CSCS