ARTICLE IN PRESS

Physical Therapy in Sport 7 (2006) 93–100

www.elsevier.com/locate/yptsp

Original research

Effects of gastrocnemius stretching on ankle dorsiflexion and time-to

heel-off during the stance phase of gait
Marie A. Johansona,, Michael Woodena,b, Pamela A. Catlina, Leanne Hemarda,
Kristina Lotta, Robert Romalinoa, Tamara Stillmana
a
Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, USA
b
Physiotherapy Associates, Tucker, GA, USA
Received 9 August 2005; received in revised form 26 January 2006; accepted 22 February 2006

Abstract

Objectives: The purpose was to determine the effects of a gastrocnemius stretching program on passive ankle dorsiflexion range of
motion and ankle dorsiflexion and time-to-heel-off during the stance phase of gait.
Design: This study was a randomized-control trial design.
Setting: The study was conducted in a biomechanical laboratory setting.
Participants: Nineteen volunteers (17 women and 2 men, mean age ¼ 30.3 years; SD ¼ 9.8 years), with less than 81 of passive ankle
dorsiflexion range of motion bilaterally and a history of lower extremity overuse injury were randomly assigned to the experimental
(n ¼ 11) or control group (n ¼ 8).
Intervention: The experimental group participated in a static gastrocnemius stretching program of five repetitions held for 30-s, two
times daily, for 3 weeks. The control group received no intervention.
Main outcome measures: Passive ankle dorsiflexion range of motion and ankle dorsiflexion and time-to-heel-off during the stance
phase of gait were measured before and after the intervention.
Results: The experimental group had significantly greater passive dorsiflexion range of motion at post-test than the control group
on both the right (p ¼ 0.000) and left (p ¼ 0.002) sides. Ankle dorsiflexion and time-to-heel-off during the stance phase of gait were
not different among group, time, or foot (p40.05).
Conclusions: A gastrocnemius stretch performed two times daily, for 3 weeks increased passive ankle dorsiflexion, but did not alter
ankle dorsiflexion or time-to-heel-off during the stance phase of gait. Thus, when an increase in ankle dorsiflexion or time-to-heel-off
during the stance phase of ambulation is a clinical goal, it is unlikely to result from the stretching regimen used in this study.
r 2006 Elsevier Ltd. All rights reserved.

Keywords: Gastrocnemius muscle stretching; Ankle dorsiflexion; Gait analysis

1. Introduction contributes to forward body movement (Norkin &

The ankle joint dorsiflexes 8–101 beyond neutral
during the stance phase of ambulation (Murray, Kory,
Clarkson, & Sepic, 1966; Norkin & Levangie, 2001;
Wright, Desai, & Henderson, 1964). Normal gait
requires tibial advancement over the foot, which
Corresponding author. 1441 Clifton Rd, Suite #170, Atlanta, GA
30322, USA, Tel.: +1 404 727 6581; fax: +1 404 712 4130.
E-mail address: majohan@emory.edu (M.A. Johanson).
Levangie, 2001; Subotnick, 1971). Limited ankle joint
dorsiflexion has been associated with many overuse
injuries of the lower extremity including plantar fasciitis
(Kibler, Goldberg, & Chandler, 1991; Riddle, Pulisic,
Pidcoe, & Johnson, 2003; Warren & Davis, 1988), achilles
tendonopathy (Kaufman, Brodine, Shaffer, Johnson, &
Cullison, 1999; Kvist, 1991; Paavola et al., 2002; Warren
& Davis, 1988; Wilder & Sethi, 2004), shin splints
(Lilletvedt, Kreigheaum, & Phillips, 1979; Messier &
Pittala, 1988), iliotibial band syndrome (Messier &

1466-853X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ptsp.2006.02.002
 ARTICLE IN PRESS
94 M.A. Johanson et al. / Physical Therapy in Sport 7 (2006) 93–100

Pittala, 1988), and patellofemoral pain syndrome (Lun, dorsiflexion and time-to-heel-off during the stance phase
Meeuwisse, Stergiou, & Stefanyshyn, 2004). of gait were taken before and after a 3-week, gastro-
Limited ankle dorsiflexion may decrease the amount of cnemius stretching program. The subjects were ran-
ankle dorsiflexion before heel-off and decrease time-to- domly assigned to a control group (n ¼ 8) or an
heel-off during gait (Cornwall & McPoil, 1999; Donatelli experimental group (n ¼ 11). The order of measure-
& Wooden, 1996; Selby-Silverstein, Farrett, Maurer, & ments were randomly sequenced, first by order of static
Hillstrom, 1997; Subotnick, 1971; Tiberio, 1987). Gastro- and dynamic measurements, then within static measure-
cnemius muscle tightness limits ankle dorsiflexion range of ments, and finally, by foot. The same random sequence
motion (Kibler et al., 1991; Riemann, DeMont, Ryu, & of measurements was used at both pre- and post-test
Lephart, 2001; Wooden, 1996). Therefore, when clinicians sessions per subject.
determine that the gastrocnemius muscle is tight they
commonly prescribe gastrocnemius stretching exercises to
2.2. Subjects
prevent or treat overuse injuries (Cornwall & McPoil,
1999; Davis, Cooper, & Garbalosa, 1996; Kibler et al.,
Convenience sampling was used to recruit two men
1991; Riemann et al., 2001). Gastrocnemius stretching to
and 17 women (mean age ¼ 30.3 years; SD ¼ 9.8 years).
increase passive ankle dorsiflexion range of motion
The study was approved by the Institutional Review
theoretically increases ankle dorsiflexion range of motion
Board of Emory University and all subjects signed an
before heel-off and increases time-to-heel-off during the
informed consent form prior to participation. Eligibility
stance phase of gait (Cornwall & McPoil, 1999; Donatelli
criteria included: history of one or more diagnosed
& Wooden, 1996; Selby-Silverstein et al., 1997). However,
lower extremity overuse syndrome(s) within the past 2
evidence as to the mechanism by which gastrocnemius
years (Table 1); aged 18–50 years; less than 81 of passive
muscle stretching to increase ankle dorsiflexion may
ankle dorsiflexion range of motion bilaterally when
prevent or treat lower extremity overuse injuries is lacking.
measured non-weight bearing in the subtalar neutral
Knowledge of gait parameters affected by gastrocnemius
position (Wooden, 1996); a neutral or varus forefoot
stretching to increase ankle dorsiflexion may assist
position bilaterally; greater than 41 valgus standing calf-
clinicians in identifying which patients may most benefit
to-calcaneal angle bilaterally; leg length discrepancy of
from this intervention.
less than 1 cm; no pain in the lower extremities during
Increasing ankle dorsiflexion and time-to-heel-off
walking; no history of neurological dysfunction or
during the stance phase of gait reduces the time of
disease, systemic disease affecting the lower extremities
weight bearing solely on the forefoot (Donatelli &
or ambulation, macrotrauma involving bone or nerve
Wooden, 1996; Selby-Silverstein et al., 1997), which
injury to the lower extremity, or musculoskeletal soft
hypothetically eases stress to tissues involved in some
tissue injury to the lower extremity within 6 months of
patients’ lower extremity overuse conditions. In theory,
participation in the study. Passive ankle joint dorsiflex-
increasing ankle dorsiflexion may also reduce the
ion range of motion measured in non-weight bearing of
dorsiflexion that is a component of compensatory
less than 81 was chosen as an eligibility criteria because
pronation at the subtalar and midtarsal joints related
most of the normative data on normal ankle dorsiflexion
to restricted dorsiflexion at the talo-crural joint (Dona-
range of motion has been reported using a non-weight
telli & Wooden, 1996; Karas & Hoy, 2002). Subtalar
bearing position and less than 81 is below that reported
joint pronation unlocks the midtarsal joint, resulting in
as normal.
dorsiflexion at that joint (Subotnick, 1971), as well as
plantarflexion of the talus (Norkin & Levangie, 2001).
Midtarsal joint dorsiflexion and increased talar plantar-
flexion both allow increased anterior tibial progession
relative to the foot during stance. The purpose of this Table 1
study was to ascertain the effects of gastrocnemius Number and type of subjects’ diagnosed lower extremity overuse
injuries
stretching on passive ankle dorsiflexion and ankle
dorsiflexion and time-to-heel-off during the stance phase Lower extremity overuse injury Frequency Percentagea
of gait in subjects with limited dorsiflexion.
Plantar fasciitis 7 37
Achillis tendonopathy 5 26
Shin splints 4 21
2. Methods Patellofemoral syndrome 3 16
Iliotibial band friction syndrome 3 16
2.1. Design Metatarsalgia 1 5
a
Total percentage greater than 100% as some subjects with a history
This study was a randomized-control trial design. of more than one diagnosed lower extremity overuse injury within 2
Passive ankle dorsiflexion range of motion and ankle years of participation in study.
 ARTICLE IN PRESS
M.A. Johanson et al. / Physical Therapy in Sport 7 (2006) 93–100 95

2.3. Measurements and instrumentation

Active ankle dorsiflexion range of motion, passive

ankle dorsiflexion range of motion with the subtalar
joint positioned in neutral and the knee joint extended,
and forefoot position in non-weight bearing were
measured three times each using standard goniometric
procedures with the subject in the prone position
(Diamond, Mueller, Delitto, & Sinacore, 1989; Smith-
Orichio & Harris, 1990; Wooden, 1996), averaged, and
recorded in degrees. The above measures were taken
bilaterally in random order, at both the pre- and post-
test sessions. The passive ankle joint dorsiflexion
measurement was taken with the subject positioned in
prone and the knee extended in the method described by
Wooden (1996). The axis of a standard 8-inch plastic
goniometer (Benchmark Medical, Inc., Malvern, PA,
USA) was placed over the lateral calcaneus, the
stationary arm was aligned with the fibular head and
the moving arm was aligned over the fifth metatarsal.
Passive force was applied through the plantar aspect of
the midfoot and forefoot while maintaining the subtalar
joint in approximate neutral until firm resistance to
further movement was encountered. For the passive
ankle dorsiflexion measurement the anatomical position
of the ankle joint was considered 01. Fig. 1. Placement of reflective markers.
Leg length was determined during the pre-test session
by measuring the distance in centimeters from the Velcro straps to the lateral aspect of the calf (Fig. 1).
anterior superior iliac spine to the ipsilateral lateral The center of the Velcro strap on the calf was placed at a
malleolus with a tape measure with the subject supine point midway along a line connecting the fibular head
(Woerman & Binder-Macleod, 1984). and the lateral malleolus.
Calf-to-calcaneal angle was measured (in degrees) Prior to data collection sessions, the Qualisys motion
with the subject in relaxed standing on an elevated analysis system was calibrated using known distances
walkway (Jonson & Gross, 1997). Sliding calipers between reflective markers on a wand and L-shaped bar
(Innovation Sports, Inc., Foothill Ranch, CA, USA) to establish a 3-D coordinate system for three cameras
were used to identify midpoints on the posterior calf and (Qualisys, Incorporated, 2000). The calibration was
calcaneus, and lines were drawn longitudinally bisecting accepted if the range of the wand length was less than
the posterior calf and calcaneus (Selby-Silverstein et al., 5.0 mm and standard deviation of the wand length was
1997). Calf-to-calcaneal angle was measured with a less than 2.0 mm. All walking trials were recorded with
goniometer as the angle between the vertical midline of the three cameras set at a frequency of 100 Hz.
the calf and the vertical midline of the calcaneus. Ankle dorsiflexion and time-to-heel-off measurements
Ankle dorsiflexion and time-to-heel-off during the were taken as the subject walked across an elevated
stance phase of gait were measured using the Qualisis walkway in bare feet at a self-selected speed. First, the
motion analysis system (Qualisys, Incorporated, 2000) subject walked until the subject reported feeling
and custom software. The Qualisis motion analysis comfortable and appeared comfortable to the research-
system was used to establish a 3-D coordinate system, ers. The subject then walked the length of the walkway
track markers, and calculate time-to-heel-off. Custom until eight trials per leg were successfully recorded. A
software in Labview (National Instruments Corpora- successful recording was defined as a trial in which all
tion, Austin, TX, USA) and Matlab (The Mathworks, three cameras recorded all markers from 10 frames prior
Natick, MA, USA) was then used to smooth and plot to heel-strike through 10 frames following toe-off. Heel-
the data and calculate 2-D ankle angles. strike was defined as the first frame in which the lateral
Reflective markers were placed on the dorsum of the calcaneus marker ceased to move forward. Toe-off was
first metatarsal head, on the lateral aspect of the fifth defined as the first frame in which the marker on the first
metatarsal just proximal to the metatarsal head, on the metatarsal head began to move upward. The marker
lateral malleolus, and on the inferior aspect of the lateral paths were tracked in PCReflex software (Qualisys,
calcaneus (Fig. 1). Three markers were attached with Incorporated, 2000).
 ARTICLE IN PRESS
96 M.A. Johanson et al. / Physical Therapy in Sport 7 (2006) 93–100
Fig. 2. Gastrocnemius muscle stretching exercise.
Time-to-heel-off was calculated (in milliseconds) in
PCReflex software by determining frame time at heel-off
and at heel-strike and then subtracting the second value
from the first. Heel-off was defined as the first frame in
which the lateral calcaneus marker began to move
upward. Time-to-heel-off was then divided by stance
time to measure time-to-heel-off as a percentage of
stance time. The tracked data then were exported and
custom software in Labview smoothed the marker paths
retaining 97% of the signal energy. Custom software in
Matlab was then used to plot sagittal plane ankle angles
and calculate the greatest dorsiflexion angle, using the
distal marker on the calf, the marker on the lateral
malleolus, and the marker on the fifth metatarsal head
(Fig. 1). The marker on the lateral malleolus (rather
than the marker on the lateral calcaneus) was used for
this calculation because of expected greater consistency
of marker placement. The custom software in Matlab
identified a right angle formed between the markers on
the lateral calf, lateral malleolus, and fifth metatarsal as
901; greater motion in the direction of dorsiflexion
would be indicated by lesser degrees. The first four trials
of each side that were successfully tracked in PCReflex
software from 10 frames prior to heel-strike through 10
frames following toe-off were used in the data analysis.
Ankle dorsiflexion from these four trials were averaged
and the angle recorded in degrees. A second examiner
took passive gomiometric and time-to-heel-off measure-
ments on every fourth subject to assess interrater
reliability.
Subjects assigned to the experimental group were
instructed in the gastrocnemius stretching program. The
intervention consisted of five repetitions of a 30-s,
passive gastrocnemius stretch with a 5-s rest period
between each of the five repetitions (Fig. 2), performed
two times daily. The subject sat on the floor with their
back against the wall, and with the knee extended on the
floor and the contralateral leg bent in a comfortable
position. The subject held each end of a towel and
placed it around the ball of the foot. The subject then
pulled the towel toward their trunk until slight
discomfort was noted in the posterior calf, for 30 s,
while maintaining the subtalar joint in approximate
neutral by keeping the foot centered between pronation
and supination. The procedure was performed five times
on each leg. We chose this position to allow the subject
to observe their foot to more easily maintain the
subtalar joint in approximate neutral. The subject
received instruction until independently demonstrating
the stretch. Next, the subject was instructed to record
stretching sessions on a log sheet for the following 3-
week period to document compliance. Compliance was
defined as participation in a minimum of 36 stretching
sessions. We chose the parameters and duration of the
stretching exercise based on previous research on
stretching of the gastrocnemius and hamstring muscle
groups (Bandy & Irion, 1994; Worrell, McCullough, &
Pfeiffer, 1994). Subjects in the control group were
instructed to continue all of their usual activities but
to refrain from beginning new activities until after the
second testing session.
At the completion of the first session, all subjects were
scheduled for the post-test data collection session 3
weeks later. Experimental subjects were called after 3
 ARTICLE IN PRESS
M.A. Johanson et al. / Physical Therapy in Sport 7 (2006) 93–100 97

days, and weekly thereafter, to address any difficulties
with the stretching program, and to encourage com-
pliance.
At the post-test session, the log sheets of experimental
subjects were assessed for compliance and activity level
was reassessed for any changes since the pre-test. The
sequence of measurements during the post-test was
identical to that determined at the pre-test.
2.4. Data analysis
Passive goniometric measurements and measurements
during gait were summarized across subjects with
means, standard deviations, and minimum and max-
imum values at pre- and post-test per group. Normality
of distribution and homogeneity of variance of the static
and dynamic variables were assured using the Shapiro–
Wilk test and Bartlett’s test, respectively. An alpha level
of 0.05 was set for all statistical tests. Intraclass
correlation coefficients (ICC) were used to assess
intrarater and interrater reliability (Portney & Watkins,
2000).
Passive ankle dorsiflexion range of motion and ankle
dorsiflexion and time-to-heel-off during the stance phase
of gait were compared among group (experimental and
control), time (pre- and post-test), and foot (right and
left) using a three-way, repeated measures, analysis of
variance (ANOVA). Time and foot were the repeated
factors. Independent t-tests were used for all post hoc
comparisons using a Bonferroni procedure (the alpha
level of .05 was divided by the number of t-tests
conducted per dependent variable) to control for Type
I error across multiple tests.
3. Results
Descriptive analysis of passive dorsiflexion range of
motion and ankle dorsiflexion and time-to-heel-off
during the stance phase of gait are summarized in
Table 2. ICC were as follows: intrarater ICC (3,3)
goniometric measurements 40.81; interrater ICC (3,3)
goniometric measurments 40.76 except for ankle
dorsiflexion active range of motion which was 40.51;
intrarater ICC (3,4) for ankle dorsiflexion during the
stance phase of gait 40.84; intrarater ICC (3,4) for
time-to-heel-off 40.72; and interrater ICC (3,4) for
time-to-heel-off 40.70. Due to low reliability, active
ankle dorsiflexion range of motion was omitted from
further data analysis.
Three of the subjects in the experimental group did
not meet the definition of compliance (completion of at
least 36 of 42 stretching sessions). These three subjects
completed 24, 33, and 35 of the 42 stretching sessions.
The percent change in static dorsiflexion was compared
between the compliant subjects and the three non-
compliant subjects using a two-tailed, independent t-test
for each lower extremity. The percent change in passive

Table 2
Mean, standard deviation (SD), minimum and maximum (Min–Max) values of dependent variables for the control group and experimental group at
pre- and post-test

Variable Pre-test Post-test

Mean SD Min–Max Mean SD Min–Max

Passive ankle dorsiflexion (deg)

Control
Left 3.42 1.27 2.00–5.67 2.96 1.05 2.0–4.67
Right 3.54 1.77 1.33–5.67 4.38 1.72 1.33–7.0
Experimental
Left 3.67 2.00 1.00–8.00 6.88 2.17 3.33–10.33
Right 3.08 2.53
2.00–8.33 8.65 2.70 3.00–13.67
Ankle dorsiflexion during stance (deg)
Control
Left 104.95 8.92 91.83–119.66 105.77 5.60 93.78–110.26
Right 101.63 6.59 92.80–113.58 101.87 4.57 96.35–109.29
Experimental
Left 107.76 5.28 100.95–121.06 108.01 5.00 99.53–119.06
Right 103.46 4.57 96.25–110.51 105.45 7.99 94.18–119.29

Time-to-heel-off (percentage of stance)

Control
Left 0.68 0.04 0.63–0.74 0.68 0.04 0.63–0.77
Right 0.66 0.07 0.54–0.77 0.68 0.07 0.53–0.77
Experimental
Left 0.66 0.08 0.47–0.79 0.65 0.07 0.58–0.76
Right 0.65 0.05 0.56–0.71 0.64 0.08 0.44–0.73
 ARTICLE IN PRESS
98 M.A. Johanson et al. / Physical Therapy in Sport 7 (2006) 93–100
dorsiflexion was calculated by subtracting the pre-test
value from the post-test value and dividing the residual
by the pre-test value. The percent change in static
dorsiflexion was not different (p40.05) between the
compliant and non-compliant exercise groups; therefore,
the compliant and non-compliant subjects were combined
in subsequent analyzes. One subject in the experimental
group and one in the control group had increased
running mileage since the pre-test; all other subjects had
not changed any of their usual exercise activities.
Passive ankle dorsiflexion range of motion in the
experimental group was significantly different than the
control group (F ¼ 24.10, df ¼ 1,17, p ¼ 0.000) and
significantly greater at post-test than pre-test (F ¼ 24.87,
df ¼ 1,17, p ¼ 0.000). There was no significant differ-
ence between the experimental and control groups at
pre-test for either foot (p40.0125) but the experimental
group had significantly greater passive dorsiflexion at
post-test for both the right and left feet (t ¼
6.106,
df ¼ 17, p ¼ 0.000) and (t ¼
6.971, df ¼ 17, p ¼ 0.000,
respectively). Ankle dorsiflexion and time-to-heel-off
during the stance phase of gait were not different among
group, time, or foot (p40.05).
4. Discussion
A gastrocnemius muscle stretching program for 3
weeks was effective in increasing passive ankle dorsi-
flexion range of motion, but the increase in passive
dorsiflexion was not related to an increase in ankle
dorsiflexion or time-to-heel-off during gait. The increase
in passive dorsiflexion is consistent with findings of
Selby-Silverstein et al. (1997), Wessling, DeVane, and
Hylton (1987), and Worrell et al. (1994) for which
passive, gastrocnemius stretching, of 20-, 1-min, and 20-
s durations, respectively, increased dorsiflexion range of
motion. The increase is also consistent with the studies
on hamstring stretching, which suggest that a 30-s
stretch duration is effective in increasing muscle
extensibility (Bandy & Irion, 1994).
Lack of increase in ankle dorsiflexion during gait fail
to support Selby-Silverstein et al.’s (1997) single-case
study, which demonstrated concomitant increases in
passive ankle dorsiflexion range of motion and ankle
dorsiflexion during stance. However, Selby-Silverstein
et al.’s subject exhibited
20.01 of passive dorsiflexion,
which increased to 5.01 following stretching. The
experimental group in this study initially exhibited an
average of 3.51 of passive dorsiflexion, which increased
to 6.91 on the left and 8.71 on the right following
stretching. The experimental subjects’ passive ankle
dorsiflexion range of motion may have been adequate
for anterior tibial progression during the stance phase of
gait (Cornwall & McPoil, 1999; Jordan, Cooper, &
Schuster, 1979).
Increased flexibility of the gastrocnemius muscle
theoretically allows increased dorsiflexion at the talo-
crural joint (Donatelli, 1996; Karas & Hoy, 2002;
Tiberio, 1987). However, pronation of the subtalar joint
allows dorsiflexion to occur at the midtarsal joint
(Donatelli, 1996; Karas & Hoy, 2002; Selby-Silverstein
et al., 1997). Our measurement techniques controlled
subtalar pronation, and therefore dorsiflexion, at the
midtarsal joint during the measurement of passive ankle
dorsiflexion range of motion (Tiberio, 1987), but not
during ankle dorsiflexion during the stance phase of
gait. Because the location of the foot marker on the head
of the fifth metatarsal is distal to the midtarsal joint, the
Qualisys motion analysis system could not distinguish
talocrural joint dorsiflexion from midtarsal joint dorsi-
flexion. Stretching the gastrocnemius could have re-
sulted in more dorsiflexion at the talocrural joint and
less at the midtarsal joint, without altering the absolute
values of ankle dorsiflexion during gait.
The measurement of ankle dorsiflexion during stance
used in this study differs from that often used in gait
analysis. We used an angle of reference that was formed
by the distal calf, lateral malleolus, and fifth metatarsal
markers, and consequently values of dorsiflexion during
gait (for which smaller values represent greater degrees
of dorsiflexion) and passive ankle dorsiflexion values
were not similar. We chose the marker on the lateral
malleolus because we believed we could obtain more
consistent placement of this marker between pre- and
post-test sessions than if we had used a marker on the
lateral calcaneus. The marker placement used to
calculate the ankle angle in the sagittal plane in many
previous studies is similar to the sagittal ankle angle
measured with a goniometer. The present method
allowed us to determine whether a change occurred,
but it is difficult to compare the absolute ankle
dorsiflexion values during gait with the absolute values
obtained from the goniometric measurement of passive
ankle dorsiflexion.
Both the experimental and control subjects exhibited
time-to-heel-off of about two-thirds of stance time
which is consistent with that of normal individuals
(Oatis, 2004). In a previous study, restricted passive
ankle dorsiflexion range of motion was associated with
earlier heel-off during gait (Cornwall & McPoil, 1999).
Cornwall and McPoil (1999) reported subjects with
passive ankle dorsiflexion of greater than 151 had longer
time-to-heel-off than subjects with less than 101 of
passive dorsiflexion, yet dorsiflexion during the stance
phase of gait relative to relaxed standing was no
different. Since theoretically, ankle dorsiflexion and
time-to-heel-off would be expected to be associated, this
finding was surprising. Cornwall and McPoil used self-
selected speed of gait so it is possible that the subjects
with passive ankle dorsiflexion of greater than
151 ambulated more slowly overall, than those with
 ARTICLE IN PRESS
M.A. Johanson et al. / Physical Therapy in Sport 7 (2006) 93–100
dorsiflexion less than 101. Our subjects also ambulated
at a self-selected speed, so this could have affected our
results as well. However, we compared stance time
between pre- and post-testing sessions and between the
experimental and control groups and found no sig-
nificant difference (p40.05) so walking speed was
unlikely to have been a major factor in this study.
Future research on a sample of subjects with greater
limitations in passive dorsiflexion range of motion may
further illuminate a potential association between
passive dorsiflexion and dorsiflexion during walking.
Assessing the effect of increases in passive dorsiflexion
on the kinematics of activities that require more
dorsiflexion range of motion than walking, such as
running or walking uphill, would be useful.
Limitations of this study include the method of
measurement of ankle dorsiflexion during gait which
could not differentiate between dorsiflexion at the talo-
crural joint from dorsiflexion at the subtalar or midtarsal
joints. Additionally, the error associated with calculation
of 2-D joint angles based on 3-D data could have affected
the findings of this study. The investigators performing
the assessments and analyzing the data were not blinded
to the group assignment of subjects. Finally, though there
was no mean increase in ankle dorsiflexion in the
experimental group on the post-test compared to the
pre-test, the low number of subjects resulted in a low
power to detect differences between groups.
5. Conclusions
In this study, a gastrocnemius stretching program
over 3 weeks increased passive ankle dorsiflexion range
of motion, but did not increase ankle dorsiflexion or
time-to-heel-off during the stance phase of gait.
Clinicians should question whether mild limitations in
passive ankle joint dorsiflexion range of motion affect
ankle kinematics during ambulation.
Acknowledgements
The authors thank Thomas Abelew, Ph.D., for technical
expertize and Paul Weiss, MS, for statistical analyzes.
Conflict of interest statement: We affirm that we have no
financial affiliation (including research funding) or
involvement with any commercial organization that
has a direct financial interest in any matter included in
this manuscript.
References
Bandy, W. D., & Irion, J. M. (1994). The effect of time and frequency
of static stretching on flexibility of the hamstring muscles. Physical
Therapy, 74, 845–852.
99
Cornwall, M. W., & McPoil, T. G. (1999). Effect of ankle dorsiflexion
range of motion on rearfoot motion during walking. Journal of the
American Podiatric Medical Association, 89, 272–277.
Davis, K. E., Cooper, J., & Garbalosa, J. C. (1996). Physical therapy.
In R. A. Donatelli (Ed.), The biomechanics of the foot and ankle
(2nd ed., pp. 280–323). Philadelphia: FA Davis Company.
Diamond, J. E., Mueller, M. J., Delitto, A., & Sinacore, D. R. (1989).
Reliability of a diabetic foot evaluation. Physical Therapy, 69, 797–
802.
Donatelli, R. A. (1996). Abnormal biomechanics. In R. A. Donatelli
(Ed.), The biomechanics of the foot and ankle (2nd ed., pp. 34–72).
Philadelphia: FA Davis Company.
Donatelli, R. A., & Wooden, M. J. (1996). Biomechanical orthotics. In
R. A. Donatelli (Ed.), The biomechanics of the foot and ankle (2nd
ed., pp. 255–279). Philadelphia: FA Davis Company.
Jonson, S. R., & Gross, M. T. (1997). Intraexaminer reliability,
interexaminer reliability, and mean values for nine lower extremity
skeletal measures in healthy naval midshipmen. Journal of
Orthopaedic and Sports Physical Therapy, 25, 253–263.
Jordan, R. P., Cooper, M., & Schuster, R. O. (1979). Ankle
dorsiflexion at the heel-off phase of gait: A photokinegraphic
study. Journal of the American Podiatric Association, 69, 40–46.
Karas, M. A., & Hoy, D. J. (2002). Compensatory midfoot
dorsiflexion in the individual with heelcord tightness: Implications
for orthotic device designs. Journal of Prosthetics and Orthotics, 14,
82–93.
Kaufman, K. R., Brodine, S. K., Shaffer, R. A., Johnson, C. W., &
Cullison, T. R. (1999). The effect of foot structure and range of
motion on musculoskeletal overuse injuries. American Journal of
Sports Medicine, 27, 585–593.
Kibler, W. B., Goldberg, C., & Chandler, J. T. (1991). Functional
biomechanical deficits in running athletes with plantar fasciitis.
American Journal of Sports Medicine, 19, 66–71.
Kvist, M. (1991). Achilles tendon injuries in athletes. Annales
Chirurgiae et Gynaecologine, 18, 188–201.
Lilletvedt, J., Kreigheaum, E., & Phillips, R. L. (1979). Analysis of
selected alignment of the lower extremity related to the shin splint
syndrome. Podiatric Sports Medicine, 69, 211–217.
Lun, V., Meeuwisse, W. H., Stergiou, P., & Stefanyshyn, D. (2004).
Relation between running injury and static lower limb alignment in
recreational runners. British Journal of Sports Medicine, 38, 576–580.
Messier, S. P., & Pittala, K. A. (1988). Etiological factors associated
with selected running injuries. Medicine & Science in Sports &
Exercise, 20, 501–505.
Murray, M. P., Kory, R. C., Clarkson, B. H., & Sepic, S. B. (1966).
Comparison of free and fast speed walking patterns in normal men.
American Journal of Physical Medicine, 5, 8–14.
Norkin, C. C., & Levangie, P. K. (2001). Joint structure and function: A
comprehensive analysis (4th ed.). Philadelphia: FA Davis Company.
Oatis, C. A. (2004). Kinesiology: The mechanics & pathomechanics of
human movement. Philadelphia: Lippincott Williams & Wilkins.
Paavola, M., Kannus, P., Jarvinen, T. A., Khan, K., Jozsa, L., &
Jarvinen, M. (2002). Current concepts review: Achilles tendino-
pathy. Journal of Bone and Joint Surgery (Am), 84-A, 2062–2076.
Portney, L., & Watkins, M. P. (2000). Foundations of clinical research:
Applications to practice (2nd ed.). East Norwalk, CT: Appleton &
Lange.
Qualisys, Incorporated. (2000). PCReflex user’s manual (Version N).
Glastonbury: Qualisys, Inc.
Riddle, D. L., Pulisic, M., Pidcoe, P., & Johnson, R. E. (2003). Risk
factors for plantar fasciitis: A matched case-control study. Journal
of Bone and Joint Surgery (Am), 85-A, 872–877.
Riemann, B. L., DeMont, R. G., Ryu, K., & Lephart, S. M. (2001).
The effects of sex, joint angle, and the gastrocnemius muscle on
passive ankle joint complex stiffness. Journal of Athletic Training,
36, 369–375.
 ARTICLE IN PRESS
100 M.A. Johanson et al. / Physical Therapy in Sport 7 (2006) 93–100
Selby-Silverstein, L., Farrett, W. D., Jr., Maurer, B. T., & Hillstrom,
H. J. (1997). Gait analysis and bivalved serial casting of an athlete
with shortened gastrocnemius muscles: A single case design.
Journal of Orthopaedic and Sports Physical Therapy, 25, 282–288.
Smith-Orichio, K., & Harris, B. A. (1990). Interrater reliability of
subtalar neutral, calcaneal inversion and eversion. Journal of
Orthopaedic and Sports Physical Therapy, 12, 10–15.
Subotnick, S. I. (1971). Equinus deformity as it affects the forefoot.
Journal of the American Podiatric Association, 61, 423–427.
Tiberio, D. (1987). Evaluation of functional ankle dorsiflexion using
subtalar neutral position: A clinical report. Physical Therapy, 67,
955–957.
Warren, B. L., & Davis, V. (1988). Determining predictor variables for
running-related pain. Physical Therapy, 68, 647–651.
Wessling, K. C., DeVane, D. A., & Hylton, C. R. (1987). Effects of
static stretch versus static stretch and ultrasound combined on
triceps surae muscle extensibility in healthy women. Physical
Therapy, 67, 674–679.
Wilder, R. P., & Sethi, S. (2004). Overuse injuries: Tendinopathies,
stress fractures, compartment syndrome, and shin splints. Clinics in
Sports Medicine, 23, 55–81.
Woerman, A. L., & Binder-Macleod, S. A. (1984). Leg-length
discrepancy assessment: Accuracy and precision in five clinical
methods of evaluation. Journal of Orthopaedic and Sports Physical
Therapy, 5, 230–239.
Wooden, M. J. (1996). Biomechanical evaluation for functional
orthotics. In R. A. Donatelli (Ed.), The biomechanics of the foot
and ankle (2nd ed., pp. 168–188). Philadelphia: FA Davis
Company.
Worrell, T. W., McCullough, M., & Pfeiffer, A. (1994). Effect of foot
position on gastrocnemius/soleus stretching in subjects with normal
flexibility. Journal of Orthopaedic and Sports Physical Therapy, 19,
352–356.
Wright, D. G., Desai, S., & Henderson, W. H. (1964). Action of the
subtalar and ankle joint complex during the stance phase of
walking. Journal of Bone and Joint Surgery (Am), 46-A, 361–382.