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Journal of Science and Medicine in Sport 14 (2011) 90–92

Original paper

Dorsiflexion range of motion significantly influences dynamic balance

Matthew C. Hoch ∗ , Geoffrey S. Staton, Patrick O. McKeon 1
Division of Athletic Training & Rehabilitation Sciences Doctoral Program, University of Kentucky, College of Health Sciences,
Lexington, KY 40536-0200, United States
Received 21 January 2010; received in revised form 2 July 2010; accepted 5 August 2010

Abstract
The purpose of this study was to examine the relationships between dorsiflexion range of motion on the weight-bearing lunge test (WBLT)
and normalized reach distance in three directions on the Star Excursion Balance Test (SEBT). Thirty-five healthy adults (14 males, 21 females,
age: 25.9 ± 6.7 years, height: 166.7 ± 22.9 cm, weight: 76.7 ± 22.8 kg) participated. All subjects performed three trials of maximum lower
extremity reach in the anterior, posteromedial, and posterolateral directions of the SEBT on each limb to assess dynamic balance. Subjects
performed three trials of the WBLT to measure maximum dorsiflexion range of motion. Dependent variables included the means of the SEBT
normalized reach distances in the anterior, posteromedial, and posterolateral directions and the mean of the WBLT. Only the anterior direction
(mean: 79.0 ± 5.8%) of the SEBT was significantly related to the WBLT (mean: 11.9 ± 2.7 cm), r = 0.53 (p = 0.001). The r2 for this simple
linear regression was 0.28, indicating that the WBLT explained 28% of the variance in the anterior normalized reach distance. The WBLT
explained a significant proportion of the variance within the anterior reach distance signifying this direction of the SEBT may be a good
clinical test to assess the effects of dorsiflexion range of motion restrictions on dynamic balance.
© 2010 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Keywords: Postural control; Lower extremity injury; Ankle

1. Introduction as a measure of performance. Shorter reach distances are

Dorsiflexion range of motion (DROM) deficits have been
identified following ankle sprain, Achilles’ tendinopathy, and
an array of other foot and ankle injuries.1–3 Additionally,
decreased DROM has been detected during walking in indi-
viduals with diagnosed ankle arthrosis4 and jogging in those
with chronic ankle instability.5 Static stretching of the triceps
surae complex1 and posterior talar glide joint mobilization
techniques3,6 have been previously investigated and appear
to successfully address this deficit. Despite these findings,
limited evidence exists regarding the relationship between
DROM and performance on clinical assessments of dynamic
postural control such as the Star Excursion Balance Test
(SEBT). The SEBT is a battery of lower extremity maximal
reach tests while the contra-lateral limb attempts to maintain
single-limb balance.7 In this test, reaching distance serves
∗ Corresponding author. Tel.: +1 859 323 1100x80839.
E-mail address: mcho222@uky.edu (M.C. Hoch).
1 Tel.: +1 859 323 1100x80885.
typically associated with mechanical or sensorimotor system
constraint. Hertel8 recommends using the anterior (ANT),
posteromedial (PM), and posterolateral (PL) directions ver-
sus the traditional 8 directions to avoid capturing redundant
information. Identifying clinical tests to evaluate the effects
of DROM restrictions are important for the assessment and
rehabilitation of foot and ankle injuries. Therefore, the objec-
tive of this study was to examine the relationships between
DROM on the weight-bearing lunge test (WBLT) and the
normalized SEBT reach distance in ANT, PM, and PL direc-
tions.
2. Methods
Thirty-five healthy adults (14 males, 21 females,
age: 25.9 ± 6.7 years, height: 166.7 ± 22.9 cm, weight:
76.7 ± 22.8 kg) participated in this cross-sectional study. All
subjects had no history of lower extremity injury in the past 6
months, no self-reported disability in the foot and ankle, and

1440-2440/$ – see front matter © 2010 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jsams.2010.08.001
 M.C. Hoch et al. / Journal of Science and Medicine in Sport 14 (2011) 90–92 91

Fig. 1. The anterior (left), posteromedial (middle), and posterolateral (right) directions of the SEBT were used to assess dynamic postural control.

no history of lower extremity surgery or balance disorders. progressed backwards from the wall and repeated the modi-
Prior to enrollment in the study, all subjects provided written fied lunge. Maximum dorsiflexion was measured in cm and
informed consent. All subjects reported to the research labo- defined as the distance of the great toe from the wall based
ratory on a single occasion and performed the SEBT and the on the furthest distance the foot was able to be placed with-
WBLT on both limbs. out the heel lifting off the ground while the knee was able
The ANT, PM, and PL directions of the SEBT (Fig. 1) to touch the wall.6 After performing 3 practice trials, 3 trials
were measured based on the recommendations of Hertel.8 were collected, averaged, and used for analysis.
All subjects were positioned and aligned with a series of tape Dependent variables included the mean of the SEBT nor-
measures secured to the floor. Equal halves of the length of malized reach distances in the ANT, PM, and PL directions
the stance foot was on each side of the anterior and posterior and the mean of the WBLT for each limb. Dependent t-tests
halves of the SEBT instrument. This position was marked on were conducted to determine the presence of limb differences
the tape measure to ensure accurate repositioning between for each dependent measure. In the event no differences were
trials. Subjects were instructed to perform maximal reaches detected between limbs, the data from the left and right limbs
with the opposite lower extremity followed by a single, light were pooled for each subject. Simple linear regression was
toe touch on the tape measure. Errors were recorded if the used to examine the correlation (r) and proportion of variance
hands did not remain on the hips, the position of the stance
foot was not maintained, the heel did not remain in contact
with the floor, or the subject lost balance during the trial. In the
event an error occurred, the trial was discarded and repeated.
Based on the recommendations of Robinson and Gribble,9
each subject performed 4 practice trials in each direction on
each leg. Three trials were later performed in each direc-
tion and used for analysis. Distances were measured in cm
and normalized by dividing by the subject’s lower extremity
length (anterior superior iliac spine to distal end of the medial
malleolus) and multiplying by 100.7
Subjects also performed the WBLT to estimate maximal
weight-bearing DROM (Fig. 2). The WBLT was performed
using the knee-to-wall principle described by Vicenzino et
al.6 Subjects performed 3 practice trials of the WBLT on
each limb in which they kept their test heel firmly planted
on the floor while they flexed their knee to the wall. The
opposite extremity was positioned behind the test foot and
was used to maintain stability during the test. When sub-
jects were able to maintain heel and knee contact, they were Fig. 2. Subject positioning for the weight-bearing lunge test.
92 M.C. Hoch et al. / Journal of Science and Medicine in Sport 14 (2011) 90–92
(r2 ) explained among the 4 dependent variables. Alpha level
was set a priori at p < 0.05.
3. Results
No significant differences were detected between limbs for
any of the dependent variables (p > 0.05) allowing data from
the right and left limbs to be pooled. The ANT direction of the
SEBT (mean: 79.0 ± 5.8%) was significantly correlated to the
WBLT (mean: 11.9 ± 2.7 cm; r = 0.53, r2 = 0.28, p = 0.001).
There were no significant correlations between the WBLT
and the PM direction (mean: 90.0 ± 9.1%; r = 0.21, r2 = 0.04,
p = 0.23) or the PL direction (mean: 82.0± 13.1%; r = 0.22,
r2 = 0.05, p = 0.20). All three SEBT normalized reach dis-
tances were significantly correlated, ANT to PM direction
(r = 0.60, p < 0.001), ANT to PL (r = 0.61, p < 0.001), and
PM to PL (r = 0.89, p < 0.001).
4. Discussion
Our findings indicate that there is a significant correlation
between maximum weight-bearing DROM and performance
on the ANT direction of the SEBT. This finding directly
contradicts previous reports that DROM is not significantly
related to performance on the SEBT.7 This suggests that
health conditions associated with a loss in DROM may expe-
rience deleterious alterations in certain aspects of dynamic
postural control. To support our findings, a recent investi-
gation exploring kinematic predictors of the SEBT reported
that sagittal plane motion of the knee and hip account for
approximately 78% of the variance in ANT reach.10 Our find-
ings suggest that DROM accounted for an estimated 28%
of the variance in ANT reach. Had this previous investi-
gation explored ankle sagittal plane motion, they may have
accounted for a much greater proportion of the variance in
ANT reach.
Despite the significant correlation between weight-
bearing DROM and ANT reach, there does not appear to
be a significant relationship between DROM and the PM
or PL reach directions. This is not surprising as previous
reports have indicated that hip flexion alone accounted for
88.6% and 94.5% of the variance in the PM and PL direc-
tions, respectively.10 The 4–5% of the variance accounted for
in this investigation is justified by the reliance on proximal
lower extremity joints. Therefore, the ANT reach direction
of the SEBT may be a more useful clinical indicator of lower
extremity function for individuals with a lower extremity
injury in which DROM is a clinical consideration.
Decreased performance on the ANT reach direction in
those with a history of foot or ankle pathology may be
indicative of triceps surae tightness or ankle arthrokinematic
restriction specifically related to decreases in posterior talar
glide. Future investigations should examine the relationship
between increases in DROM and ANT reach in individuals
with DROM deficits following stretching or joint mobi-
lization interventions. Also, the minimal detectable change
and/or minimally clinically important difference should be
determined for the SEBT and WBLT for clinical goal setting
and outcome assessment. In conclusion, the WBLT explained
a significant proportion of the variance within the ANT reach
distance. Therefore, the ANT direction of the SEBT may be
a good clinical test to assess the effects of DROM restrictions
on dynamic balance.
Acknowledgement
There was no external financial assistance with this
project.
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