Clearance Exams for Foot and Ankle Stress Fractures

Stress fractures of the foot and ankle are common among runners. Fractures of the navicular, metatarsals and calcaneus are all common among endurance athletes. When recovering from these types of bone stress injuries, I feel it is very easy for runners to be underprepared in their rehab prior to returning to running. With all stress fractures, the focus of rehab should be progressively improving the tolerance of the bone to load and catering that loading progression to the specific demands of running. Often runners are given a few band drills, maybe some basic single leg exercises and then plugged into pool running or an anti gravity treadmill. It is very easy for the body to “find the path of least resistance” and progress all the way back to training without ever actually applying load through the affected bone. This puts the runner in a bad position both short and long term.

Here are a few simple clearance exams I use before I am willing to start a running program for a runner recovering from a foot or ankle stress fracture. The goal is that we stress the foot, ankle and entire leg in a single leg fashion with varying directions of force. These are non-negotiables with me. You have to show me you are comfortable loading through the foot before we can progress towards the next phase of rehab which includes plyometrics and running. Credit is due to Chris Johnson for showing me many of these drills.

One key point with these assessments. A common strategy for runners performing weight bearing drills is to curl their toes and “grip” to provide some more stability and maintain their balance. My goal is that you can keep even pressure throughout the foot and avoid any “hot spots”. A simple cue to focus on is “imagine your foot is in mud and you are trying to make the biggest foot print you can”. Check out the pictures below to see an example of “good” and “bad” toe positions. Keep scrolling to check out the video.

GOOD TOE POSITION

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TOE GRIPPING

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SIMPLE CLEARANCE DRILLS VIDEO

Thanks for reading!

Nathan Carlson DPT