Knee to wall is a very common assessment tool and exercise prescribed when it comes to rehabbing a stiff ankle. However, I think there are many ways to enhance the exercise and the most important way isn’t even on the below list.
The biggest mistake I see with knee to wall when done as an exercise is that people simply just go through the motions. There is no intent or focus during the mobilization to change ankle mechanics. People either don’t push to their end range, or they go through the exercise with poor mechanics, or they are day dreaming about how bad their plantar fasciitis, shin splint, patellar tendonitis, hip impingement (etc.) is and how this small exercise can’t possibly help with their injury. News flash, it can and will help if you put in the effort to change your mechanics, which most people don’t realize how much that takes. This is a huge piece of patient education I have been trying to instil with my patients lately. Every exercise you do has to have intent. You can’t just rock back and forth on that ankle 10 times with no specific focus and expect that ankle joint that has been stiff for 10 years since your ankle fracture to be all better.
You need to focus on making it an active exercise and using your musculature like your tibialis anterior to actually pull your tibia over your ankle. You need to focus on not collapsing through your ankle. You need to focus on keeping your ankle in a good position, but not letting your big toe lose contact with the ground. You may need to work on more side to side motion of the ankle or rotational movement vs straight forward dorsiflexion. It is often thought of as a simple exercise to give patients just as a piece of the puzzle, but with a bit more complexity and intent behind it can evolve into a powerful exercise to create change in even some of the most stubborn ankles. Below are 5 different ways you can enhance the knee wall exercise
- Lateral Tibia knee to walls
This exercise is important because it aids in the ability for the foot to maintain a neutral flat position while the client works on the ability to move their tibia laterally over the foot while they dorsiflex (similar to a squat). Mistakes would be going too far over they lose their flat position too significantly or collapsing through the ankle too significantly that it promotes bad mechanics. Will feel this stretch on either side of the ankle, everyone seems to vary.
2. Medial Tibia knee to walls
These are done somewhat in a groin stretch type position though I find it helpful to come out of that stretch a bit to focus more on the ankle motion. The opposite to exercise #1 this exercise helps to work on keeping a neutral foot position as we move the tibia medially over the foot while grooving dorsiflexion range of motion. Common faults with this would be letting the knee collapse too much or the foot. The motion should be focussed to the ankle joint and again could be felt on either side of the ankle. This is important to note because often times people say ankle ROM is limited by either anterior displaced talus or posterior musculature restriction, but often times the tissues on either side of the ankle joint can be the limiting factor. I also like to add a bit of a rotational effort to this exercise to improve distal tibial rotation around the ankle to hopefully take rotational stress off the knee. You can see my struggle to keep a neutral foot, but as long as there is significant effort to maintain the proper position it will improve.
3. Foot Unscrew knee to walls
As I mentioned a few weeks ago, a lot of times people with stiff ankles will develop what I call a “screwed foot”. This happens when their mid-ankle collapses into pronation and their forefoot starts to get locked into forefoot supination. This ends up looking like the individual either collapses medially through their ankle or they keep a neutral ankle position, but their forefoot is now not in contact with the ground because it has lost its ability to be neutral. This is important to groove when doing the knee to wall exercise so we can restore proper foot activation/positioning patterns. In the below exercise I focus on putting my weight somewhat excessively on the lateral aspect of my calcaneus to exaggerate not collapsing. My big toe pops off the ground and then using musculature I try to drive the first ray down into the ground while keeping my calcaneus position without allowing it to collapse. I then complete a knee to wall to start to groove this position.
4. Tibial Internal rotation knee to walls
As I mention in the below video I use this method to promote proper ankle alignment from the knee down. The biceps femoris can get very overactive in individuals and I use this one to promote activity of the medial hamstring group. The medial hamstring group is going to help aid in keeping the tibia in a position of internal rotation and not allow the tibia to spin out into excessive external rotation. Working on this positioning from the top down will help improve ankle dorsiflexion down stream by grooving proper mechanics. I expect someone to say that you can’t differentiate medial and lateral hamstring activation and maybe that is true, but it is more so about doing this exercise with an intent of positioning. I personally feel if I really put in an effort to get that medial hamstring group involved I not only feel it, but it has helped my knee mechanics out a bunch.
5. Banded variations
As most physios have seen by now, banded self mulligan mobilizations can be very helpful for patients in particular when the talus is anterior in the joint and causing a block to dorsiflexion. Below is a video showing the banded technique with the band pulling posteriorly on the ankle and in particular the talus. I also like the dowel on the outside of the foot trick he is using here to promote a slight lateral movement of the tibia and not allowing the knee to collapse inward. I saved this one for last because it is more commonly known. I personally have found a ton of benefit to addressing my side to side ankle ROM with the first 2 exercises and I think it is important to groove ROM actively as well which both exercise #3 and #4 do. This is more of a passive technique, but can be helpful in grooving proper ankle mechanics in certain cases.
I hope you guys enjoyed the post. Do you have any tips and tricks for knee to wall you like to implement? Thanks for reading!