Assessing and Treating the Stiff Ankle: A Practical Approach
Chronic ankle stiffness is common after previous ankle injuries. A patient may have sustained a sprain years ago, returned to activity, and yet continue to demonstrate limitations in dorsiflexion, tibial rotation, foot mobility, or load acceptance.
Rather than viewing ankle dorsiflexion as a single movement occurring at a single joint, it can be useful to consider the different components contributing to the overall motion.
If you want to learn more about this topic, you can watch Dave Leyland's lecture here:
In his lecture, Dave Leyland presents a practical approach to assessing these components and using the findings to guide manual therapy and exercise selection.
Start by identifying where the limitation comes from
Dorsiflexion depends on the coordinated contribution of several regions:
✔ Tibial internal rotation
✔ Talocrural joint mobility
✔ Subtalar pronation
✔ Midfoot pronation
A limitation in any of these areas may influence how the patient achieves dorsiflexion. Therefore, simply measuring a knee-to-wall distance may tell us that a limitation exists, but not necessarily why.
A useful assessment strategy is to combine a global measure, such as the knee-to-wall test, with more specific tests that help identify where movement may be restricted.
Look beyond the knee-to-wall test
The lecture demonstrates several practical assessments, including the prone dorsiflexion test, the Wiggle Test for tibial rotation, the calcaneal rock test for subtalar mobility, and the Table Torsion Test for midfoot mobility. These tests can help clinicians determine whether the restriction appears to be primarily at the talocrural joint, tibia, subtalar joint, or midfoot.
Importantly, these findings should not be interpreted in isolation. They should be considered alongside the patient's history, symptoms, movement screening, and functional tasks such as squatting and single-leg stance.
Here are a few key clips from Dave Leyland's lecture demonstrating the assessment process.
Treat the limitation you actually find
Once the assessment identifies a relevant restriction, treatment can be directed toward that specific component rather than applying the same ankle mobilization to every patient.
For example, talocrural restrictions can be addressed with posterior glide techniques, while subtalar or midfoot limitations may require different positions and force directions. The lecture also demonstrates how these techniques can progress from table-based mobilizations toward loaded, closed-chain positions.
This progression is particularly relevant for patients with chronic stiffness. The objective is not simply to create more passive movement, but to help the patient access and control that movement during functional tasks.
Watch Dave Leyland demonstrate the Ankle Rock Mobilization technique in this video.
Don't forget tibial rotation
One of the most useful clinical themes throughout the lecture is the relationship between ankle mobility and tibial rotation.
Patients with previous ankle injuries may develop movement strategies in which the foot turns outward or the tibia externally rotates to compensate for restricted motion. The Wiggle Test provides a quick way to compare tibial rotation between sides and examine how rotation changes when the ankle is placed into dorsiflexion.
Treatment and exercise can then be used to help the patient regain tibial motion while reducing unnecessary compensations.
Exercises such as tibial internal rotation drive-outs and seated tibial internal rotations provide ways to continue this work actively after manual treatment.
See Dave Leyland’s explanation of Tibial IR drive-outs in this short clip.
From manual therapy to active control
Manual therapy may provide an opportunity to change movement or symptoms, but the next step is helping the patient actively use the available range.
The lecture includes several practical options:
→ Tibial IR drive-outs
→ Seated tibial internal rotations
→ Banded talocrural self-mobilization
→ Banded eversion and peroneal strengthening
→ Foot and subtalar dissociation drills
A particularly important consideration is how the patient performs the exercise, rather than simply which exercise they perform.
For example, during banded eversion, patients may compensate by rotating the entire tibia and lower limb instead of producing the desired movement at the ankle. The exercise can therefore be progressed by maintaining tibial control while working through plantarflexion and eversion, challenging the peroneal muscles without allowing excessive tibial external rotation.
Similarly, tibial rotation exercises should emphasize movement occurring at the tibia while keeping the foot, pelvis, and trunk appropriately controlled.
The bigger picture
A stiff ankle is rarely just about a single joint.
A patient with a history of ankle injury may develop limitations across the talocrural joint, tibia, subtalar joint, and midfoot, alongside changes in strength and movement control.
The clinical challenge is therefore not simply to "increase ankle dorsiflexion," but to determine where the limitation is occurring, how the patient is compensating, and whether the available movement can be used effectively under load.
Clinical Insights
• Assess the components of dorsiflexion rather than relying exclusively on a global measurement.
• Compare sides and pay attention to the patient's perceived restriction as well as your physical findings.
• Consider tibial rotation when a patient demonstrates persistent foot-out or external rotation strategies.
• Use assessment findings to determine which manual therapy and exercises are most appropriate.
• Progress from passive or table-based work toward active, loaded movement.
• During exercises, control of compensations can be just as important as the movement itself.
• The ultimate goal is not simply more ROM—it is restoring useful movement and load tolerance.
For patients with chronic ankle stiffness, a more detailed assessment can help turn a vague finding such as "limited dorsiflexion" into a more specific and clinically useful treatment plan.
If you want to learn more about this topic, you can watch Dave Leyland's lecture here:
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