A One-Sided Inline Lunge in a Masters Footballer
A 41-year-old masters football player trains Tuesday and Thursday evenings and plays a 90-minute match every Sunday. He has no current pain but rolled his right ankle badly two years ago; it was braced for a week and never rehabilitated. He wants to add heavy barbell split squats and single-leg Romanian deadlifts for a summer tournament in eight weeks, and says his right ankle "has never been the same".
Screen results after a standard warm-up: deep squat 2; hurdle step 2/2; inline lunge 3 with the left leg forward and 1 with the right leg forward - he loses balance, the dowel lifts off the sacrum, the torso rotates to the left, the right knee tracks inside the foot, and the rear knee never touches the board; shoulder mobility 3/3; active straight leg raise 2/2, slightly tighter on the right; trunk stability push-up 3; rotary stability 3 on the left and 2 on the right. No pain anywhere, and no pain on any clearing test.
1. How do you record and interpret these results? Explain the rule for bilateral screens, what the asymmetry flag means, and why the composite score is misleading here.
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Recording. For the five bilateral screens (hurdle step, inline lunge, shoulder mobility, active straight leg raise, rotary stability) you record the lower of the two sides and note the side and the fact that the two sides differ. So: inline lunge 1, asymmetric; rotary stability 2, asymmetric; the rest as scored. The composite is 2 + 2 + 1 + 3 + 2 + 3 + 2 = 15 out of 21, but the number is not the headline.
What the asymmetry flag means. A left-right difference is treated as a more meaningful finding than a low but symmetrical score, because symmetry is the baseline expectation for a bilateral pattern in a healthy mover. Two people can both score 15 - one with seven symmetrical 2s, one with a cluster of asymmetry - and they do not have the same problem. The flag says: this pattern fails on one side only, so look for a one-sided cause.
Why the composite misleads. It averages away exactly the information that matters. His 3 on the left means the pattern is available to him; the 1 on the right means it is not, and a 1 on the inline lunge is qualitatively different from a 2 - a 2 is a compensation (rotation, loss of dowel contact, knee that doesn't touch), whereas a 1 is a loss of balance, which is a control failure, not just a range-of-motion shortfall.
The contextual read. The failing side is the side of an unrehabbed ankle sprain, and the other asymmetric finding (rotary stability) is also on the right, with the active straight leg raise slightly tighter on the right. A side-consistent cluster around a known injury is the story to pursue, not a coincidence to average out. What the screen does not tell you is whether the cause is ankle mobility, hip control, or balance - that is the next task.
2. Rank your hypotheses for the right-leg-forward failure and describe the tests that would separate them.
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1. Right ankle dorsiflexion restriction after the sprain (most likely). If the right tibia cannot advance over the foot, the body has to find range elsewhere: the front knee drifts inside as the foot pronates or the heel lifts, the pelvis rotates to unload the ankle, and the dowel lifts off the sacrum. Test with knee-to-wall, both sides, heel flat, and watch the calcaneus for excessive eversion. Compare the distance to the left, which we know is enough to score a 3.
2. Right stance-leg frontal-plane control (hip abduction and external rotation). Knee valgus under a split-stance load is a control finding as much as a mobility one. Test with a single-leg stance, a slow single-leg squat to a target, and a lateral step-down, observing the knee and pelvic drop. This often coexists with an ankle restriction; the question is whether the valgus persists when the ankle demand is removed (for example, front foot elevated and heel supported).
3. Balance and proprioceptive deficit after the sprain. A 1 is a balance loss. Test single-leg stance with eyes closed, timed, both sides, and a reach test (anterior, posteromedial, posterolateral). A large side-to-side difference with good strength and range points here.
4. Thoracic rotation asymmetry. Possible but lower priority: the dowel lifted off the sacrum, which points to pelvic position rather than a shoulder-driven problem, and his shoulder mobility is 3/3 with no pain.
Ranking logic. The history, the side consistency and the mechanical story make the ankle the first thing to change, because a mobility restriction upstream will keep re-creating the compensation no matter how much hip control work you add. But do not treat this as a single-cause puzzle: the pragmatic approach is to spend two weeks on the ankle and single-leg control, retest the inline lunge, and let the retest tell you which hypothesis was load-bearing.
3. He wants heavy barbell split squats and single-leg Romanian deadlifts now. What do you allow, modify, and hold over the next four weeks, and what are your progression criteria?
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Hold: heavy barbell split squats with the right leg forward. That is the exact configuration that scores 1, and loading a balance-loss pattern under a barbell is how an eight-week tournament block turns into a missed tournament. Also hold any loaded split-stance work where the front heel is unsupported and the load is above bodyweight.
Modify:
- Split squats return as an isometric hold with the front foot on a low step and the heel supported, which removes the ankle demand, with a vertical dowel or a wall for reference. Load is bodyweight plus a light dumbbell, held on the left side only if it does not reproduce the rotation.
- Single-leg Romanian deadlifts are allowed but de-loaded to roughly 60% of what he proposed, with a slow tempo, a target for the pelvis, and a mirror or video check for the knee valgus and pelvic rotation. Stop the set at the first loss of position, not at a rep target.
- Keep his bilateral strength work and his football - the goal is to preserve conditioning while the pattern is rebuilt.
Add: daily ankle dorsiflexion work (knee-to-wall holds, calf mobility), foot intrinsic work, split-stance isometric holds, and single-leg balance progressions, four to five short exposures a week rather than one long session.
Progression criteria at four weeks: inline lunge right side at least a 2, no loss of balance, dowel contact maintained at head, thoracic spine and sacrum, knee touching the board, front foot flat, and no asymmetry flag. Only then reintroduce barbell split squats, starting around 60–70% of his previous load and building weekly. If the retest is unchanged, the ankle work was not the answer - go back to the hip-control and balance hypotheses before adding load. Also give him the honest timeline: eight weeks is enough to change a pattern, not enough to rush it.