Ankle & Foot (2)

1. Ankle & Foot (2)

2. Inversion: Tarsal Joints

3.  Range of motion 0° – 35 ° Testing position Short sitting with knee flexed to 90° & the lower leg over the edge of the supporting surface Stabilization Stabilize the tibia and fibula to prevent: Medial rotation & extension of knee + lateral rotation & abduction of hip

4.  Goniometer Alignment Fulcrum Anterior aspect of the ankle midway between the malleoli Proximal Arm Anterior midline of the lower leg, using the tibial tuberosity for reference Distal Arm Anterior midline of the second metatarsal

5.  Patient Instruction Ask the patient to turn their foot in.

6.  Normal End Feel Firm, because of tension in: • Joint capsule • Anterior & posterior talofibular ligaments • Calcaneofibular ligament • Anterior, posterior & interosseous talocalcaneal ligament • Dorsal calcaneal ligaments • Dorsal calcaneocuboid ligament • Dorsal talonavicular ligament • Lateral band of bifurcate ligament • Transverse metatarsal ligament • Dorsal, planter, interosseous cuboidonavicular, cuneonavicular, intercuneiform, cuneocuboid, TMT, & intermetatarsal joints • Peroneus longus & brevis muscles

7. Inversion Muscle Tibialis posterior

8. Tibialis Posterior Origin: Shaft of tibia + interosseous membrane + shaft of fibula + deep transverse fascia + intermascualr septum Insertion: Navicular tuberosity + cuneiform bones + suntestaculum tail + 2-4 metatarsal Innervation: Tibial Nerve (L4-L5, & sometimes S1)

9.  Patient Position Short sitting with ankle in slight planter flexion Test For Grades 5, 4, 3, 2, 1 and 0  Therapist and Patient Instructions   Sitting next to test limb place the resistance hand over the dorsum and medial side of the foot at the metatarsal heads. The stabilizing hand is placed around the posterior ankle just above the malleoli. Resistance is given in the direction of eversion and toward slight dorsiflexion, almost as if pulling up and around laterally. Ask the patient to, “turn your foot down and in, toward your other foot, don’t let me push it out.”

10. Grade 5 (Normal): completes full range of motion and holds against maximal resistance. Grade 4 (Good): completes available range of motion and holds against strong to moderate resistance. Grade 3 (Fair): the patient will be able to invert the foot through full available range of motion. Grade 2 (Poor): completes only partial range of motion. Grade 1 (Trace): palpate tendon of tibialis posterior between the medial malleolus & navicular bone, or above the malleolu. If palpable activity occurs with no movement, the grade is 1. Grade 0 (Zero): no palpable contraction Test For Grades 5, 4, 3, 2, 1 and 0

11. Substitution by the Flexors of the toes should remain relaxed to prevent substitution by the Flexor digitorum longus & Flexor hallucis longus  Substitution 

12. Eversion: Tarsal Joints

13.  Range of motion 0° – 25 ° Testing position Short sitting with knee flexed to 90° & the lower leg over the edge of the supporting surface Stabilization Stabilize the tibia and fibula to prevent: Lateral rotation & flexion of knee + Medial rotation & abduction of hip

14.  Goniometer Alignment Fulcrum Anterior aspect of the ankle midway between the malleoli Proximal Arm Anterior midline of the lower leg, using the tibial tuberosity for reference Distal Arm Anterior midline of the second metatarsal

15.  Patient Instruction Ask the patient to turn their foot out.

16. Normal End Feel Hard, because of tension in: • Contact between the calcaneus & the floor of the sinus tarsi Or Firm, because of tension in: • Joint capsule • Deltoid ligament • Medial talocalcaneal ligament • Planter calcaneonavicular ligament • Calcaneocuboid ligament • Dorsal talonavicular ligament • Medial band of bifurcate ligament • Transverse metatarsal ligament • Dorsal, planter, interosseous cuboidonavicular, cuneonavicular, intercuneiform, cuneocuboid, TMT, & intermetatarsal joints • Tibialis posterior muscles

17. Foot Eversion With Planter Flexion

18. Foot Eversion With Planter Flexion Muscles Peroneus Longus Peroneus brevis

19. Peroneus Longus Origin: Head & shaft of fibula + lateral condyle of tibia + fascia cruris + intermascular septum Insertion: 1st metatarsal + medial cuneiform + occasionally from other metatarsals Innervation: Superficial Peroneal Nerve (L5-S1)

20. Peroneus Brevis Origin: Shaft of fibula + crural intermascular septum Insertion: 5th metatarsal Innervation: Superficial Peroneal Nerve (L5-S1)

21.  Patient Position Short sitting with ankle in neutral position Test For Grades 5, 4, 3 and 2  Therapist and Patient Instructions   Sitting on stool beside the patient’s test limb, one hand stabilizes by gripping around the ankle. Resistance is given around the dorsum and lateral border of the foot. Resistance is in the direction of inversion and slight dorsiflexion, or in an up and medial direction. Ask the patient to, “turn your foot down and out, don’t let me push it in.”

22. Grade 5 (Normal): completes full range of motion and holds against maximal resistance. Grade 4 (Good): completes available range of motion and holds against strong to moderate resistance. Grade 3 (Fair): the patient will be able to invert the foot through full available range of motion but tolerate no resistance. Grade 2 (Poor): completes only partial range of eversion motion. Grading

23.  Patient Position Short sitting or supine  Therapist and Patient Instructions   Sitting on stool beside the patient’s test limb, or standing at the end of table. To palpate Peroneus longus, place fingers on the lateral leg over the upper one-third just below the head of the fibula. The tendon of the muscle can be felt posterior to the lateral malleolus behind the tendon of the Peroneus brevis. To palpate tendon of Peroneus brevis place the index finger over the tendon as it comes forward from behind the lateral malleolus, proximal to the base of 5th metatarsal. The belly of the muscle can be palpated on the lateral surface of the distal leg over the fibula Test For Grades 1 and 0

24. Grade 1 (Trace): palpation will reveal contractile activity in either or both muscles, which may cause the tendon to stand out. No motion occurs Grade 0 (Zero): no palpable contraction Grading

25. To Isolate Peroneus Longus give resistance against the planter surface of the head of the 1st metatarsal in a direction toward invesion & dorsiflexion. • Foot Eversion With Dorsiflexion: if peroneus tertius is present, it can be tested by asking the patient to evert & dorsiflex the foot. In this motion, however, Extensor digitorum longus participates. The tendon of peroneus tertius can be palpated on the lateral aspect of the dorsum of the foot, lateral to the tendon of Extensor digitorum longus.  Notes 

26. Inversion: Subtalar Joint (Rearfoot)

27.  Range of motion 0° –5 ° Testing position Prone Stabilization Stabilize the tibia and fibula to prevent: lateral rotation of knee + lateral rotation & abduction of hip

28.  Goniometer Alignment Fulcrum Posterior aspect of the ankle midway between the malleoli Proximal Arm Posterior midline of the lower leg Distal Arm Posterior midline of the calcaneus

29.  Patient Instruction Ask the patient to turn their foot in.

30.  Normal End Feel Firm, because of tension in: • Lateral Joint capsule • Anterior & posterior talofibular ligaments • Calcaneofibular ligament • Anterior, posterior & interosseous talocalcaneal ligament

31. Eversion: Subtalar Joint (Rearfoot)

32.  Range of motion 0° –5 ° Testing position Prone Stabilization Stabilize the tibia and fibula to prevent: Medial rotation flexion of knee + Medial rotation & abduction of hip

33.  Goniometer Alignment Fulcrum Posterior aspect of the ankle midway between the malleoli Proximal Arm Posterior midline of the lower leg Distal Arm Posterior midline of the calcaneus

34.  Patient Instruction Ask the patient to turn their foot out.

35. Normal End Feel Hard, because of tension in: • Contact between the calcaneus & the floor of the sinus tarsi Or Firm, because of tension in: • Deltoid ligament • Medial talocalcaneal ligament • Tibialis posterior muscles

36.  Good Luck To You All 