Ankle and Foot: Counterstrain Treatment

• Treating foot and ankle issues involves using anatomy knowledge and diagnostic techniques.
• Prior to treatment, range of motion and palpation are reviewed, looking at:
  • Inversion
  • Eversion
  • Plantar flexion
  • Dorsiflexion
  • Major muscle groups
  • Ligamentous structures on the medial and lateral aspects of the ankle

Counterstrain Points

• Counterstrain tender points are sometimes found in the peroneus longus and on the lateral aspect of the ankle.
• For lateral ankle treatment, tender points are located proximally and distally.
• Focus on the proximal treatment
• Find the tender point in the peroneus longus muscle just inferior to the fibular head.
• Patient positioning: prone.
• Motion: eversion with slight plantar flexion at the ankle.
• Establish pain scale, fine-tune position to reduce pain to less than 3/10, hold for 90 seconds while monitoring the tender point, then passively return patient to neutral and reassess.
• On the medial aspect of the ankle, tender points are associated with the tibialis anterior and the deltoid ligament.
• For the tibialis anterior, treatment position is subtalar joint in inversion.
• Localize the tender point, establish a pain scale, and follow counterstrain steps.
• Ligamentous antenna structures on the lateral or medial aspect of the ankle can assist in fine-tuning the treatment position.

Plantar Fasciitis Assessment

• Plantar fasciitis is a common cause of foot pain.
• Assess the plantar fascia by finding tension along the plantar fascia from its origin to its insertion towards the metatarsal heads.
• Also assess for hypertonic musculature in the plantar aspect of the foot.

Myofascial Release Technique

• This technique is used for restrictions or plantar fasciitis.
• Patient position: supine with the physician at the foot of the table.
• Physician crosses thumbs over the area of concern and applies a distal and lateral force until feeling a restriction and holds until a release is palpated.
• The patient can plantar flex, dorsiflex, or simply flex and extend the toes.
• A kneading type of motion can also be performed with the thumbs.
• Re-evaluate for any other restrictions.

Longitudinal Stretch

• Patient position: supine with the physician at the foot of the table.
• The physician places the supportive hand on the dorsum of the foot.
• Treatment hand: make a fist with the fifth proximal phalanx, just proximal to the metatarsal heads.
• Press the fist into the fascia and roll proximally along the plantar fascia, towards the calcaneus.
• Repeat in slow, rhythmic motions for a minute or two, or until improvement or loosening of the plantar fascia is detected.
• Passively extend the toes to add more stretch to the plantar fascia.
• Re-evaluate for additional areas that need to be addressed.

Tibial-Talar Mechanics

• In dorsiflexion, the talus glides posteriorly.
• In plantar flexion, the talus glides anteriorly.
• Hand positions for monitoring and diagnosing talus movement:
  • Fingers on the talus and thumbs on the plantar surface.
  • Thumbs directly on the talus as it moves into dorsiflexion and plantar flexion.

Muscle Energy for Talus

• Plantar flexion dysfunction with dorsiflexion restriction is more common.
• Patient position: supine with the physician at the foot of the table, on the side of the affected foot.
• Physician hand position: hands wrapped around the dorsum of the foot, with the fifth fingers contacting the anterior aspect of the talus and thumbs on the plantar surface of the foot.
• Apply an inferior traction force and dorsiflex the foot into the barrier, then patient plantar flexes their ankle as the physician provides resistance using thumbs.
• Maintain for 3-5 seconds, then have the patient relax, reposition, re-engage the barrier, and repeat three to five times.

HVLA Thrust to the Talus

• Diagnosis of plantar flexed talus is the same.
• Patient position: supine on the table, with the physician standing at the side of the foot of the table.
• Physician hand position: hands wrapped around the dorsum of the foot, with the fifth fingers contacting the talus and thumbs on the plantar surface of the foot.
• Apply traction force as the foot is brought into dorsiflexion to the barrier.
• Patient takes a deep breath in and out, while traction force and dorsiflexion are increased to engage the barrier.
• Apply a high velocity, low amplitude thrust in an inferior and posterior direction through the fifth fingers.
• Return to neutral and reassess for improvement in dorsiflexion restriction.

Tarsal Bones

• Palpate on the plantar aspect of the foot, on the navicular, cuboid, and cuneiform.
• Test glides at each of those bones to see which is dysfunctional.

HVLA for Tarsal Bones

• Dysfunction of the cuboid, navicular, cuneiform is usually a dropped tarsal bone describing a plantar glide.
• Patient position: prone on the table.
• Physician grasps the patient's foot with fingers on the dorsum and thumbs overlapping directly over the dysfunctional tarsal bone.
• Engage the barrier by pressing down through the thumbs and flexing the midfoot.
• Perform a thrust using a whipping motion by thrusting the thumbs down into the sole of the foot, through the dysfunctional tarsal bone.
• Directionality depends on the bone:
  • Navicular: J shape.
  • Cuboid: reverse J shape.
  • Cuneiform: straight, directly down.
• Return to neutral and reassess, while inverting, everting, and fine-tuning.