Ankle Plantar Flexion MMT
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A patient can only perform 10 heel raises with proper form before fatiguing. According to the presented material, what is the MOST appropriate MMT grade for this patient's ankle plantar flexors, assuming the test was conducted against gravity with appropriate stabilization?

  • 2/5, implying the patient can only initiate the movement but cannot sustain it against gravity for a functional number of repetitions.
  • 4/5, suggesting the patient demonstrates moderate weakness in plantar flexion endurance. (correct)
  • 3/5, signifying that the patient can complete the motion partially but not with sufficient repetitions.
  • 5/5, indicating normal strength and endurance beyond the expected threshold.

During MMT for ankle plantar flexion, a patient exhibits visible contraction of the gastrocnemius and soleus but cannot initiate any heel raise against gravity. When moved into a gravity-minimized position, the patient achieves full ROM plantar flexion. Given these findings, what is the MOST accurate MMT grade according to the provided information?

  • 1/5, demonstrating a trace contraction without functional movement against gravity.
  • 2/5, signifying the ability to complete full ROM in a gravity-minimized position. (correct)
  • 3/5, indicating that the patient can initiate movement against gravity, even if incompletely.
  • 0/5, suggesting no palpable contraction or visible movement in any position.

A physical therapist performs MMT on a patient who reports pain during resisted plantar flexion. Which modification to the standard testing procedure is MOST appropriate initially to differentiate between muscular and tendinous involvement, assuming all other standard protocols are followed?

  • Assess plantar flexion strength with the knee flexed to reduce gastrocnemius contribution and emphasize soleus function. (correct)
  • Apply manual resistance proximally to the Achilles tendon to isolate the gastrocnemius and minimize soleus activation.
  • Transition directly to dynamometry to quantitatively measure force output and identify objective weakness.
  • Increase the speed of plantar flexion repetitions to assess for pain provocation related to fatigue.

A patient presents with decreased plantar flexion strength following a lower leg injury. Palpation reveals tenderness along the medial aspect of the distal tibia. Which muscle is LEAST likely to be implicated as a primary contributor to the observed weakness based on the provided information?

<p>Peroneus Longus, because it primarily contributes to ankle eversion and assists weakly in plantar flexion. (B)</p> Signup and view all the answers

During a manual muscle test for plantar flexion, a patient demonstrates a complete active range of motion against gravity but is unable to tolerate any added resistance before breaking. Which of the following represents the MOST appropriate MMT grade according to the provided information?

<p>3/5, suggesting fair strength with the ability to complete full ROM against gravity but no added resistance. (A)</p> Signup and view all the answers

A researcher aims to evaluate the inter-rater reliability of MMT for ankle plantar flexion in a clinical setting. Which statistical measure would be MOST appropriate to quantify the agreement between two physical therapists' MMT scores, considering the ordinal nature of the data?

<p>Spearman's rank correlation coefficient, used to evaluate monotonic relationships between ordinal variables. (C)</p> Signup and view all the answers

A patient rehabilitating from an Achilles tendon rupture consistently demonstrates a 2/5 MMT grade for plantar flexion. What intervention strategy should be prioritized to MOST effectively facilitate progression of MMT grade from 2/5 to 3/5, based on the presented context?

<p>Applying neuromuscular electrical stimulation (NMES) in conjunction with volitional plantar flexion attempts to augment motor unit recruitment. (A)</p> Signup and view all the answers

A patient presents with restricted talocrural dorsiflexion following prolonged immobilization. Considering the arthrokinematics of the talocrural joint, which mobilization technique would MOST effectively address this limitation, assuming capsular restriction is the primary cause?

<p>Posterior glide of the tibia on the talus, performed in an open-packed position. (D)</p> Signup and view all the answers

During a biomechanical assessment, a patient exhibits excessive subtalar pronation. Which of the following muscle groups is MOST likely to be adaptively shortened, contributing to this postural imbalance?

<p>Peroneus longus and brevis. (A)</p> Signup and view all the answers

A researcher is investigating the reliability of subtalar neutral assessment using different palpation techniques. Which of the following factors would MOST significantly influence the inter-rater reliability of this assessment?

<p>The examiner's experience in palpating subtle bony contours and awareness of anatomical variations. (D)</p> Signup and view all the answers

In a patient with chronic plantar fasciitis, which of the following muscle length tests would MOST specifically assess the contribution of the gastrocnemius to the condition?

<p>Measuring ankle dorsiflexion range of motion with the knee in both extended and flexed positions. (A)</p> Signup and view all the answers

During electrodiagnostic testing, a patient exhibits reduced amplitude in the compound muscle action potential (CMAP) of the abductor hallucis muscle. Which nerve is MOST likely implicated in this finding?

<p>Medial plantar nerve. (A)</p> Signup and view all the answers

A patient post-Achilles tendon rupture is being assessed for plantarflexion strength using a handheld dynamometer. To isolate the soleus muscle during the MMT, what specific positioning modification is MOST crucial?

<p>Flexing the knee to approximately 90 degrees. (B)</p> Signup and view all the answers

A patient reports paresthesia along the plantar aspect of the third and fourth toes. Which of the following conditions is MOST likely responsible, considering potential nerve entrapment sites in the foot?

<p>Morton's neuroma affecting the common digital nerve. (C)</p> Signup and view all the answers

During gait analysis, a patient demonstrates excessive ankle eversion during the mid-stance phase. Which muscle group would be the MOST appropriate target for strengthening to address this deviation?

<p>Tibialis posterior and tibialis anterior. (B)</p> Signup and view all the answers

Following a distal fibular fracture, a patient exhibits persistent pain and limited range of motion in the ankle. Considering potential complications, which of the following is MOST critical to assess to rule out complex regional pain syndrome (CRPS)?

<p>Skin temperature and color changes, edema, and allodynia in the affected limb. (D)</p> Signup and view all the answers

A patient presents with limited composite ankle eversion following a distal fibula fracture. Despite pain management, the therapist notes restricted range of motion. Assuming soft tissue restrictions are the primary limitation, which of the following joint mobilization techniques would MOST directly address the arthrokinematics hindering composite ankle eversion, considering the coupled motions that occur?

<p>Anterior glide of the talus on the tibia, combined with a posterior glide of the fibula on the tibia to improve external rotation of the fibula. (B)</p> Signup and view all the answers

A researcher aims to quantify the contribution of the plantar fascia to arch support during the toe-off phase of gait. Which biomechanical measurement would provide the MOST direct insight into this contribution?

<p>Strain measurements within the plantar fascia using ultrasound elastography. (D)</p> Signup and view all the answers

A physical therapist assistant (PTA) is measuring subtalar joint inversion in a patient with chronic ankle instability. After placing the patient in the prone position and finding subtalar neutral, the PTA notes significant hypermobility during inversion. Which of the following modifications to the standard goniometric alignment would provide the MOST reliable and valid measurement of subtalar inversion ROM in this patient, mitigating the effects of the instability?

<p>Apply manual stabilization to the calcaneus, directly opposing the direction of inversion, to isolate subtalar motion and reduce accessory movements. (A)</p> Signup and view all the answers

During the assessment of a high-level gymnast complaining of persistent pain at the first metatarsophalangeal (MTP) joint, a PTA observes a subtle but distinct alteration in the joint's biomechanics. Despite achieving a seemingly normal range of motion during standard goniometric measurement of 1st MTP extension, the gymnast reports a painful 'block' at the end range. Which adjunctive assessment would BEST identify a potential intra-articular restriction that might be masked by compensatory movements?

<p>Assess the accessory movements of the first MTP joint, specifically anterior/posterior and medial/lateral glides, to identify capsular restrictions. (A)</p> Signup and view all the answers

A researcher is investigating the reliability of goniometric measurements for ankle dorsiflexion in patients with spasticity due to cerebral palsy. A standard goniometer is used, and measurements are taken with the knee extended. Considering the influence of gastrocnemius spasticity on ankle joint range of motion (ROM), which modification to the standard measurement protocol would MOST effectively improve the validity of assessing isolated ankle joint dorsiflexion?

<p>Maintaining the knee in a fully flexed position during ankle dorsiflexion measurement to minimize the effect of gastrocnemius spasticity. (D)</p> Signup and view all the answers

A PTA is assessing a patient with suspected talonavicular joint dysfunction. Palpation reveals tenderness and restricted joint play. Considering the coupled motions at the midtarsal joint, which combined movement assessment would BEST differentiate between an isolated talonavicular restriction versus a more complex midtarsal joint dysfunction affecting both the talonavicular and calcaneocuboid joints?

<p>Independently assess talonavicular and calcaneocuboid joint play in multiple planes while monitoring for compensatory movements at adjacent joints. (D)</p> Signup and view all the answers

In a clinical setting, a patient presents with isolated weakness in extending the metatarsophalangeal (MTP) joint of the great toe, but maintains dorsiflexion strength. Assuming a localized lesion, which of the following muscles is MOST likely affected, considering their distinct innervation and function?

<p>Extensor Hallucis Longus (C)</p> Signup and view all the answers

A physical therapist is assessing a patient with suspected peripheral neuropathy affecting the lower extremity. During manual muscle testing, the therapist observes weakness in both ankle dorsiflexion and extension of all toes. Which of the following scenarios BEST explains the potential differential involvement based on the provided information?

<p>Compromise of the Deep Peroneal nerve, impacting both ankle dorsiflexion and toe extension due to its innervation of the Extensor Digitorum Longus, Extensor Hallucis Longus, and Tibialis Anterior. (A)</p> Signup and view all the answers

During a gait analysis, a patient exhibits excessive plantarflexion at terminal stance, coupled with an inability to actively extend the great toe. Electromyography (EMG) reveals denervation potentials in the Extensor Hallucis Longus. Which of the following compensatory mechanisms is MOST likely to develop over time to maintain foot clearance during swing phase?

<p>Exaggerated hip and knee flexion (steppage gait) to ensure foot clearance, circumventing the need for active ankle dorsiflexion and toe extension. (A)</p> Signup and view all the answers

A patient reports experiencing anterior ankle pain that increases with resisted dorsiflexion and great toe extension. Magnetic Resonance Imaging (MRI) reveals tendinosis of both the Tibialis Anterior and Extensor Hallucis Longus tendons within the anterior compartment. Considering the biomechanical interaction between these muscles, which of the following interventions should be MOST emphasized during the EARLY rehabilitation phase?

<p>Activity modification focusing on reducing repetitive ankle dorsiflexion and great toe extension, combined with gentle range-of-motion exercises to prevent adhesions. (A)</p> Signup and view all the answers

A trained ballet dancer is diagnosed with Flexor Hallucis Longus (FHL) tendinopathy. Given the dancer’s need for strong plantarflexion and toe flexion for pointe work, which of the following strategies would be the MOST appropriate and comprehensive approach to rehabilitation, ensuring a safe return to dancing?

<p>Implementing a progressive loading program that gradually increases the demands on the FHL, integrating exercises that mimic specific dance movements, and addressing any biomechanical imbalances or technique flaws that may contribute to the condition. (A)</p> Signup and view all the answers

A researcher is investigating the effects of targeted muscle fatigue on postural control. Participants perform repetitive maximal voluntary contractions (MVCs) of the Extensor Digitorum Longus (EDL) until fatigue is reached. Which of the following outcomes would MOST likely be observed regarding postural sway during a subsequent balance task?

<p>An increase in postural sway due to impaired ability to make fine adjustments at the ankle joint. (C)</p> Signup and view all the answers

A patient with chronic exertional compartment syndrome (CECS) in the anterior compartment of the lower leg reports significant pain and paresthesia during prolonged running. The pain is primarily attributed to increased pressure within the compartment, affecting local neurovascular structures. Considering the anatomy of the anterior compartment, which nerve is MOST likely to be compressed, contributing to the reported paresthesia?

<p>Deep Peroneal Nerve (D)</p> Signup and view all the answers

A patient presents with a claw toe deformity affecting the second toe. Electrophysiological studies reveal isolated weakness of the intrinsic muscles of the foot, with normal function of the extrinsic flexors and extensors. Which of the following intrinsic muscle groups is MOST likely affected to cause this specific deformity pattern?

<p>Lumbricals and Interossei (C)</p> Signup and view all the answers

In a research study examining the effects of different footwear on lower extremity biomechanics during running, force plate data reveals that one group of participants demonstrates significantly increased ground reaction forces (GRF) and a prolonged loading rate at initial contact. Based on the muscles discussed, which of the following scenarios would MOST likely explain these findings?

<p>Participants are wearing minimalist shoes, leading to decreased activation of the Tibialis Anterior and subsequent heel strike mechanics. (B)</p> Signup and view all the answers

In assessing the Flexor Digitorum Longus (FDL), if the muscle exhibits weakness, yet the Flexor Hallucis Longus (FHL) function remains intact, which compensatory mechanism is MOST likely to manifest, leading to digital deformity?

<p>Isolated distal interphalangeal (DIP) joint flexion coupled with MTP hyperextension, culminating in hammer toe formation. (A)</p> Signup and view all the answers

During a manual muscle test (MMT) for the Flexor Hallucis Longus (FHL), stabilization of the metatarsophalangeal (MTP) joint in neutral with the ankle positioned between plantarflexion (PF) and dorsiflexion (DF) is crucial. What biomechanical rationale BEST justifies this stabilization protocol?

<p>To reduce the impact of the windlass mechanism on MTP joint kinematics, thus optimizing the specificity of isolated FHL contraction assessment. (B)</p> Signup and view all the answers

A patient demonstrates weakness in Flexor Hallucis Longus (FHL) function. What long-term biomechanical adaptation would MOST likely occur during weight-bearing activities to compensate for this deficiency?

<p>Pronation of the subtalar joint to permit medial loading, potentiating the effect of the spring ligament and plantar fascia. (D)</p> Signup and view all the answers

During manual muscle testing for the Flexor Hallucis Brevis (FHB), resistance is applied to the plantar aspect of the metatarsophalangeal (MTP) joint at the proximal phalanx, directed towards extension. What biomechanical principle dictates this specific resistance application?

<p>To maximize the external moment arm acting against FHB contraction, thereby optimizing the sensitivity of strength grading. (A)</p> Signup and view all the answers

A patient presents with a notable reduction in the ability to flex the metatarsophalangeal (MTP) joint of the first toe, concurrent with observed hammer toe deformities in the lesser toes. Which intrinsic foot muscle imbalance is MOST likely contributing to these findings?

<p>Impaired function of the Flexor Hallucis Brevis (FHB), permitting relative overactivity of the Extensor Digitorum Longus (EDL) on lesser toes. (A)</p> Signup and view all the answers

In a gross manual muscle test (MMT), what is the MOST critical distinction separating it from a specific muscle MMT, concerning the biomechanical precision of joint positioning and stabilization?

<p>Gross MMT permits deviation from the optimal muscle length-tension relationship, whereas in specific MMT, such positioning is paramount. (D)</p> Signup and view all the answers

During a gross manual muscle test (MMT) designed to assess lower extremity strength for basic activities of daily living (ADLs), transfers, and gait, which evaluation parameter offers the MOST clinically relevant insight into a patient's functional capacity?

<p>The patient's perceived exertion level during repetitive sit-to-stand transfers, correlated with observed compensatory movement patterns. (A)</p> Signup and view all the answers

Differentiate between the testing positions of the Flexor Hallucis Longus (FHL) and Flexor Hallucis Brevis (FHB) against gravity. What key element distinguishes the stabilization protocol required for each during manual muscle testing?

<p>FHL necessitates ankle stabilization between plantarflexion and dorsiflexion; FHB warrants stabilization of the foot and ankle in a neutral position. (C)</p> Signup and view all the answers

Considering the intricate interplay between the Flexor Hallucis Longus (FHL) and the intrinsic musculature of the foot, which biomechanical consequence is MOST likely to arise from FHL weakness during the propulsive phase of gait?

<p>Compensatory recruitment of the Flexor Digitorum Longus (FDL) to augment toe-off force, precipitating claw toe deformities in the lesser digits. (A)</p> Signup and view all the answers

What is the MOST pertinent clinical implication of mastering gross manual muscle testing (MMT) techniques in a rehabilitation setting concerning patient management and treatment planning?

<p>Efficient screening for generalized strength deficits impacting functional mobility, informing the design of comprehensive rehabilitation programs. (D)</p> Signup and view all the answers

Flashcards

Ankle Plantar Flexors

Muscles responsible for ankle plantar flexion.

Gastrocnemius

Part of the tendocalcaneus group, plantar flexes the ankle.

Soleus

A deep calf muscle, plantar flexes the ankle.

Plantaris

A smaller muscle, assists with ankle plantar flexion.

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Tibialis Posterior

Muscle that inverts the foot and assists with plantar flexion.

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Peroneus Longus & Brevis

Muscles that evert the foot and assist with ankle plantar flexion.

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Ankle Plantar Flexion 5/5

Highest MMT score where patient raises heel through full plantar flexion range 25 times in good form w/o fatigue.

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Composite Ankle Eversion

Combined movement of the ankle involving dorsiflexion, abduction, and eversion.

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Subtalar Inversion

Movement of the sole of the foot inward at the subtalar joint.

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Subtalar Eversion

Movement of the sole of the foot outward at the subtalar joint.

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1st Toe MTP Extension

Bending the big toe towards the top of the foot at the metatarsophalangeal joint.

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Finding Subtalar Neutral

Determining the neutral position of the subtalar joint, often in prone.

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Extensor Digitorum Longus and Brevis

Extends the toes and performs dorsiflexion of the ankle.

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Muscles That Extend the Great Toe

Muscles that extend the great toe (hallux).

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Extensor Hallucis Longus and Brevis

Muscles that extend the great toe (hallux) and also contribute to dorsiflexion of the ankle.

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Testing Position: Extensor Hallucis

Seated, foot stabilized in plantarflexion, extend MTP and IP joints of great toe, resist flexion.

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Weakness in Extensor Hallucis

Decreased extension of the first toe and decreased ankle dorsiflexion.

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Testing Position Across Gravity:

Side-lying, slight plantarflexion of ankle, support limb and foot.

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Muscles That Flex the Toes

Muscles that flex the toes.

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Flexor Digitorum Longus and Quadratus Plantae

Muscles responsible for flexing the toes, working together to provide plantarflexion.

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Testing Position

Supine, foot in neutral position.

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Weak toe extensors

Extension of MTPs, flexion of DIPs.

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Toe Extensors Test (Across Gravity)

Side-lying, limb and foot supported.

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Flexor Hallucis Longus Action

IP joint flexion of the great toe.

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Flexor Hallucis Longus (Against Gravity)

Supine.

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Weak Flexor Hallucis Longus

Weakness leads to hyperextended IP, hammer toe, reduced ankle PF strength.

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Flexor Hallucis Brevis Action

Flexion of the MTP of the 1st toe.

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Flexor Hallucis Brevis Test

Supine with neutral foot and ankle.

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Weak Flexor Hallucis Brevis

Reduced ability to flex the MTP of the 1st toe; hammer toes.

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Flexor Hallucis Brevis Test (Across Gravity)

Side-lying.

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Gross MMT

Basic strength awareness for ADLs – not exact MMT.

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Talocrural Dorsiflexion

Movement that decreases the angle between the foot and the lower leg, bringing the foot upward towards the shin.

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Talocrural Plantarflexion

Movement that increases the angle between the foot and the lower leg, pointing the foot downward.

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1st Toe MTP Flexion

Bending the big toe towards the sole of the foot at the metatarsophalangeal (MTP) joint.

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Talocrural dorsiflexion ROM

Tests the range of motion (ROM) of the ankle joint when the foot is moved upwards (dorsiflexion).

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Study Notes

  • Therapeutic Measurement and Testing (PTA 1008) covers ankle and foot assessments.

Objectives

  • Review bones, joints, ligaments, and musculature of the ankle and foot and surrounding areas.
  • Learn ankle and foot range of motion measurements using goniometry.
  • Learn manual muscle test positions for ankle and foot musculature against and across gravity.
  • Review dermatomes on and near the ankle and foot.
  • Discuss when range of motion and manual muscle testing are appropriate or inappropriate.
  • Learn to document the objective section of a note regarding goniometry and strength testing for the ankle and foot.
  • Review normal and abnormal end feels and discuss each joint's capsular patterns.

Functions of the Foot

  • Supports for upright posture.
  • Allows mechanism for rotation of the tibia and fibula during the stance phase of gait.
  • Allows shock absorption.
  • Provides flexibility for uneven terrain.
  • Used as a lever during push-off.

Musculoskeletal Overview

  • Includes joints and motions, bones and bony landmarks, and ligaments.

Planes of Motion

  • Ankle dorsiflexion/plantarflexion occurs in the sagittal plane around a frontal axis.
  • Ankle Inversion/Eversion occurs in the Frontal plane around a Sagittal axis.
  • Foot Abduction/Adduction occurs in the transverse plane around a Vertical axis.

Terms for Motions

  • Ankle Supination combines plantar flexion, inversion, and adduction in a non-weight bearing or open chain.
  • Ankle Pronation combines dorsiflexion, eversion, and abduction in a non-weight bearing or open chain.
  • Calcaneal Valgus means the distal part of the calcaneus is angled away from the midline.
  • Calcaneal Varus means the distal part of the calcaneus is angled towards the midline.

Arthrokinematics

  • The convex Talus moves on the concave Tibia during ankle dorsiflexion.
  • Dorsiflexion: glides posteriorly.
  • Plantarflexion: glides anteriorly.

Joints

  • Superior Tibiofibular Joint is a planar, synovial joint between the superior aspect of the tibia and fibula.
  • Inferior Tibiofibular Joint is a Fibrous joint allowing slight movement.
  • Talocrural Joint is the ankle joint, where the tibia and fibula articulate with the talus, allowing motion in the sagittal plane.
  • Subtalar Joint allows motion in an inversion/eversion.
  • MTP (Metatarsophalangeal Joint) allows Motion in flexion/ext, abduction/adduction; the midline is the second toe.
  • PIP and DIP Joints are the joints between the phalanges of the digits of the foot which allow motions of flexion and extension.

Bones

  • Includes the Fibula, Tibia, First, Second, Third Cuneiform, Navicular, Cuboid, Talus, and Calcaneus.

Functional Areas of the Foot

  • Include the Forefoot, Midfoot, and Hindfoot.

Calcaneal Varus and Valgus

  • Indicate a non-neutral position of the calcaneus.

Ligaments of Lateral Ankle

  • The Lateral Ligament connects the lateral malleolus to the talus and calcaneus in 3 parts
  • Consists of the anterior talofibular ligament, posterior talofibular ligament, and calcaneofibular ligament.

Ligaments of Medial Ankle

  • The Deltoid Ligament connects the medial malleolus to the talus, navicular, and calcaneus in 4 parts.
  • Consists of the Posterior tibiotalar ligament, Anterior tibiotalar ligament, Tibionavicular ligament, and Tibiocalcaneal ligament.

Ankle Joint

  • A Tri-planar joint.

Subtalar Joint and Transverse Tarsal Joint

  • Talus articulates with the Calcaneus.
  • Navicular, Cuboid, Talus, Calcaneus compose the joints.

Arches of the Foot

  • Includes the Medial and Lateral Longitudinal Arches.
  • The Medial arch includes the Navicular, 1st cuneiform, Talus, 1st metatarsal, and Calcaneus.
  • The Lateral arch includes the Cuboid, 5th metatarsal, Talus, and Calcaneus.

Arches of the Foot: Transverse Arch

  • Includes the Cuboid, the Cuneiforms (3rd, 2nd, 1st), and Talus.

Support of the Right Foot Medial View

  • The structures are the Navicular, 1st cuneiform, 1st metatarsal, spring ligament, Tibia, Talus, Calcaneus, plantar fascia, short plantar ligament, and the long plantar ligament.

Support of the Arches of the Right Foot Inferior View

  • The support includes the Long plantar L, 5th Mt, Short plantar L, 1st cuneiform, Navicular, Spring L, Tibialis posterior, Talus, and Calcaneus. The 4th 3rd and 2nd Mt contribute as well

The Windlass Effect

  • The Plantar fascia and the windlass effect.
  • Plantar flexors pull upward as the Calcaneus rises with the Plantar fascia tension lifting arch which allows the MTP joints to extend.

Goniometry of the Ankle and Foot

  • Measuring the angles and range of motion of the ankle and foot.

Goniometry: Talocrural Dorsiflexion

  • The normal range for Ankle dorsiflexion (talocrural joint) is 0-20 degrees.
  • Position the patient sitting with the knee flexed to 90 degrees, foot at 0 degrees of inversion/eversion.
  • Position the therapist alongside the patient, stabilizing the tibia and fibula.
  • The goniometer's fulcrum is over the lateral malleolus.
  • The movable arm is parallel to the lateral aspect of the 5th metatarsal.
  • The stationary arm is lateral midline of the fibula (fibular head).

Alternate Ways to Measure Dorsiflexion

  • Can be measured with the patient sitting.
  • Can also measure it with weight bearing.

Ankle dorsiflexion with the knee extended

  • The Gastrocnemius is a two-joint muscle crossing the tibiofemoral and talocrural joints.
  • Gastrocnemius length may limit dorsiflexion range of motion when tested with the knee extended.
  • Muscle length testing for one versus two joint ankle plantar flexors can be referenced.

Goniometry: Talocrural Plantar Flexion

  • The normal range for Ankle plantar flexion (talocrural jt:) is 0-50 degrees.
  • Position the patient sitting with the knee flexed to 90, foot at 0 degrees of inversion/eversion.
  • Position therapist alongside patient, stabilizing the tibia and fibula.
  • The goniometer's fulcrum over the lateral malleolus.
  • The Movable Arm: parallel to the lateral aspect of the 5th metatarsal.
  • The Stationary arm: lateral midline of the fibula (fibular head).

Plantar Flexion Normal End-Feel

  • Can be capsular/firm due to tension in the anterior joint capsule, the anterior portion of the deltoid ligament, the anterior talofibular ligament, tibialis anterior, extensor hallucis longus, and extensor digitorum longus muscles.
  • It can be bony due to contact between posterior tubercles of the talus and posterior margin of tibia.

Muscle Length testing for the Plantar Flexor Group

  • If a restriction into DF is found, the end feel can indicate tightness in either muscular tissue or the capsule.
  • Elastic restrictions mean further testing help identify if the restrictions are primarily because of loss of mobility in the Gastrocnemius, the Soleus or both structures.
  • Interventions depend on the tissue targeted.
  • Tests can be done non-weight bearing or in weight bearing positions.
  • Weight bearing positions typically find greater ROM.

1 vs 2 Joint Plantar Flexor Muscle Length Test

  • The Goniometer's Fulcrum: lateral aspect of lateral malleolus.
  • The Stationary Arm: lateral midline of the fibula (head of fibula).
  • The Movable Arm: parallel to lateral aspect of the 5th metatarsal.

1 vs 2 Joint Plantar Flexor Muscle Length Test

  • The Patient begins in the prone position, foot hanging off the edge of the plinth.
  • The goniometer is aligned as noted in the previous slide with the foot at 0 degrees of inv/ever.
  • Measure passive DF with the knee extended= should be 10 degrees or greater.
  • Then flex the knee passively and re-measure DF at end range- the motion should increase by 10 degrees to a total of 20 degrees.

1 vs. 2 Joint PF Muscle Length Test Results

  • If DF is 10 degrees or more with leg extended and 20 degrees once flexed, there is a normal length of all plantar flexors.
  • If DF is 10 degrees with the leg extended but does not increase once the knee is flexed, the soleus is tight (1 joint muscle).
  • If the DF is less than 10 degrees with the knee extended, but is full (20 degrees) with the knee flexed, the gastrocnemius is tight (2 joint muscle).

Weight bearing assessment (Kendall)

  • Test for 2-joint plantar flexor extensibility: standing with knees in extension (but not locked)
  • Dorsiflexion in this position should be 10 degrees.
  • Test for 1-joint plantar flexor extensibility: sit forward in a chair; slide feet back until the heels rise slightly; push the thigh down.
  • Dorsiflexion in this position should be 20 degrees.

Goniometry of Composite Ankle Inversion (Tarsal Joints)

  • A normal range of motion is between 0-35 degrees.
  • Position the patient sitting, knee flexed to 90, hip in no add/abd/rot.
  • In front of the patient stabilizing the tibia and fibula
  • The goniometer's fulcrum is anterior ankle between malleoli.
  • The stationary arm is on the anterior midline of the tibia (tibial tuberosity). -The Movable arm is on the anterior midline of the 2nd metatarsal.

Composite Ankle Inversion

  • Fulcrum: anterior ankle between malleoli.
  • Stationary arm: anterior midline of the tibia (tibial tuberosity).
  • Movable arm: anterior midline of the 2nd metatarsal.

Composite Inversion Normal End Feel

  • A capsular/firm end feel is caused by tension in joint capsules, anterior and posterior talofibular ligament, calcaneofibular ligament, anterior, posterior, lateral, and interosseous talocalcaneal ligaments, dorsal calcaneal ligaments, dorsal calcaneocuboid ligament, dorsal talonavicular ligament, the lateral band of bifurcate ligament, transverse metatarsal ligament, and by the peroneus longus and brevis muscles.

Composite Ankle Eversion

  • A normal range of motion is between 0-15 degrees.
  • Position the patient sitting with the knee flexed to 90, hip in no abd/add/rot.
  • Position the therapist in front of the patient stabilizing the tibia and fibula.

Composite Eversion

  • Fulcrum: anterior ankle between malleoli.
  • Stationary arm: anterior midline of the tibia (tibial tuberosity).
  • Movable arm: anterior midline of the 2nd metatarsal.

Composite Ankle Eversion Normal End Feel

  • A capsular/firm feel is due to tension of joint capsules, the deltoid ligament (many other ligaments), and the tibialis posterior muscle.
  • A bony feel is due to contact between the calcaneus and floor of sinus tarsi.

Finding Subtalar Neutral

  • Allows evaluation in a non-weight bearing position

Finding Subtalar Neutral

  • Position: Prone with foot off the edge and other leg crossed over behind. Technique:
  • Grasps foot at 4th and 5th MT heads using thumb and index.
  • The other hand palpates medial and lateral sides of the dorsal talus.
  • Gently and passively DF until resistance; then move through arc of pronation feeling for the neutral point.
  • The neutral point is the "fall off" to one side or the other in arc-non-weight bearing position of the subtalar joint.

Goniometry Subtalar Inversion

  • Hindfoot/subtalar inversion is measured within a range of 25-30 degrees.
  • The patient is prone, with the knee and hip in neutral and the foot over the edge of the table
  • The therapist should be standing at the foot of the patient.
  • While full DF, find subtalar neutral.
  • Fulcrum: posterior ankle midway between malleoli
  • Stationary Arm: posterior midline of lower leg
  • Movable Arm: posterior midline of calcaneus

Subtalar Inversion End Feel

  • A capsular/firm end feel is due to tension in the lateral joint capsule, anterior and posterior talofibular ligaments, calcaneofibular ligament, and lateral, posterior, anterior, and interosseous talocalcaneal ligaments.

Goniometry of Subtalar Eversion

  • The hindfoot/subtalar has an eversion range of 5-10°
  • Position the patient prone, with the knee and hip in neutral and the foot over the side of the table.
  • The therapist should be standing at the foot of the patient.
  • While full DF, find subtalar neutral.
  • This will be your starting number, measuring is done after this.
  • Fulcrum: posterior ankle between the malleoli.
    • Stationary arm: posterior midline of the lower leg.
    • Movable arm: posterior midline of the calcaneus.

Calculating Subtalar Inversion and Eversion

  • Obtain the measurement of the subtalar neutral; this will often not be 'zero' on the goniometer.
  • Move the calcaneus into the intended direction of inversion/eversion.
  • Then, obtain the measurement of the end position.
  • Determine how many degrees difference from the starting position to the end position and document.

Subtalar Eversion End Feel

  • Can be capsular/firm.
  • Or may be bony

Goniometry of MTP flexion of 1st Toe

  • The MTP flexion of the great toe is normally 0-45 deg.
  • Place the Patient: supine or seated with leg supported by the table, ankle/foot in neutral; MTP 0 abd/add and IP O flex/ext.
  • While Position of therapist: stabilize MTs, do NOT hold other MTs in extension.
  • The Goniometer's Fulcrum: over the dorsal side of 1st MTP joint
    • The Stationary: the arm is over the dorsal midline of the 1st metatarsal.
  • While Movable arm: over the dorsal midline of the proximal phalanx
  • A normal end-feel is Capsular/firm and that tension in the dorsal joint capsule/collateral ligaments; tension in the extensor digitorum brevis muscle may contribute.

Goniometry of MTP Extension of 1st Toe

  • MTP extension of great toe: 0-70 deg
  • Patient Position - Supine or Seated with leg supported by the table, ankle and foot in neutral, MTP 0 abd/add and IP O flex/ext, Stabilize MT's
  • The Goniometer's Fulcrum: over the dorsal side of the 1st MTP joint
  • Stabilize the patient · Normal End Feel - Capsular/Firm, tension in plantar joint capsule, the plantar pad, FHB and FDB mm.

Alternate Goniometer Placement

  • Used if a goniometer does not permit measuring the full motion from the MTP
  • Fulcrum: center of joint
    • Stationary arm: midline of proximal bone
    • Movable arm: midline of distal bone

Principles of ROM

  • Examples of capsular patterns, meaning patterns of restriction in a joint where certain motions are predictably more limited than others.
  • Talocrural: PF > DF
  • Subtalar (Talocalcaneal): Inversion > Eversion
  • 1st MTP: Extension > flexion
  • 2-5 MTP and IP joints: Flex > or = Ext
  • Talonavicular/calcaneocuboid: Inversion (PF, Add, Sup) > DF

Functional Ranges of the Ankle and Foot during Locomotion

  • During Dorsiflexion and Plantarflexion with Gait Level occurs on Surfaces while Ascending and Descending Stairs.
    • Dorsiflexion (Murray) = 0-10, (Rancho) = 0-10, (Ascending Stairs (Livingston et al)) = 20-24, and (Descending Stairs (Livingston et al)) 26-36.
    • Plantarflexion (Murray) = 15-30, (Rancho) = 0-15, (Ascending Stairs (Livingston et al)) = 24-30, and (Descending Stairs (Livingston et al)) 26-31.

Manual Muscle Testing Around or Involving the Ankle and Foot

  • A method for assessing the strength of muscles around the ankle and foot by testing their ability to move against gravity and resistance.

MMT Grading Review

  • 0/5 (Zero): No palpable muscle contraction.
  • 1/5 (Trace): Palpable muscle contraction, or tendon prominent but no joint movement.
  • 2-/5 (Poor Minus): Partial muscle range of motion in gravity eliminated.
  • 2/5 (Poor): Complete range of motion in gravity eliminated.
  • 2+/5 (Poor Plus): Partial range of motion against gravity OR complete across gravity against slight resistance.
  • 3-/5 (Fair Minus): Gradual release from the test position.
  • 3/5 (Fair): Holds the test position against gravity.
  • 3+/5 (Fair Plus): Able to hold the test position against gravity with slight pressure.
  • 4-/5 (Good Minus): Hold the test position against gravity with slight-moderate pressure.
  • 4/5 (Good): Hold the test position against gravity with moderate pressure.
  • 4+/5 (Good Plus): Hold test position against gravity with moderate-strong pressure.
  • 5/5 (Normal): Holds test position against gravity with strong pressure.

MMT of the Ankle and its Movements: Plantarflexion

  • Gastrocnemius (tendocalcaneus group).
  • Soleus (tendocalcaneus group).
  • Plantaris (tendocalcaneus group).
  • Flexor Hallucis Longus and Flexor Digitorum Longus (toe and forefoot and ankle jt PFs).

Gastrocnemius and Plantaris

  • Tests leg strength.

Ankle Plantarflexors

  • Perform Standing a testing position on the legs.

Grading of Plantarflexors

  • Standing: Patient completes > 25 heel raises = 5/5, 10-24 heel raises = 4/5, 1-9 heel raises = 3/5, and can't heel raise but clear heel slightly = 2+/5
  • Prone: Completes range and holds against maximal resistance = 2+/5, completes PF range but no resistance = 2/5, and completes partial range in prone = 2-/5.

Soleus

  • Used in tests of leg strength.
  • Testing position against gravity: prone with knee flexed at least 90 degrees.
    • Stabilization: lower leg proximal to the ankle.
    • Movement: plantar flexion (without inv/ever version).
    • Resistance: against the calcaneus into dorsiflexion.
      • Weakness: Unable to plantar flex

Tibialis Posterior

  • Testing position against gravity: supine, with leg in lateral rotation.
  • Stabilization: leg by the therapist above the ankle.
    • Resistance: on the medial and plantar foot into dorsiflexion and eversion.
    • Weakness: toes flex and inability to perform against resistance.

MMT of the Ankle and its Movements: Dorsiflexion

  • Extensor Hallucis Longus and Brevis (toe).
  • Tibialis Anterior.
  • Extensor Digitorum Longus and Brevis

Extensor Hallucis Longus and Brevis

  • Testing position against gravity is the supine or sitting.
  • Movement is the extension of MTP and IP of the great.

Tibialis Anterior

  • Medial cuneiform allows dorsiflexion and inversion of foot.
  • Key Test Points
  • Testing Position against Gravity: Seated
  • Movement: into Dorsiflexion and Inversion w/o great toe extension
  • Resistance: at the medial side, dorsal surface, towards ankle PF and foot eversion
  • Weakness: Inability to flex without eversion

What Muscles Evert the Foot

  • Peroneus Longus and Peroneus Brevis muscles for ankle and foot movement.

Peroneus Longus and Brevis (Eversion and Plantarflexion)

  • Key Test Points are:
  • Testing Position against Gravity: Supine with Medial Rotation
  • Movement: Eversion of the foot and ankle
  • Stabilize above ankle joint
  • Weakness: Unable to hold the test position

The Extensor Digitorum Longus and Brevis Muscles

  • Extend the toes and their positions on the foot

Extensor Digitorum Longus and Brevis (and Peroneus Tertius):

  • Used with seated Testing Position against Gravity. Movement: ext. of all joints of 2nd-5th digits. Resistance: dorsal surface of toes into flexion. Weakness: Decreased toe Extension,Foot drop .Foot varus tendency. Testing position across gravity: a sideline where feet are supported.

What Muscles Flex the Toes

  • The Flexor Digitorum Longus (assisted by Quadratus Plantae) flexes the toes.

Flexor Digitorum Longus (assisted by Quadratus Plantae):

  • Testing points against gravity are as follows:*
  • Supine position, knee Flexed to allow Neutral Foot
  • Stabilize dorsal metatarsals with foot/ankle neutral
  • Movement: toe flexion DIP 2-5
  • Weakness tends to hyperextend DIP
  • Side-Lying gravity test with limb and foot supported

What Muscles Flex the Toes

  • Flexor Digitorum Brevis also assists with MMT
  • Flexes middle phalanges, at the PIP's

The Tests are what?

  • -*Testing Position Against Gravity =Supine
  • -Stabilzation* =Dorsal Proximal Phalanges Neutral Foot and Ankle
  • Movement: Flexion of the PIP 2 to 5
  • Resistance: Plantar Middle Phalanx 2:5 to Extension

Flex the MTP joint

  • The lumbricals help stabilize this and are also involved.

Lumbricals:

  • Testing position against gravity: supine
  • Position the Stabilization: the dorsal mid-tarsal region by a practitioner.
  • Movement: flexion of the MTP 2-5 not with the IP that can hurt
  • Resistance: applied is plantar surface Proximal phalanx 2-5 toward ex

Flexor Hallucis Longus (base of the distal phalanx of the great toe):

  • The key test points include:* -Testing Points Against Gravity: a supine The Stabilization: a MTP Joint.
  • Movement: IP joint flexion of the great toe
  • Weakness: reduce ankle strength and may be caused by hyper-tension.

Flexor Hallucis Brevis Test

  • A Testing position against gravity is supine
  • the stabilization point: neutral foot and the Proximal MTP Joint
  • A movement is a flexion of the Mtp
  • A Resistive Planus force.

Gross MMT

  • A quick MMT to get a basic awareness of the strength in a primary motion

  • Does not require the patient and joint to be in the exact MMT test position as when testing specific muscles

  • The Goal* Test is to get what general ideas about strength the ADLS can transfer stand gata but there are limiting factor due to op limitation

  • It includes performing MMT in the Chart is the "Gross" must document positions from the previous document

Functional Application

  • A tool for stability, provide and an adequate base while also showing balance.

Normal Gait at the Subtalar Joint

  • Loading Responses of joint and impact The Tibialis Posterior/Soleus joints work to stabilize joint and Terminal STanaces

Functional Application in Weight Bearing :

  • Consist of Abd + DF that includes Calcaneus while in
  • The ADD force is talas during rotation

Review-Dermatomes of Ankle Foot Areas and Review on the touch

  • The Deep Tendon Reflex DTR -is graded by tendon simulation on an ankle and measures by contraction*

There are various reflex grading scores can be reviewed to determine a normal versus abnormal response from deep tissue stimulation.

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Description

This quiz covers manual muscle testing (MMT) for ankle plantar flexion, including grading strength, differentiating muscular and tendinous pain, and modifications for limited range of motion. Scenarios involve gravity resistance and minimized positions.

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