PTA 1008: Therapeutic Measurement & Testing (Ankle & Foot) PDF

1/22/2025 Therapeutic Measurement And Testing (PTA 1008) Ankle and Foot PowerPoint #5 © Stanbridge University 2025 1 1 ...

1/22/2025 Therapeutic Measurement And Testing (PTA 1008) Ankle and Foot PowerPoint #5 © Stanbridge University 2025 1 1  1/22/2025 1. Students will review the bones, joints, ligaments, and musculature of the ankle and foot and close surrounding areas 2. Students will learn the range of motion measurements of the ankle and foot using goniometry. 3. Students will learn the manual muscle test positions for the ankle and foot musculature, against and across gravity. 4. Students will review the dermatomes on and near the ankle and foot. Objectives 5. Students will be able to discuss when range of motion and manual muscle testing are appropriate or inappropriate. 6. Students will be able to document the objective section of a note regarding goniometry and strength testing for the ankle and foot. 7. Students will review normal and abnormal end feels and discuss the capsular patterns of each joint. © Stanbridge University 2025 2 2  1/22/2025 Functions of the Foot Mechanism for Support for upright rotation of the tibia Provides flexibility for posture and fibula during the uneven terrain stance phase of gait Shock absorption Lever during push-off © STANBRIDGE UNIVERSITY 2025 3 3  1/22/2025 Musculoskeletal overview of the ankle and foot Joints and Motions Bones and Bony landmarks Ligaments © STANBRIDGE UNIVERSITY 2025 4 4  1/22/2025 Planes of Motion (Review on your own) Ankle dorsiflexion/plantarflexion - Sagittal plane/Frontal axis Ankle Inversion/Eversion - Frontal plane/Sagittal axis Foot Abduction/Adduction - Transverse plane/Vertical axis © Stanbridge University 2025 5 5  1/22/2025 Terms for Motions (Review on your own) Ankle Supination - combination of plantar flexion, inversion and adduction (non-weight bearing or open chain) Ankle Pronation - combination of dorsiflexion, eversion, and abduction (non- weight bearing or open chain) Calcaneal Valgus - distal part of calcaneus is angled away from midline Calcaneal Varus - distal part of calcaneus is angled towards midline © Stanbridge University 2025 6 6  1/22/2025 Arthrokinematics (Review on your own) Convex Talus moves on Concave Dorsiflexion: Glides Plantarflexion: Tibia during ankle posteriorly Glides anteriorly dorsiflexion © Stanbridge University 2025 7 7  1/22/2025 Joints (Review on your own) Superior Tibiofibular Joint - Planar joint, synovial joint between superior aspect of tibia and fibula Inferior Tibiofibular Joint - Fibrous joint allowing slight movement Talocrural Joint - Ankle joint, tibia, fibula articulating with talus, motion in sagittal plane Subtalar Joint - Motion occurs in an inversion/eversion motion MTP (Metatarsophalangeal Joint) - Motion in flexion/ext, abduction/adduction, midline is the second toe PIP and DIP Joints - Joints between the phalanges of the digits of the foot, motions of flexion and extension © Stanbridge University 2025 8 8  1/22/2025 Bones (Review on your own) Lippert, 2017 © Stanbridge University 2025 9 9  1/22/2025 Functional Areas of the Foot (Lippert, 2017) (Review on your own) © Stanbridge University 2025 10 10  1/22/2025 Calcaneal Varus and Valgus Lippert, 2017 (Review on your own) © Stanbridge University 2025 11 11  1/22/2025 Ligaments of Lateral Ankle (Lippert, 2017) (Review on your own) Lateral Ligament: lateral malleolus to talus and calcaneus in 3 parts a) Anterior talofibular ligament b) Posterior talofibular ligament c) Calcaneofibular ligament © Stanbridge University 2025 12 12  1/22/2025 Ligaments of Medial Ankle (Lippert, 2017) (Review on your own) Deltoid Ligament :medial malleolus to talus, navicular and calcaneus in 4 parts a) Posterior tibiotalar ligament b) Anterior tibiotalar ligament c) Tibionavicular ligament d) Tibiocalcaneal ligament © Stanbridge University 2025 13 13  1/22/2025 Ankle Joint is Tri-planar (Lippert, 2017) (Review on your own) © Stanbridge University 2025 14 14  1/22/2025 Subtalar Joint and Transverse Tarsal Joint (Lippert, 2017) (Review on your own) © Stanbridge University 2025 15 15  1/22/2025 Arches of the Foot: Medial and Lateral Longitudinal Arches of the Right Foot (Lippert, 2017) (Review on your own) © Stanbridge University 2025 16 16  1/22/2025 Arches of the Foot: Transverse Arch, Front view of Right Foot (Lippert, 2017) (Review on your own) © Stanbridge University 2025 17 17  1/22/2025 Support of the Right Foot Medial View (Lippert, 2017) (Review on your own) © Stanbridge University 2025 18 18  1/22/2025 Support of the Arches of the Right Foot Inferior View (Lippert, 2017) (Review on your own) © Stanbridge University 2025 19 19  1/22/2025 Windlass Effect (Lippert, 2017) (Review on your own) © Stanbridge University 2025 20 20  1/22/2025 Goniometry of the Ankle and Foot © Stanbridge University 2025 21 21  1/22/2025 GONIOMETRY: TALOCRURAL DORSIFLEXION Ankle dorsiflexion (talocrural joint): 0-20 degrees Position of patient: Sitting, knee flexed to 90, foot 0 deg of inv/ever. Position of therapist: Along side the patient stabilizing the tibia and fibula Position of the Goniometer: Fulcrum: over lateral malleolus Movable Arm: parallel to the lateral aspect of the 5th metatarsal Stationary: lateral midline of the fibula (fibular head) © Stanbridge University 2025 22 22  1/22/2025 Why is it important that the knee be flexed to 90 degrees during this measurement? © Stanbridge University 2025 23 23  1/22/2025 Stationary Arm Talocrural DF (Norkin and White, 2016) © Stanbridge University 2025 24 24  1/22/2025 Dorsiflexion Normal End Feel Capsular/firm: due to tension in posterior joint capsule, soleus muscle, Achilles tendon, posterior portion of the deltoid ligament, posterior talofibular ligament, and calcaneofibular ligament © Stanbridge University 2025 25 25  1/22/2025 Alternate Ways to Measure Dorsiflexion (Norkin and White, 2016) © Stanbridge University 2025 26 26  1/22/2025 Ankle dorsiflexion with the knee extended: Gastrocnemius is a two joint muscle that crosses the tibiofemoral and talocrural joints If tested with the knee extended, gastrocnemius length may limit the dorsiflexion range of motion Refer to muscle length testing for the one versus two joint ankle plantar flexors in this lecture How would the end feel be different with the knee extended if the gastrocnemius was adaptively shortened? © Stanbridge University 2025 27 27  1/22/2025 Goniometry: Talocrural Plantar Flexion Ankle plantar flexion (talocrural jt): 0-50 degrees Position of patient: Sitting, knee flexed to 90, foot 0 deg of inv/ever Position of therapist: Along side the patient stabilizing the tibia and fibula Position of the Goniometer: Fulcrum: over lateral malleolus Movable Arm: parallel to the lateral aspect of the 5th metatarsal Stationary: lateral midline of the fibula (fibular head) © Stanbridge University 2025 28 28  1/22/2025 Goniometry of Talocrural Plantar Flexion (Norkin and White, 2016) © Stanbridge University 2025 29 29  1/22/2025 Plantar flexion Normal End-Feel Capsular/firm: tension in anterior joint capsule; anterior portion of deltoid ligament; anterior talofibular ligament; tibialis anterior, extensor hallucis longus, and extensor digitorum longus muscles or Bony: due to contact between posterior tubercles of the talus and posterior margin of tibia © Stanbridge University 2025 30 30  1/22/2025 Muscle length testing for the Plantar Flexor Group When a restriction into DF is found, the end feel can indicate tightness in either muscular tissue or the capsule If elastic restrictions are found, further testing can help identify if the restrictions are primarily due to loss of mobility in the Gastrocnemius, the Soleus or both structures This will direct the interventions assigned so that the appropriate tissue is targeted Tests can be done non-weight bearing or in weight bearing positions Weight bearing positions typically find greater ROM © Stanbridge University 2025 31 31  1/22/2025 1 and 2 joint Plantar Flexor Muscle Length Goniometer position Measurements Fulcrum: lateral aspect of lateral malleolus Stationary Arm: lateral midline of fibula (head of fibula) Movable Arm: parallel to lateral aspect of the 5th metatarsal © Stanbridge University 2025 32 32  1/22/2025 1 vs 2 Joint Plantar Flexor Muscle Length Test Patient begins in the prone position, foot hanging off the edge of the plinth Align the goniometer as noted in previous slide (foot 0 deg of inv/ever) Measure passive DF with the knee extended= should be 10 degrees or greater) Then flex the knee passively, re-measure DF at end range- the motion should increase by 10 degrees to a total of 20 degrees © Stanbridge University 2025 33 33  1/22/2025 1 vs. 2 Joint PF Muscle Length Test Results If DF is 10 degrees or more with leg extended and 20 degrees once flexed = 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) © Stanbridge University 2025 34 34  1/22/2025 Weight bearing assessment (Kendall) Test for 2-joint plantar flexor extensibility Test for 1-joint plantar flexor extensibility Sit forward in a chair, slide feet back until the heels rise slightly, push thigh down Dorsiflexion in this position should be Standing with knees in extension (but not 20 degrees locked) Dorsiflexion in this position should be 10 degrees © Stanbridge University 2025 35 35  1/22/2025 Goniometry of Composite Ankle Inversion (Tarsal Joints) (Norkin and White. Pg. 276-277) Range: 0-35 degrees Position of patient: Sitting, knee flexed to 90, hip in no add/abd/rot. Position of therapist: In front of the patient stabilizing the tibia and fibula © Stanbridge University 2025 36 36  1/22/2025 Composite Ankle Inversion Position of goniometer: Fulcrum: anterior ankle between malleoli Stationary arm: anterior midline of the tibia (tibial tuberosity) Movable arm: anterior midline of the 2nd metatarsal © Stanbridge University 2025 37 37  1/22/2025 Composite Inversion Normal End Feel Capsular/firm: 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; lateral band of bifurcate ligament; transverse metatarsal ligament; and other ligaments; peroneus longus and brevis muscles © Stanbridge University 2025 38 38  1/22/2025 COMPOSITE ANKLE EVERSION Range: 0-15 degrees Position of patient: Sitting, knee flexed to 90, hip no abd/add/rot Position of therapist: In front of the patient stabilizing the tibia and fibula © Stanbridge University 2025 39 39  1/22/2025 Composite Eversion Position of goniometer: Fulcrum: anterior ankle between malleoli Stationary arm: anterior midline of the tibia (tibial tuberosity) Movable arm: anterior midline of the 2nd metatarsal © Stanbridge University 2025 40 40  1/22/2025 Composite Ankle Eversion Normal End Feel Capsular/firm: due to tension of joint capsules, deltoid ligament (many other ligaments) and tibialis posterior muscle Bony: TarsaldueJoint to contact betweenNormal Eversion: calcaneus and floor of sinus tarsi End Feel 41 © Stanbridge University 2025 41  1/22/2025 Finding Unweighted Subtalar Neutral © Stanbridge University 2025 42 42  1/22/2025 Finding Subtalar Neutral (Magee, pg.622-623) Position: Prone with foot off the edge and other leg crossed over behind (figure 4) Technique: 1. SPTA grasps foot at 4th and 5th MT heads using thumb and index 2. Other hand palpates medial and lateral sides of the dorsal talus 3. Gently and passively DF until resistance; then move through arc of supination and pronation feeling for the talus 4. Point in arc where there is a “fall off” to one side or the other is the neutral, non-weight bearing position of the subtalar joint Magee, David J. Orthopedic Physical Assessment, 3rd Edition. Philadelphia: WB Saunders Company, 1997, pg 622-623. © Stanbridge University 2025 43 43  1/22/2025 Hindfoot/subtalar inversion (range 25-30 degrees Subtalar Instability Peritalar Symposium) Position of patient: prone, knee and hip in neutral with foot over edge of table. Goniometry Position of therapist: standing at the foot of the patient Place the patient in full DF, then find subtalar neutral (this will Subtalar be your starting number, before measuring); (the other leg is in a figure 4) Inversion Position of goniometer: Fulcrum: posterior ankle midway between malleoli Stationary Arm: posterior midline of lower leg Movable Arm: posterior midline of calcaneus 44 © Stanbridge University 2025 44  1/22/2025 Goniometry Subtalar Inversion left foot (posterior) (Norkin and White, 2016) © Stanbridge University 2025 45 45  1/22/2025 Subtalar Inversion End Feel Capsular/firm: tension in lateral joint capsule, anterior and posterior talofibular ligaments, calcaneofibular ligament and lateral, posterior, anterior, and interosseous talocalcaneal ligaments © Stanbridge University 2025 46 46  1/22/2025 Goniometry of Subtalar Eversion Hindfoot/subtalar eversion (range 5-10⁰ Subtalar Instability Peritalar Symposium) Position of patient: prone, knee and hip in neutral, foot over the side of the table Position of therapist: standing at the foot of the patient Put the patient in full DF, then find subtalar neutral (this will be your starting number, before measuring); (other leg is in figure 4) Position of goniometer: Fulcrum: posterior ankle between the malleoli Stationary arm: posterior midline of the lower leg Movable arm: posterior midline of the calcaneus © Stanbridge University 2025 47 47  1/22/2025 Goniometry Subtalar Eversion Left Foot (posterior) (Norkin and White, 2016) © Stanbridge University 2025 48 48  1/22/2025 Calculating Subtalar Inversion and Eversion 1. Obtain measurement of subtalar neutral. This will often not be ‘zero’ on the goniometer 2. Move the calcaneus into the intended direction (subtalar inversion or eversion) 3. Obtain the measurement of the end position 4. Determine how many degrees difference from the starting position to the end position and document that number © Stanbridge University 2025 49 49  1/22/2025 Calculating Subtalar Inversion and Eversion Example: Subtalar neutral position measured at 4 degrees of subtalar inversion. The calcaneus is then moved into subtalar eversion and measured at 5 degrees of subtalar eversion. Movement was from 4 degrees of subtalar inversion (baseline) to 5 degrees of subtalar eversion for a total of 9 degrees of subtalar eversion motion. Document subtalar eversion as 9 degrees. For subtalar inversion of the same person: Subtalar neutral is measured at 4 degrees of subtalar inversion. The calcaneus is then moved into subtalar inversion and measured at 32 degrees of subtalar inversion. Movement was from 4 degrees of subtalar inversion (baseline) to 32 degrees of subtalar inversion for a total of 28 degrees of subtalar inversion motion. Document subtalar inversion as 28 degrees. © Stanbridge University 2025 50 50  1/22/2025 Subtalar Eversion End Feel Capsular/firm May be bony © Stanbridge University 2025 51 51  1/22/2025 Goniometry of MTP flexion of 1st Toe MTP flexion of great toe: 0-45 deg Position of patient: supine or seated with leg supported by the table; ankle and foot in neutral; MTP 0 abd/add and IP 0 flex/ext Position of therapist: stabilize MTs (do not hold other MTs in extension) Position of goniometer Fulcrum: over the dorsal side of 1st MTP joint Stationary arm: over the dorsal midline of the 1st metatarsal Movable arm: over the dorsal midline of the proximal phalanx Normal End-Feel: Capsular/firm: tension in the dorsal joint capsule and collateral ligaments; tension in extensor digitorum brevis muscle may contribute 52 © Stanbridge University 2025 52  1/22/2025 Goniometry of MTP flexion of 1st Toe © Stanbridge University 2025 53 53  1/22/2025 Goniometry of MTP Extension of 1st Toe MTP extension of great toe: 0-70 deg Position of patient: supine or seated with leg supported by the table; ankle and foot in neutral; MTP 0 abd/add and IP 0 flex/ext Position of therapist: stabilize MTs (do not hold other MTs in flexion) Position of goniometer Fulcrum: over the dorsal side of 1st MTP joint Stationary arm: over the dorsal midline of the 1st metatarsal Movable arm: over the dorsal midline of the proximal phalanx (alternative placement to position goniometer medial side) Normal End-Feel: Capsular/firm: tension in plantar joint capsule, the plantar pad, flexor halluces brevis, flexor digitorum brevis, and flexor digiti minimi muscles © Stanbridge University 2025 54 54  1/22/2025 Goniometry: MTP Extension of 1st Toe © Stanbridge University 2025 55 55  1/22/2025 Alternate Goniometer Placement If the goniometer does not permit or measure full motion (especially during MTP extension of the 1st toe) with placement on top of the joint and bones, you can place a clear goniometer along the side of the joint and bones. Fulcrum: center of joint Stationary Arm: midline of proximal bone Movable Arm: midline of distal bone © Stanbridge University 2025 56 56  1/22/2025 Principles of ROM: EXAMPLES OF CAPSULAR PATTERNS 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 © Stanbridge University 2025 57 57  1/22/2025 Functional Ranges of the Ankle and Foot during Locomotion (Norkin and White 309, Table 10.8) Motion Gait Level Ascending Stairs Descending Stairs Surfaces dorsiflexion 0-10 (Murray) 20-24 (Livingston et al) 26-36 (Livingston et al) 0-10 (Rancho) plantarflexion 15-30 (Murray) 24-30 (Livingston et al) 26-31 (Livingston et al) 0-15 (Rancho) © Stanbridge University 2025 58 58  1/22/2025 Manual Muscle Testing Around or Involving the Ankle and Foot © Stanbridge University 2025 59 59  1/22/2025 MMT Grading Review 1/5 Trace: palpable 2-/5 Poor Minus : partial 2/5 Poor: complete range 0/5 Zero: no palpable muscle contraction, or muscle range of motion in of muscle being tested in muscle contraction tendon prominent, NO gravity eliminated gravity eliminated joint movement 2+/5Poor Plus: partial range of motion against 3-/5 Fair Minus : gradual 3+/5 Fair Plus: able to hold gravity; 3/5 Fair: holds test release from the test test position against OR complete across gravity position against gravity position occurs gravity with slight pressure movement against slight resistance 4-/5 Good Minus: hold test 4/5 Good: hold test 4+/5 Good Plus: hold test 5/5 Normal: holds test position against gravity position against gravity, position against gravity, position against gravity with slight-moderate moderate pressure moderate-strong pressure with strong pressure pressure © Stanbridge University 2025 60 60  1/22/2025 What muscles plantar flex the talocrural joint? © Stanbridge University 2025 61 61  1/22/2025 Muscles responsible for movement of ankle PF: ✓ Gastrocnemius (tendocalcaneus group) ✓ Soleus (tendocalcaneus group) ✓ Plantaris (tendocalcaneus group) MMT of ✓ Tibialis Posterior (forefoot and ankle jt) the Ankle ✓ Peroneus Longus and Brevis (forefoot and ankle jt) and Foot ✓ Flexor Hallucis Longus and Flexor Digitorum Longus (toe and forefoot and ankle jt PFs) © Stanbridge University 2025 62 62  1/22/2025 Gastrocnemius and Plantaris Kendall, 2005 © Stanbridge University 2025 63 63  1/22/2025 Testing position against gravity: Standing on testing leg Stabilization: pt. can have hand on table for support but no pressure Ankle through hand Movement: full heel rise onto toes with body weight upwards Plantar Weakness: unable to perform complete heel rise onto toes, lean flexors forward and/or flex knee Testing position across gravity: prone with leg supported and foot (Kendall, off end of table 2005) Hislop, Helen J.; Montgomery, Jacqueline. Daniels and Worthingham’s Muscle Testing Techniques of Manual Examination, 8th Edition. St. Louis: Saunders, 2007, pgs 227-230. © Stanbridge University 2025 64 64  1/22/2025 5/5: Patient successfully raises heel from floor through range of motion of plantar flexion a minimum of 25 times in good form and without apparent fatigue. Grading of 4/5: Full range of motion between 10-24 times Plantar 3/5: Full range of motion between 1-9 times flexors in 2+/5: Patient can just clear the heel from the floor (exception for 2+ testing, no grade in standing for a 2) standing Hislop and Montgomery © Stanbridge University 2025 65 65  1/22/2025 2+/5: completes PF range and holds against maximal Grading of resistance Plantar 2/5: completes PF range but no resistance 2-/5: completes only partial range of motion in prone flexors in Prone Hislop and Montgomery © Stanbridge University 2025 66 66  1/22/2025 SOLEUS Kendall, 2005 © Stanbridge University 2025 67 67  1/22/2025 Testing position against gravity: prone, knee flexed at least 90 degrees Stabilization: lower leg proximal to the ankle Movement: plantar flexion (w/o inv/ever) Resistance: against calcaneus into dorsiflexion Weakness: unable to plantar flex Soleus Testing position across gravity: side lying, knee bent to 90 deg. Stabilization: support limb © Stanbridge University 2025 68 68  1/22/2025 Tibialis Posterior Kendall, 2005 © Stanbridge University 2025 69 69  1/22/2025 Testing position against gravity: supine, leg in lateral rotation Stabilization: leg by the therapist above the ankle Movement: inversion of the foot with plantar flexion Tibialis of ankle Resistance: on the medial and plantar foot into Posterior dorsiflexion and eversion (Inv, PF) Weakness: toes flex and inability to perform against resistance Testing position across gravity : side lying with LE supported © Stanbridge University 2025 70 70  1/22/2025 What muscles dorsiflex the talocrural joint? © Stanbridge University 2025 71 71  1/22/2025 Extensor Hallucis Longus and Brevis Kendall, 2005 © Stanbridge University 2025 72 72  1/22/2025 Testing position against gravity: supine or sitting Stabilization: foot by therapist in slight ankle plantar flexion Movement: extension of MTP and IP of the great Extensor toe Resistance: against dorsal surface of distal and Hallucis proximal phalanges of the great toe into plantar flexion Longus Weakness: unable to extend great toe and difficulty with DF ankle and Brevis Testing position across gravity: side lying supporting leg © Stanbridge University 2025 73 73  1/22/2025 Tibialis Anterior Kendall, 2005 © Stanbridge University 2025 74 74  1/22/2025 Testing position against gravity: sitting with knee flexed (if any gastrocnemius tightness) Stabilization: leg by therapist proximal to the ankle joint Movement: into Dorsiflexion and Inversion w/o great toe Tibialis extension Resistance: at the medial side, dorsal surface, towards ankle Anterior PF and foot eversion Weakness: inability to flex without eversion (DF and Inv) Testing position across gravity: side lying, testing leg on top Stabilization: support leg © Stanbridge University 2025 75 75  1/22/2025 What muscles evert the foot? © Stanbridge University 2025 76 76  1/22/2025 Peroneus Longus and Peroneus Brevis Kendall, 2005 © Stanbridge University 2025 77 77  1/22/2025 Testing position against gravity: supine with medial rotation Peroneus Stabilization: above ankle joint Longus and Movement: eversion of the foot with plantar flexion of ankle Peroneus Resistance: lateral border and plantar surface into Brevis inversion and dorsiflexion Weakness: unable to hold position (Eversion and Plantar Testing position across gravity: side-lying flexion) Stabilization: leg supported by therapist © Stanbridge University 2025 78 78  1/22/2025 79 What muscles extend the toes? © Stanbridge University 2025 EDL, EDB,PT 79  1/22/2025 Testing position against gravity: seated Stabilization: foot by therapist in slight PF Movement: ext. of all joints of 2nd-5th digits (5th only Extensor longus) Digitorum Resistance: dorsal surface of toes into flexion Weakness: decreased toe extension; foot drop and Longus forefoot varus tendency, decreased DF of ankle and eversion of foot and Brevis (and Testing position across gravity: side-lying, foot supported Peroneus ✓ Flat feet increased likelihood for weakness ✓ Peroneus tertius is a part of the Extensor Digitorum Tertius) Longus ✓ Without extensor longus, no ext. of 5th digit occurs. © Stanbridge University 2025 80 80  1/22/2025 Extensor Digitorum Longus and Brevis Kendall, 2005 © Stanbridge University 2025 81 81  1/22/2025 82 What muscles extend the great toe? © Stanbridge University 2025 82  1/22/2025 Extensor Hallucis Longus and Brevis (Ext of toes and DF of ankle) Peroneus Tertius on Right © Stanbridge University 2025 83 83  1/22/2025 Testing position against gravity: seated Stabilization: foot by therapist in slight ankle PF Movement: extension of MTP and IP of the great toes Extensor Resistance: dorsal DP and PP of the great toe towards flexion Hallucis Weakness: decreased extension of 1st toe and decreased ankle DF Longus Testing position across gravity: side-lying, slight and Brevis PF of ankle Stabilization: support limb and foot © Stanbridge University 2025 84 84  1/22/2025 85 What muscles flex the toes? © Stanbridge University 2025 85  1/22/2025 Flexor Digitorum Longus and Quadratus Plantae Kendall, 2005 © Stanbridge University 2025 86 86  1/22/2025 Testing position against gravity: supine, foot in Flexor neutral (if gastric. tight, permit knee flexion to allow neutral foot) Stabilization: dorsal metatarsals with foot/ankle Digitorum neutral Movement: toe flexion DIP 2-5 Longus Resistance: Plantar surface of distal phalanx 2-5 towards extension (assisted Weakness: tends to hyperextend DIP, decreased by inversion of foot and PF of ankle; WB tends to pronate Quadratus Testing position across gravity: side-lying, support limb and foot Plantae) © Stanbridge University 2025 87 87  1/22/2025 Flexor Digitorum Brevis © Stanbridge University 2025 88 88  1/22/2025 Testing position against gravity: supine Stabilization: dorsal proximal phalanges, neutral Flexor foot and ankle (if triceps surae (gastroc+soleus) is paralyzed, stabilize calcaneus) Digitorum Movement: flexion of the PIP 2-5 Resistance: plantar middle phalanx 2-5 towards Brevis: extension inserts at the Weakness: decreased flexion of the PIP 2-5; middle reduced longitudinal and transverse arch support phalanges, Testing position across gravity: side-lying with limb supported flexes PIP’s © Stanbridge University 2025 89 89  1/22/2025 Lumbricals and Interossei © Stanbridge University 2025 90 90  1/22/2025 Lumbricals (Kendall, 2005) © Stanbridge University 2025 91 91  1/22/2025 Testing position against gravity: supine Stabilization: dorsal mid-tarsal region by therapist Movement: flexion of the MTP 2-5 (avoid IP Lumbricals: flexion) Resistance: plantar surface proximal phalanx 2-5 MTP flexion, towards ext. and IP Weakness: hyperextension of MTPs (if flexor extension digitorum longus ok), DIPs flex → hammer toes; reduced transverse arch support Testing position across gravity: side-lying, limb and foot supported © Stanbridge University 2025 92 92  1/22/2025 Flexor Hallucis Longus (Kendall, 2005) © Stanbridge University 2025 93 93  1/22/2025 Flexor Hallucis Longus (base of the distal phalanx of the great toe) Testing position against gravity: supine Stabilization: MTP joint in neutral with ankle between PF and DF (if longus is weak, stabilize PP in slight extension) Movement: IP joint flexion of the great toe Resistance: plantar distal phalanx towards extension Weakness: tendency towards hyperextension of IP and hammer toe great toe; reduced ankle PF and foot inv strength; in WB permits pronation tendency Testing position across gravity: side-lying with limb and foot supported © Stanbridge University 2025 94 94  1/22/2025 Flexor Hallucis Brevis (Kendall, 2005) © Stanbridge University 2025 95 95  1/22/2025 Testing position against gravity: supine Stabilization: neutral foot and ankle, hold proximal to MTP Movement: flexion of the MTP Resistance: plantar MTP at the proximal Flexor phalanx towards extension Hallucis Weakness: reduced ability to flex the MTP Brevis of the 1st toe; hammer toes Testing position across gravity: side-lying Weakness demonstrated by hammer toes © Stanbridge University 2025 96 96  1/22/2025 Gross MMT (Review) 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 is to get a general idea of the strength needed for basic ADL’s, transfers, standing, gait, etc. The patient might not be able to get in the test position due to post operative limitation, pain, or general functional limitations © Stanbridge University 2025 97 97  1/22/2025 Gross MMT (Review) Gross MMT must be noted in the chart that the test was “gross”, and should be documented how it was performed (patient position) Gross testing is often used to test each of the primary motions knowing the weakness, pain, and general limitations of the hospital setting Gross testing typically reduces the number of transitions or movements required of the patient © Stanbridge University 2025 98 98  1/22/2025 Gross MMT Patient position or observed task Hip flexion seated seated, or in side-lying in the middle of the Hip abduction transfer (supine to sit) observation of bridge, or in side-lying in the Hip extension middle of the transfer Hip external seated Gross MMT: rotation Hip internal Lower extremity rotation seated example Knee flexion seated Knee seated extension Ankle seated dorsiflexion Ankle seated plantarflexion © Stanbridge University 2025 99 99  1/22/2025 Functional Application The foot provides a stable base for upright activities such as standing and walking and is important in balance. Adequate foot strength and range are important. During normal gait, in loading response, foot support is on the heel. In mid stance, it is on the foot flat. In terminal stance, it is on the forefoot and toes. In pre-swing, it is on the medial forefoot. Perry and Burnfield. Gait Analysis Normal and Pathological Function, 2 nd Edition. Lippert, 2017 © Stanbridge University 2025 100 100  1/22/2025 Functional Application in Weight Bearing (Closed Kinetic Chain) Supination= Abd + DF of talus & Inversion of calcaneus, and tibiofibular lateral rotation Pronation= Add + PF of talus & Eversion of calcaneus, and tibiofibular medial rotation © Stanbridge University 2025 101 101  1/22/2025 During Normal Gait at the Subtalar Joint, Supination and Pronation of the foot occur Functional In supination the foot is more of a rigid lever, and in pronation Application in the foot is more of a flexible support. Weight During Loading Response subtalar joint pronation assists in Bearing the shock absorption of the limb loading impact as well as unlocking the midtarsal joint for forefoot floor contact. (Closed Kinetic Chain) In late Terminal Stance, Tibialis Posterior and Soleus Activity acts concentrically to move the Subtalar joint towards supination, this increases stability of the midtarsal joints and creates a Rigid Forefoot Lever during Terminal Stance. © Stanbridge University 2025 102 102  1/22/2025 Functional Application: non-weight bearing (open chain) combined motions Supination: plantarflexion of the talocrural joint, inversion, and adduction Pronation: dorsiflexion of the talocrural joint, eversion, and abduction Lippert, 2017 103 © Stanbridge University 2025 103  1/22/2025 Achilles Tendon Reflex Innervation: S1-2 Deep -patient should be completely relaxed and should Tendon understand the test Reflex -the muscle should be placed on a slight stretch Review -the hammer should deliver a direct strike, without “pecking” -compare both limbs (right versus left) © Stanbridge University 2025 104 104  1/22/2025 DTR grading Reflex Grading Interpretation 0 = no response (areflexia) Always abnormal 1+ = diminished/depressed response May or may not be normal (compare (hyporeflexia) bilaterally) 2+ = active, normal response Normal 3+ = brisk/exaggerated response (hyperactive) May or may not be normal (compare bilaterally) 4+ = very brisk/hyperactive; abnormal Always abnormal response (hypereflexive) © Stanbridge University 2025 105 105  1/22/2025 Dermatomes of the Ankle Area © Stanbridge University 2025 106 Copyright © 2017 by F. A. Davis Company 106  1/22/2025 Documentation Goniometry Follow guidelines outlined previously in intro to goniometry MMT Therapeutic Follow guidelines outlined previously in intro to Measurement goniometry Sensory Testing and Testing Type of sensory test performed (TMT) of the Where the test was performed (dermatomes) Patient response: note any areas of hypoaesthesia, Ankle and hyperaesthesia, dysaesthesia or normal response Foot Sensory Grading Intact, poor, fair, good (subjective) 0 = absent; 1= impaired; 2 = intact; NT= not tested © Stanbridge University 2025 107 107  TMT: Ankle and Foot PTA 1008 Week 5 Techniques you will learn this week All of these are eligible for your competency and Practical #2. Ankle and foot ROM and Ankle Strength Testing Reflex and Sensation Testing Muscle Length Tests Talocrural dorsiflexion Gastrocnemius MMT – against DTR- Achilles tendon reflex Talocrural plantar gravity Light touch sensation- L4, L5, flexion Soleus MMT – against gravity S1, S2 dermatomes Composite ankle Tibialis posterior MMT – against inversion gravity Composite ankle Extensor hallucis longus and brevis eversion MMT Subtalar inversion Tibialis anterior MMT Subtalar eversion Peroneus longus and brevis MMT 1st toe MTP flexion Extensor digitorum longus and 1 toe MTP extension st brevis MMT Muscle length testing Flexor digitorum longus and for plantar flexors quadratus plantae MMT Finding subtalar Flexor digitorum brevis MMT neutral Lumbricals and interossei MMT Flexor hallucis longus and brevis MMT Lab Section 1: Ankle and foot ROM and Muscle Length Tests Lab Activity: In pairs, practice measuring each of the following ankle and foot goniometry (PROM and AROM), and muscle length tests with your partner. Follow the Goniometry Assessment Guide Talocrural (Norkin and White, 2016) Ankle dorsiflexion (talocrural jt): 0-20 dorsiflexion degrees Position of patient: Sitting, knee flexed to 90, foot 0 of inv/ever. (subtalar neutral) Position of therapist: Alongside the patient stabilizing the tibia and fibula Position of the Goniometer: Fulcrum: over lateral malleolus Movable Arm: parallel to the lateral aspect of the 5th metatarsal Stationary: Lateral midline of the fibular (fibular head) 1  TMT: Ankle and Foot PTA 1008 Week 5 Alternate ways to measure dorsiflexion (Norkin and White, 2016) Talocrural Ankle plantar flexion (talocrural jt): (Norkin and White, 2016) Plantar flexion 0-50 degrees Position of patient: Sitting, knee flexed to 90, foot 0 of inv/ev. (subtalar neutral) Position of therapist: Alongside the patient stabilizing the tibia and fibula Position of the Goniometer: Fulcrum: over lateral malleolus Movable Arm: parallel to the lateral aspect of the 5th metatarsal Stationary: Lateral midline of the fibular (fibular head) 2  TMT: Ankle and Foot PTA 1008 Week 5 Composite Ankle Range: 0-35 degrees (Norkin and White, 2016) Inversion Position of patient: Sitting, knee flexed (Tarsal Joints) to 90, hip in no add/abd/rot. (Norkin and White. Pg. Position of therapist: In front of the 276-277) patient stabilizing the tibia and fibula Position of goniometer: Fulcrum: anterior ankle between malleoli Stationary arm: anterior midline of the tibia (tibial tuberosity) Movable arm: anterior midline of the 2nd metatarsal Composite ankle Range: 0-15 degrees eversion Position of patient: Sitting, knee flexed to 90, hip no abd/add/rot Position of therapist: In front of the patient stabilizing the tibia and fibula Position of goniometer: Fulcrum: anterior ankle between Malleoli Stationary arm: anterior midline of the tibia (tibial tuberosity) Movable arm: anterior midline of the 2nd metatarsal (Norkin and White, 2016) Subtalar Inversion Range: 0-25 (or 30) degrees (Norkin Position of patient: prone, knee and hip and in neutral with foot over edge of table White, Position of therapist: standing at the 2016) foot of the patient; place the patient in full DF, then find subtalar neutral (this will be your starting number, before measuring); the other leg is in a figure 4 Position of goniometer: Fulcrum: posterior ankle midway 3  TMT: Ankle and Foot PTA 1008 Week 5 between malleoli Stationary Arm: posterior midline of lower leg Movable Arm: posterior midline of calcaneus Subtalar Eversion Range: 0- 5 (or 10⁰) Subtalar (Norkin and White, 2016) Position of patient: prone, knee and hip in neutral, foot over the side of the table Position of therapist: standing at the foot of the patient; put the patient in full DF, then find subtalar neutral (this will be your starting number, before measuring); (other leg is in figure 4) Position of goniometer: Fulcrum: posterior ankle between the malleoli Stationary arm: posterior midline of the lower leg Movable arm: posterior midline of the calcaneus MTP flexion 1st Toe Range: 0-45 deg Position of patient: supine or seated with leg supported by the table; ankle and foot in neutral; MTP 0 abd/add and IP 0 flex/ext Position of therapist: stabilize MTs (do not hold other MTs in extension) Position of goniometer Fulcrum: over the dorsal side of 1st MTP joint Stationary arm: over the dorsal midline (Norkin and White, 2016) of the 1st metatarsal Movable arm: over the dorsal midline of the proximal phalanx 1st Toe MTP Range: 0-70 deg (Norkin and White, 2016) Extension Position of patient: supine or seated with leg supported by the table; ankle and foot in neutral; MTP 0 abd/add and IP 0 flex/ext Position of therapist: stabilize MTs (do not hold other MTs in flexion) Position of goniometer Fulcrum: over the dorsal side of 1st MTP joint Stationary arm: over the dorsal midline of the 1st metatarsal 4 TMT: Ankle and Foot PTA 1008 Week 5 Movable arm: over the dorsal midline of the proximal phalanx (alternative placement to position goniometer medial side) Finding Subtalar Neutral Position: Prone with foot off the edge and other leg crossed over behind Technique: 1. sPTA grasps foot at 4th and 5th MT heads using thumb and index 2. other hand palpates medial and lateral sides of the dorsal talus 3. gently and passively DF until resistance; then move through arc of supination and pronation feeling for the talus 4. point in arc where there is a “fall off” to one side or the other is the neutral, non-weight bearing position of the subtalar joint Magee, 623 Ankle measurement with Figure 8 method: The patient seated or lies in the supine position, with the ankle in 20° of plantarflexion. The sPTA places a tape measure ‘zero mark’ on the anterior ankle midway between the malleoli. The tape is then drawn medially and is placed just distal to the navicular tuberosity. The tape is then pulled under the foot, across the plantar arch and just proximal to the fifth metatarsal. The tape is then pulled up and across the tibialis anterior tendon and around the anterior ankle to a point just distal to the medial malleolus, and then pulled posteriorly across the Achilles tendon laterally and placed just distal to the lateral malleolus. The tape is then placed anteriorly and across to the start of the tape. 1. Pull the tape snugly without creating indentation in the skin and read the circumference in centimeters (or inches). 2. Recommend taking three measurements and record the average. 3. Repeat steps for involved limb. 5 TMT: Ankle and Foot PTA 1008 Week 5 Muscle length testing for the plantar flexor group When a restriction into DF is found, the end feel can indicate tightness in either muscular tissue or the capsule If elastic restrictions are found, further testing can help identify if the restrictions are primarily due to loss of mobility in the 1 joint (mainly soleus) vs 2 joint (mainly gastrocnemius) plantar flexors, or both structures This will direct the interventions assigned so that the appropriate tissue is targeted Tests can be done non-weight bearing or in weight bearing positions Weight bearing positions typically find greater ROM Knee extended: all plantar flexors are lengthened Knee flexed: gastroc (and plantaris) are in slack behind the knee, so less tension in the gastroc around the ankle 6 TMT: Ankle and Foot PTA 1008 Week 5 Non-Weight Bearing Assessment 1 vs 2 Joint Ankle Plantar Flexor Length Test for 2-joint plantar flexor extensibility Test for 1-joint plantar flexor extensibility Position: prone (or supine) on the table Position: In prone, passively flex the with thigh supported and feet off the table knee to 90 degrees Test: knee extended (but not locked), Test: move ankle into end range measure full passive DF in subtalar neutral dorsiflexion in subtalar neutral Dorsiflexion in this position should be 10 Dorsiflexion in this position should be degrees 20 degrees 7  TMT: Ankle and Foot PTA 1008 Week 5 Non-Weight Bearing Assessment 1 vs 2 Joint Ankle Plantar Flexor Length (Alternate Positioning) Lab Section 2: Ankle and foot MMT, reflex testing and sensation review Lab Activity: In pairs, practice measuring each of the following ankle and foot strength and sensation testing techniques with your partner. Follow the MMT Assessment Guide Ankle Testing position against gravity: Standing on (Kendall, Plantar flexors testing leg 2005) Stabilization: pt. can have hand on table for support but no pressure through hand Movement: full heel rise onto toes with body weight upwards Weakness: UA to perform complete heel rise onto toes, lean forward and/or flex knee Testing position across gravity: prone with leg supported and foot off end of table Grading in standing: 5/5: Patient successfully raises heel from floor through range of motion of plantar flexion a minimum of 25 times in good form and without apparent fatigue. 4/5: Full range of motion between 10-24 times 3/5: Full range of motion between 1-9 times 2+/5: Patient can just clear the heel from the 8  TMT: Ankle and Foot PTA 1008 Week 5 floor (exception for 2+ testing, no grade in standing for a 2) Grading in prone: 2+/5: completes PF range and holds against maximal resistance 2/5: completes PF range but no resistance 2-/5: completes only partial range of motion in prone Soleus Testing position against gravity: prone, knee flexed at least 90 degrees Stabilization: lower leg proximal to the ankle Movement: plantar flexion (w/o inv/ever) Resistance: against calcaneus into dorsiflexion Weakness: unable to plantar flex Testing position across gravity: side lying, knee bent to 90 deg. Stabilization: support limb (Kendall, 2005) Tibialis posterior Testing position against gravity: supine, leg in lateral rotation Stabilization: leg by the therapist above the ankle Movement: inversion of the foot with plantar flexion of ankle (Kendall, 2005) Resistance: on the medial and plantar foot into dorsiflexion and eversion Weakness: toes flex and inability to perform against resistance Testing position across gravity: side lying with LE supported 9  TMT: Ankle and Foot PTA 1008 Week 5 Extensor hallucis Testing position against gravity: supine or longus and brevis sitting Stabilization: foot by therapist in slight ankle plantar flexion Movement: extension of MTP and IP of the great toe Resistance: against dorsal surface of distal and proximal phalanges of the great toe into plantar flexion Weakness: unable to extend great toe and difficulty with DF ankle Testing position across gravity: side lying (Kendall, 2005) supporting leg Tibialis anterior Testing position against gravity: sitting with knee flexed (if any gastrocnemius tightness) Stabilization: leg by therapist proximal to the ankle joint 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 Testing position across gravity: side lying, testing leg on top Stabilization: support leg (Kendall, 2005) Peroneus longus Testing position against gravity: supine with and peroneus medial rotation brevis Stabilization: above ankle joint Movement: eversion of the foot with plantar flexion of ankle Resistance: lateral border and plantar surface into inversion and dorsiflexion (Kendall, 2005) Weakness: unable to hold position Testing position across gravity: side lying Stabilization: leg supported by therapist 10  TMT: Ankle and Foot PTA 1008 Week 5 Extensor Digitorum Testing position against gravity: seated Longus and Brevis Stabilization: foot by therapist in slight PF (and Peroneus Movement: ext. of all joints of 2nd-5th digits Tertius) (5th only longus) Resistance: dorsal surface of toes into flexion Weakness: decreased toe extension; foot drop and forefoot varus tendency, decreased DF of ankle and eversion of foot Testing position across gravity: side-lying, foot supported Flat feet increased likelihood for weakness Peroneus tertius is a part of the Extensor Digitorum Longus (Kendall, 2005) Without extensor longus, no ext. of 5th digit occurs. Flexor Digitorum Testing position against gravity: supine, foot (Kendall, Longus (assisted in neutral (if gastric. tight, permit knee flexion 2005) by Quadratus to allow neutral foot) Plantae) Stabilization: dorsal metatarsals with foot/ ankle neutral Movement: toe flexion DIP 2-5. Resistance: Plantar surface of DIP 2-5 towards extension Weakness: tends to hyperextend DIP, decreased inversion of foot and PF of ankle; WB tends to pronate Testing position across gravity: side-lying, support limb and foot Flexor Digitorum Testing position against gravity: supine (Kendall, Brevis Stabilization: dorsal proximal phalanges, neutral 2005) foot and ankle (if triceps surae (gastroc+soleus) is paralyzed, stabilize calcaneus) Movement: flexion of the PIP 2-5 Resistance: plantar middle phalanx 2-5 towards extension Weakness: decreased flexion of the PIP 2-5; reduced longitudinal and transverse arch support Testing position across gravity: side-lying with limb supported 11  TMT: Ankle and Foot PTA 1008 Week 5 Lumbricals Testing position against gravity: supine Stabilization: dorsal mid-tarsal region by therapist Movement: flexion of the MTP 2-5 (avoid IP flexion) Resistance: plantar surface proximal phalanges 2-5 towards ext. Weakness: hyperextension of MTPs (if flexor digitorum longus ok), DIPs flex à hammer toes; reduced transverse arch support Testing position across gravity: side-lying, limb and foot supported (Kendall, 2005) Flexor hallucis Testing position against gravity: supine longus Stabilization: MTP joint in neutral with ankle btwn PF and DF (if longus is weak, stabilize PP in slight ext) Movement: IP joint flexion of the great toe Resistance: plantar distal phalanx towards extension Weakness: tendency towards hyperextension of IP and hammer toe great toe; reduced ankle PF and foot inv strength; in WB permits (Kendall, 2005) pronation tendency Testing position across gravity: side-lying with limb and foot supported Flexor hallucis Testing position against gravity: supine brevis Stabilization: neutral foot and ankle, hold proximal to MTP Movement: flexion of the MTP Resistance: plantar MTP at the proximal phalanx towards extension Weakness: reduced ability to flex the MTP of the 1st toe; hammer toes Testing position across gravity: side-lying Weakness demonstrated by hammer toes (Kendall, 2005) 12  TMT: Ankle and Foot PTA 1008 Week 5 Review: Dermatomes of the ankle and foot area (L4, L5, S1, S2) Review light touch, sharp/dull, and temperature sensation testing. Deep Tendon Reflex (DTR) Testing A tendon is stimulated with a reflex hammer and the muscle contraction response is graded Occurs due to the reflex arc in either brainstem or innervating spinal cord segment Lower Motor Neuron (LMN) lesion to the peripheral nervous system (peripheral nerves): results in hypo- reflexive response Upper Motor Neuron (UMN) lesion to central nervous system (brain or spinal cord): results in hyper- reflexive response If an absent DTR accompanies: -sensory loss in corresponding nerve distribution of the reflex à possibly afferent arc of reflex (sensory nerve or dorsal horn) affected or -paralysis, fasciculations, or atrophy à possibly lesion in efferent arc (efferent nerve (motor nerve), anterior horn cells or both) Achilles Tendon Reflex Innervation: S1-2 -patient should be completely relaxed and should understand the test -the muscle should be placed on a slight stretch -the hammer should deliver a direct strike, without “pecking” -compare both limbs (right versus left) 13 TMT: Ankle and Foot PTA 1008 Week 5 14 Handout for Lecture - Ankle: 1. What motions are available at the talocrural joint? o Dorsiflexion o Plantarflexion 2. What is the primary plane that these actions occur in, and around what axis? o Sagittal plane o Frontal axis 3. Goniometer Placement for Measuring Ankle Motions: Motion Fulcrum Stationary Arm Movable Arm Dorsiflexion Lateral Lateral midline of Parallel to lateral aspect of the 5th malleolus fibula metatarsal Plantarflexion Lateral Lateral midline of Parallel to lateral aspect of the 5th malleolus fibula metatarsal 4. Normal AAOS Ankle Range of Motion and End Feels: Motion Normal AAOS Range Normal End Feel Dorsiflexion 0-20° Firm (capsular) Plantarflexion 0-50° Firm or hard (bony) Inversion 0-35° Firm (capsular) Eversion 0-15° Firm (capsular) or hard 5. Capsular Pattern for the Talocrural Joint: o Plantarflexion > Dorsiflexion 6. Ankle Range of Motion during Normal Gait Phases: o Initial Contact: Neutral (0°) o Loading Response: 5-10° plantarflexion o Midstance: 5-10° dorsiflexion o Terminal Stance: 10-15° dorsiflexion o Pre-Swing: 15-20° plantarflexion  o Swing Phase: Neutral (0°) 7. Muscles Acting in Talocrural Plantarflexion: o Prime Movers: Gastrocnemius, Soleus o Assistive Muscles: Tibialis Posterior, Flexor Hallucis Longus, Flexor Digitorum Longus, Peroneus Longus, Peroneus Brevis, Plantaris 8. Manual Muscle Testing (MMT) Against Gravity: o Plantarflexion: Standing on testing leg, full heel rise onto toes. o Dorsiflexion: Sitting with knee flexed, patient dorsiflexes against resistance. o Inversion: Supine, patient inverts foot while resisting pressure on the medial foot. o Eversion: Supine, patient everts foot while resisting pressure on the lateral foot. 9. Why is the ankle stabilized in slight plantar flexion during the extensor hallucis longus and brevis MMT? o This reduces passive resistance from the gastrocnemius, allowing better isolation of the extensor muscles. 10. Why should there not be great toe extension during the anterior tibialis MMT? o Extending the great toe can lead to compensation by the extensor hallucis longus, making the test invalid. 11. Difference in Patient Position for Peroneus Longus and Brevis MMT vs. Posterior Tibialis MMT? o Peroneus Longus & Brevis: Supine with medial rotation o Posterior Tibialis: Supine with lateral rotation 12. What does the plantar flexor length test assess? o It differentiates between one-joint (Soleus) and two-joint (Gastrocnemius) tightness by comparing dorsiflexion range with the knee extended vs. flexed. Handout for Lecture - Foot: 1. What motions are available at the foot and at what joints? o Subtalar Joint: Inversion & Eversion o Transverse Tarsal Joint: Pronation & Supination  o MTP Joints: Flexion, Extension, Abduction, Adduction o PIP & DIP Joints: Flexion, Extension 2. Goniometer Placement for Measuring Toe Motions: Motion Fulcrum Stationary Arm Movable Arm Great Toe MTP Dorsal aspect of Dorsal midline of 1st Dorsal midline of Flexion MTP joint metatarsal proximal phalanx Toes 2-5 MTP Dorsal aspect of Dorsal midline of Dorsal midline of Flexion MTP joint corresponding metatarsal proximal phalanx Toes 2-5 PIP Dorsal aspect of Dorsal midline of proximal Dorsal midline of Flexion PIP joint phalanx middle phalanx Toes 2-5 DIP Dorsal aspect of Dorsal midline of middle Dorsal midline of Flexion DIP joint phalanx distal phalanx 3. Normal AAOS Toe Range of Motion and End Feels: Motion Normal AAOS Range Normal End Feel Great Toe MTP Flexion 0-45° Firm Great Toe MTP Extension 0-70° Firm Toes 2-5 MTP Flexion 0-40° Firm Toes 2-5 PIP Flexion 0-35° Firm Toes 2-5 DIP Flexion 0-60° Firm 4. Manual Muscle Testing (MMT) Against Gravity for Foot Muscles: o Toe Flexion: Supine, patient curls toes while therapist applies resistance at proximal phalanx. o Toe Extension: Supine, patient extends toes against downward pressure. o Big Toe Flexion: Supine, patient flexes big toe while resisting force applied under the toe. o Big Toe Extension: Supine, patient extends big toe against resistance at the distal phalanx.  o Lumbricals MMT: Supine, patient flexes MTP joints while therapist applies resistance at proximal phalanges. 5. Weak Muscles Leading to Hammer Toes: o Lumbricals and Interossei 6. Muscles that Evert the Foot: o Peroneus Longus o Peroneus Brevis o Peroneus Tertius 7. Muscles that Invert the Foot: o Tibialis Posterior o Tibialis Anterior o Flexor Digitorum Longus o Flexor Hallucis Longus 8. Difference in Resistance Location for Lumbricals, Flexor Digitorum Longus, and Flexor Digitorum Brevis MMT: o Lumbricals: Resistance at proximal phalanges (MTP flexion) o FDL: Resistance at distal phalanges (DIP flexion) o FDB: Resistance at middle phalanges (PIP flexion) 9. Two Muscles with Common Actions of Dorsiflexion and Eversion: o Peroneus Tertius o Extensor Digitorum Longus 10. Differences in Action Between Extensor Digitorum Longus and Extensor Digitorum Brevis: o EDL: Extends all four lateral toes o EDB: Extends only toes 2-4 at MTP 11. Difference in Action Between Extensor Hallucis Longus and Extensor Hallucis Brevis: o EHL: Extends both MTP and IP of great toe o EHB: Extends only MTP of great toe 12. Muscle that Assists Flexor Digitorum Longus: o Quadratus Plantae 13. Difference in Toe Flexion Between FDL and FDB: o FDL: Flexes DIP o FDB: Flexes PIP 14. How Do Lumbricals of the Foot Compare to the Hand? o Both flex MTP joints and extend IP joints 15. Difference in Flexion Between FHL and FHB: o FHL: Flexes IP & MTP o FHB: Flexes only MTP 16. Weak Muscles Leading to Hammer Toes: o Lumbricals and Interossei 17. Why Knee is Flexed in Soleus MMT? o To eliminate gastrocnemius involvement 18. Why Ankle in Slight Plantar Flexion for EHL/EHB and EDL/EDB MMT? o To reduce passive resistance and isolate the extensors