Ankle and Lower Leg: Anterior Structures PDF

ANKLE AND LOWER LEG: ANTERIOR STRUCTURES Tibialis Anterior Muscle Sartorius Tibialis anterior Gastrocnemius Extensor digitorum longus Soleus The tibialis anterior muscle belly is located at the upper two thirds of the tibia and immediately lateral to its bony ridge. The tendon of this muscle, o...

ANKLE AND LOWER LEG: ANTERIOR STRUCTURES Tibialis Anterior Muscle Sartorius Tibialis anterior Gastrocnemius Extensor digitorum longus Soleus The tibialis anterior muscle belly is located at the upper two thirds of the tibia and immediately lateral to its bony ridge. The tendon of this muscle, one of the most prominent of the foot, traverses medially across the ankle joint. The muscle and its tendinous orientation assists to slow foot and ankle pronation during the initial phases of gait. Origin: Lateral tibial condyle and upper two thirds of the lateral tibial surface Insertion: First (medial) cuneiform and the base of the first metatarsal Action: Ankle dorsiflexion, foot inversion and adduction (supination) at the subtalar and midtarsal joints; supports the arch during ambulation Anterior Palpation Procedure • The patient can be placed supine or prone, but E6296/Speicher/Fig. 05.02/532042/JG/R1 the tissue must be relaxed. • Find the ridge, or tibial crest, of the tibia and move just laterally off of it at its upper two thirds to find the tibialis anterior muscle belly. • Resistive ankle dorsiflexion with inversion will bring out the belly of the muscle under the fingers. • Once found, strum across the muscle and then follow its course to its tendinous aspect. • Note the location of any tender points or fasciculatory response at the muscle or tendon and their attachments. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • The patient is prone with the knee flexed to 90° and the shin supported with either your thigh or a bolster. • Move the ankle into plantar flexion and marked inversion with your far hand. • Apply downward compression at the calcaneus with your far hand. 72 Innervation: L4-L5 and often S1 (deep peroneal nerve) Tibialis anterior muscle palpation procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. ANKLE AND LOWER LEG: ANTERIOR STRUCTURES • Externally rotate the calcaneus with your far hand. • Corollary tissues treated: Tibialis anterior tendon, extensor digitorum longus See video 5.1 for the tibialis anterior muscle PRT procedure. Patient Self-Treatment Procedure • Place the involved side on the opposite thigh. • Grasp the heel and move the ankle and foot into plantar flexion and marked inversion while feeling for the most relaxed tissue position and also the presence of a fasciculation. • Once you have obtained the most relaxed position or a strong fasciculation, externally rotate the ankle and then compress it toward the knee by pushing upward against the calcaneus until the fasciculation has subsided or abated. Tibialis anterior muscle PRT clinician procedure. Tibialis anterior muscle patient self-treatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 73 ANKLE AND LOWER LEG: ANTERIOR STRUCTURES Extensor Digitorum Longus Muscle Sartorius Tibialis anterior Gastrocnemius Extensor digitorum longus Soleus The belly of the extensor digitorum longus is sandwiched between the tibialis anterior and peroneal muscles. The tendon of this muscle bifurcates below the ankle joint to form the peroneus tertius. Origin: Lateral tibial condyle, proximal medial surface of the fibular shaft, interosseous membrane Insertion: Second through fifth middle and distal phalanges Action: Extends the second through fifth toes; assists with ankle dorsiflexion and foot eversion Innervation: L5-S1 (deep peroneal nerve) Anterior Palpation Procedure • With the patient supine and the knee flexed, E6296/Speicher/Fig. 05.02/532042/JG/R1 locate the tibialis anterior muscle belly. • Slide laterally off of the tibialis anterior onto the muscle belly of the extensor digitorum longus. The peroneals are behind or lateral to the extensor digitorum longus. • While palpating, have the patient extend the lesser toes (second through fifth) against resistance. • The tendons of this muscle can also be traced superiorly to the muscle belly as well. • Note the location of any tender points or fasciculatory response of the muscle and its attachments. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Extensor digitorum longus muscle palpation procedure. PRT Clinician Procedure • The patient is prone with the knee flexed to 70 to 90° and the shin supported with either your thigh or a bolster. • Grasp the calcaneus with your far hand while applying ankle dorsiflexion with your far forearm or torso. • Extend the toes with the far forearm or torso. • Move the ankle into eversion with your far hand while applying downward calcaneal compression. 74 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. ANKLE AND LOWER LEG: ANTERIOR STRUCTURES • Externally rotate the tibia with your far hand or torso. • Corollary tissues treated: Extensor digitorum longus tendon, fibularis muscle and tendons, interosseous membrane Patient Self-Treatment Procedure • Place the involved side on the opposite thigh. • Grasp the heel and move the ankle and foot into dorsiflexion and eversion while feeling for the most relaxed tissue position and also the presence of a fasciculation. • Once you have attained either the most relaxed position or a strong fasciculation, externally rotate the ankle and then compress it toward the knee by pushing upward against the calcaneus until the fasciculation has subsided or abated. Extensor digitorum longus muscle PRT clinician procedure. Extensor digitorum longus muscle patient selftreatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 75 ANKLE AND LOWER LEG: ANTERIOR STRUCTURES Anterior Talofibular Ligament Anterior tibiofibular Posterior tibiofibular Anterior talofibular Posterior talofibular Cuboideonavicular The anterior talofibular ligament (ATF) is the weakest and one of the most commonly torn lateral collateral ligaments of the ankle. The most common mechanism to tear this ligament is excessive inversion with plantar flexion under a weight-bearing load. Origin: Anterior surface of the lateral malleolus Calcaneofibular Insertion: Lateral neck of the talus Lateral E6296/Speicher/Fig. 05.01/532039/JG/R1 Palpation Procedure • Because the ATF is a thickening of the ankle’s joint capsule, its borders are not readily identifiable, but its location can be ascertained. • Move anteriorly off the anterior portion of the lateral malleolus toward the neck of the talus. • Note the location of any tender points or fasciculatory response at the ligament and its origin and attachment. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • The patient is side-lying on the affected side with the knee flexed. • Place the lateral ankle joint below a firm bolster to serve as a fulcrum. • Move the ankle into dorsiflexion with your far hand or your leg and apply a downward force on the calcaneus to produce eversion and a lateral joint glide. • Apply calcaneal external rotation with your far hand. • Corollary tissues treated: Calcaneofibular ligament, posterior tibiofibular ligament, peroneal muscles and tendons, extensor digitorum brevis Action: Stabilizes against ankle inversion; prevents anterior luxation of the talus when in a plantarflexed position Anterior talofibular ligament palpation procedure. Anterior talofibular ligament PRT clinician procedure. See video 5.2 for the anterior talofibular ligament PRT procedure. 76 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. ANKLE AND LOWER LEG: MEDIAL STRUCTURES Deltoid Ligament The deltoid ligament is composed of four ligaments that fan distally from the medial malleolus to their respective insertion sites denoted by their names: posterior tibiotalar, tibiocalcaneal, tibionavicular, and anterior tibiotalar. Even though the deltoid ligament is located under the flexor retinaculum and flexor tendons, its anterior and posterior fibers can be distinguished. The deltoid ligament is not often injured because of the bony block to eversion created by the inferior fibula shaft. Posterior tibiotalar Anterior tibiotalar Tibionavicular Tibiocalcaneal Origin: Anterior and inferior aspects of the medial malleolus Insertion: Posterior tibiotalar: Medial tubercle Tibiocalcaneal: Sustentaculum tali of the calcaneus Tibionavicular navicular and tibiotalar: Anterior medial talar dome Medial E6296/Speicher/Fig. 05.05/532054/JG/R1 Palpation Procedure • Place the ankle in a neutral and relaxed position. • Strum across the thickening of the tibiocalcaneal ligament at the junction between the apex of the medial malleolus and sustentaculum tali. • The posterior and anterior portions of the deltoid ligament are oriented at approximately 45° angles to the tibiocalcaneal ligament and can be felt off the distal portion of the malleolus from where they insert. • Determine the most dominant tender point or fasciculation (or both) and maintain light pressure with the pad(s) of the finger(s) throughout the treatment until reassessment has occurred. Action: Stabilizes against hindfoot eversion; supports the spring ligament; resists lateral displacement of the talus; prevents external rotation of the talus Deltoid ligament PRT clinician procedure. PRT Clinician Procedure • The patient is side-lying with the knee flexed. Place the lateral ankle joint below a firm bolster to serve as a fulcrum. • Place the ankle into dorsiflexion with your far hand and apply a downward force on the calcaneus to produce inversion and a medial joint glide. • With the far hand apply internal and external rotation to fine-tune. • Corollary tissues treated: Spring ligament, tibialis posterior, flexor digitorum longus, medial flexor retinaculum, flexor hallucis longus T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 77 ANKLE AND LOWER LEG: MEDIAL STRUCTURES Tibialis Posterior Muscle and Tendon The tibialis posterior muscle is located in the deep posterior compartment of the lower leg, but its tendon and lower fibers are accessible just behind the medial malleolus. This muscle helps to stabilize the arch during ambulation. Popliteus Peroneus longus Tibialis posterior Flexor digitorum longus Flexor hallucis longus Peroneus brevis Deep Palpation Procedure 5.4/532050/JG/R1 • Place E6296/Speicher/Fig. the patient in either a prone or supine knee-flexed position to relax the gastrocnemius and soleus musculature. • Trace the tendon just medial to the medial malleolus upward along the shaft of the tibia until it dips away under the tibia. • Continue to palpate superiorly along the tibia’s shaft while reaching deep into the space between the tibia and gastrocnemius and soleus musculature. • Roll the fingers upward against the posterior lateral shaft of the tibia to apply indirect pressure to the posterior tibialis musculature through the pressure exerted on the flexor digitorum longus muscle. • Note the location of any tender points or fasciculatory response of the muscle and tendon and their attachments. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Origin: Posterior surface of the interosseous membrane, proximal two thirds of the posterior lateral shaft of the tibia, medial fibular shaft and head Insertion: Navicular tuberosity, cuneiform bones, cuboid slip, base of the second through fourth metatarsals Action: Foot inversion; assists ankle plantar flexion Innervation: L4-L5 and sometimes S1 (low branches of tibial nerve) Tibialis posterior muscle and tendon palpation procedure. PRT Clinician Procedure • The patient is prone with the knee flexed to approximately 60°. • Grasp the calcaneus with your far hand with the dorsum of the hand facing outward. 78 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. ANKLE AND LOWER LEG: MEDIAL STRUCTURES • Use the near hand to monitor the lesion. • Using the calcaneus as a fulcrum, move the lower leg and ankle into marked internal rotation with your far hand. • Move the ankle into plantar flexion and marked inversion with the far hand. • Apply cephalad calcaneal compression toward the knee with the far hand. • Apply internal rotation of the calcaneus for fine-tuning with the far hand. • Corollary tissues treated: Flexor digitorum longus, flexor hallucis longus, soleus, deltoid ligament complex See video 5.3 for the tibialis posterior muscle and tendon PRT procedure. Patient Self-Treatment Procedure • Place the involved side on the opposite thigh. • Grasp the heel and forefoot and move the ankle and foot into marked plantar flexion and inversion while feeling for the most relaxed tissue position and also the presence of a fasciculation. • Once you have obtained either the most relaxed position or a strong fasciculation, invert and internally rotate the ankle and then compress it toward the knee by pushing upward against the calcaneus until the fasciculation has subsided or abated. Tibialis posterior muscle and tendon PRT clinician procedure. Tibialis posterior muscle and tendon patient selftreatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 79 ANKLE AND LOWER LEG: POSTERIOR STRUCTURES Achilles Tendon Gastrocnemius (medial head) Gastrocnemius (lateral head) Soleus Achilles tendon The Achilles tendon, also known as the tendo calcaneus, is formed by the soleus and gastrocnemius musculature and is often a site of irritation in the athletic and recreational population. The broad aponeurosis is flatter at the musculotendinous junction and then becomes more cordlike as it approaches the calcaneus. Therefore, a strumming palpation can be performed to assess its integrity proximally. However, above the heel, a pincing and sliding motion up and down the tendon can be used to assess both the tendon and its sheath for the presence of tissue lesions. Origin: Inferior fibers of the gastrocnemius and soleus musculature Flexor retinaculum Insertion: Calcaneus Action: Plantar flexes and stabilizes the ankle Superficial posterior Palpation Procedure E6296/Speicher/Fig. 05.06/532057/JG/R1 • The patient should be positioned prone with the knee flexed and ankle bolstered to relax the triceps surae complex. • Start palpation at the posterior calcaneus and work proximally to the tendinous aspect of the tissue above the heel. Once the tendon is gained, apply light pincing coupled with a sliding motion up and down its sheath and tendon. • To evaluate the tendon’s glide in its sheath, apply slight pressure to both sides of the tendon while the patient plantar flexes the ankle. • Once the tendon flattens proximally, it can be strummed across its expanse. • Note the location of any tender points or fasciculatory response of the tendon and its attachments. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Achilles tendon palpation procedure. PRT Clinician Procedure • The patient is prone with the knee flexed to approximately 20 to 30°. • Place the ankle into marked plantar flexion on your thigh or on a bolster. • Using the near hand, place one or two fingers over the tender point. 80 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. ANKLE AND LOWER LEG: POSTERIOR STRUCTURES • Use the fingers of your far hand to translate the posterior calcaneal fascia and tendon sheath cephalad while compressing the calcaneus downward. • Distract the talocrural joint caudally, while simultaneously compressing and rotating the hindfoot downward with the palm of the treatment hand into the talocrural joint. This movement can be facilitated by either pulling the thigh away from the knee or using your far hand. • Evert or invert the ankle with the far hand based on the location of the lesion. • Apply calcaneal rotation with the far hand to fine-tune. • Corollary tissues treated: Gastrocnemius, soleus Achilles tendon PRT clinician procedure. See video 5.4 for the Achilles tendon PRT procedure. Patient Self-Treatment Procedure • Place the involved ankle on the opposite thigh. • Move the ankle into maximal plantar flexion. • Place the fingers over the tender area. • Compress and rotate the calcaneus upward with the palm while using the thumb and forefinger to translate the fascia or tendon upward. • Apply eversion, inversion, and rotation to finetune the position. • Find the position of greatest tissue comfort by using the fasciculatory response method. • Hold the position of comfort until the fasciculation subsides or until three to five minutes have elapsed. Achilles tendon patient self-treatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 81 ANKLE AND LOWER LEG: POSTERIOR STRUCTURES Soleus Plantaris Popliteus Soleus Achilles tendon The soleus lies deep to the gastrocnemius. The muscle is thick and broad but crosses only one joint, the ankle. Its inferior fibers expand beyond the borders of the Achilles tendon and are therefore accessible to palpation; however, deep palpation can be applied between the heads of the gastrocnemius to access the tissue in this location. The soleus primarily functions to prevent anterior translation of the tibia forward during standing, but also stabilizes the ankle during gait. The soleus can be isolated from the gastrocnemius by having the patient plantar flex the ankle while the knee is flexed. Origin: Posterior fibular head, proximal third of the posterior and medial tibial shaft Tibial soleal line Insertion: Calcaneus via the calcaneal tendon Action: Ankle plantar flexion, foot inversion Intermediate Palpation Procedure E6296/Speicher/Fig. 5.8/532064/JG/R1 • The patient should be positioned prone with the knee flexed and the ankle bolstered to relax the triceps surae complex. • Locate the Achilles tendon and slide the fingers off its borders to locate the lower portions of the soleus. • While palpating the lower portion of the soleus, have the patient plantar flex the foot to feel its contraction. • To palpate the deep soleus, press downward between the heads of the gastrocnemius. • Note the location of any tender points or fasciculatory response of the muscle and its distal attachment site. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Innervation: S1-S2 (tibial nerve) Soleus palpation procedure. PRT Clinician Procedure • The patient should be in a prone position. • Position yourself next to the lower leg in either a seated or standing position. • Move the knee through flexion and extension to find the location of greatest relaxation, which typically is between 60 and 90°. 82 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. ANKLE AND LOWER LEG: POSTERIOR STRUCTURES • After finding the knee flexion position, move the ankle through plantar flexion and dorsiflexion with the far hand to find again the greatest position of comfort or fasciculation, or both. • With the far hand or your torso, apply marked compression of the calcaneus downward, making sure to drop the elbow of the arm applying the compression downward along the line of the tibia to prevent excessive strain on your elbow. • Apply inversion and eversion of the ankle with the far hand based on the location of the lesion. • Apply calcaneal rotation with the far hand to fine-tune. • Corollary tissues treated: Tibialis posterior, flexor digitorum longus, flexor hallucis longus, gastrocnemius, Achilles tendon See video 5.5 for the soleus PRT procedure. Soleus PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 83 ANKLE AND LOWER LEG: POSTERIOR STRUCTURES Gastrocnemius Gastrocnemius (medial head) Gastrocnemius (lateral head) Soleus Achilles tendon Flexor retinaculum The gastrocnemius is a two-joint muscle that crosses the knee and ankle. Its two heads originate from the femoral condyles and converge distally to form the Achilles tendon. The more robust soleus muscle underneath the gastrocnemius also inserts into the Achilles tendon, and together they form the triceps surae complex. In gait, the gastrocnemius serves an integral role in stabilizing the ankle joint. Origin: Posterior femoral condyles Insertion: Calcaneus via the calcaneal tendon; the gastrocnemius fibers insert more laterally at the calcaneus Action: Ankle plantar flexion; assists knee flexion Innervation: S1-S2 (tibial nerve) Superficial posterior Palpation Procedure E6296/Speicher/Fig. 05.06/532057/JG/R1 • The patient should be positioned prone with the knee flexed and ankle bolstered to relax the triceps surae complex. • Palpate each head individually. Place a stabilizing force upward with one hand on the outside of the lateral head and to the inside for the medial head while palpating upward to their tendinous aspects behind the knee. • Determine the most dominant tender point or fasciculation (or both) and maintain light pressure with the pad(s) of the finger(s) throughout the treatment until reassessment has occurred. PRT Clinician Procedure • The patient is prone with the knee flexed to approximately 20 to 30°. • Place the ankle into marked plantar flexion in the sulcus of your thigh or on a bolster. • Using your far hand, evert (for the medial gastrocnemius head) or invert (for the lateral gastrocnemius head) the ankle based on the location of the tender point. • Using your far hand, distract the talocrural joint caudally while simultaneously compressing and rotating the hindfoot downward into the talocrural joint. • Apply calcaneal rotation to fine-tune with the far hand. • Corollary tissues treated: Tibialis posterior, flexor digitorum longus, flexor hallucis longus, soleus, Achilles tendon, gastrocnemius tendons 84 Gastrocnemius palpation procedure. Gastrocnemius PRT clinician procedure. See video 5.6 for the gastrocnemius PRT procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. ANKLE AND LOWER LEG: LATERAL STRUCTURES Calcaneofibular Ligament The calcaneofibular ligament is a cordlike extra-articular ligament that crosses both the talocrural and talocalcaneal joints. With more severe inversion ankle sprains, the calcaneofibular ligament is often stressed as a result of a disruption of the anterior talofibular ligament. Posterior tibiofibular Posterior talofibular Origin: Apex of the lateral malleolus Calcaneofibular Insertion: Lateral surface of the calcaneus Action: Limits ankle inversion; stabilizes the subtalar joint Calcaneocuboid Bifurcated Lateral Palpation Procedure • Place the ankle in a neutral, relaxed position. 05.10/532070/JG/R1 the tip of the malleolus and slide your • LocateE6296/Speicher/Fig. fingers off its tip to just underneath the bone. The ligaments fibers are behind the peroneal tubercle, running obliquely toward its insertion on the calcaneus. • Strum across the ligament’s fibers to notice its cordlike nature. • Note the location of any tender points or fasciculatory response of the ligament and its origin and insertion. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • The patient is side-lying with the knee flexed. • Place the medial ankle joint against and below a firm bolster to serve as a fulcrum. • Using your far hand, place the ankle into dorsiflexion and apply a downward force on the calcaneus to produce a lateral glide while everting the calcaneus. • Apply calcaneal rotation with your far hand to fine-tune. • Corollary tissues treated: Anterior talofibular ligament, posterior talofibular ligament, peroneal tendons Calcaneofibular ligament palpation procedure. Calcaneofibular ligament PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 85 ANKLE AND LOWER LEG: LATERAL STRUCTURES Peroneus Longus and Brevis The peroneal, or fibularis, muscles are commonly strained with inversion ankle sprains in their attempt to resist the roll of the ankle inward. The violent eccentric pull of the tendons on the base of the first metatarsal can often produce an avulsion fracture at this site. The brevis is deep to the longus, but its fibers can be felt on either side of the tendon of the longus at the lower third of the ankle. Popliteus Origin: Longus: Fibular head, upper two thirds of the fibular shaft Peroneus longus Tibialis posterior Brevis: Distal two thirds of the fibular shaft Flexor digitorum longus Insertion: Longus: Lateral plantar base of the first metatarsal and first cuneiform Flexor hallucis longus Brevis: Tuberosity of the fifth metatarsal Action: Foot eversion; also assists with ankle plantar flexion and supports the longitudinal and transverse arches. The longus also assists to depress the first metatarsal. Peroneus brevis Deep Innervation: L5-S1 (superficial peroneal nerve) Palpation Procedure E6296/Speicher/Fig. 5.4/532050/JG/R1 • The patient can be either prone or supine with the knee flexed. • Locate the fibular head, a round bony structure just inferior to the lateral knee joint. • Dip downward off the fibular head onto the peroneus longus muscle belly in line with the lateral malleolus. • Strum across the muscle belly into its posterior valley or border between the gastrocnemius and its anterior valley or border of the extensor digitorum longus. • While strumming, ask the patient to evert the foot to accentuate its location. • Continue to strum the longus downward to its tendinous aspect. • Once at the tendinous aspect of the longus, slide your fingers off either side of the tendon onto the muscle belly of the brevis and repeat the strumming procedure for this muscle, working distally to its tendon. • Note the location of any tender points or fasciculatory response of the muscles and their tendons and attachment sites. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. 86 Peroneus longus and brevis palpation procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. ANKLE AND LOWER LEG: LATERAL STRUCTURES PRT Clinician Procedure • The patient is prone with the knee flexed to 90° and the shin supported with either your thigh or a bolster. • Move the ankle through its range of motion of dorsiflexion and plantar flexion with your far hand to find the optimal treatment position. • With your far hand, apply marked ankle eversion coupled with heavy calcaneal compression. • Apply external tibial rotation with your far hand. • Apply forefoot eversion with your torso for fine-tuning. • Corollary tissues treated: Peroneal tendons, peroneus tertius, extensor digitorum brevis See video 5.7 for the peroneus longus and brevis PRT procedure. Peroneus longus and brevis PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 87