Evidence-Based Examination of the Foot Presented by Alexis Wright, PT, PhD, DPT, FAAOMPT Practice Sessions/Skill Check-offs

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Evidence-Based Examination of the Foot Presented by Alexis Wright, PT, PhD, DPT, FAAOMPT Practice Sessions/Skill Check-offs Module Five: Movement Assessment of the Foot/Ankle (1 hour CEU Time)

midfoot, forefoot) 10 1 hand on the postero-plantar calcaneus and the anterior hand on the dorsal forefoot.

1 Evidence-Based Examination of the Foot Presented by Alexis Wright, PT, PhD, DPT, FAAOMPT Practice Sessions/Skill Check-offs Module Five: Movement Assessment of the Foot/Ankle (1 hour CEU Time) Skilled Process bilateral squat Review in Chapter 7 Photo Description Check Off Look for heel lift, foot rotation, leaning away from painful side Passive physiological plantarflexion (whole foot, midfoot, forefoot) 10 1 hand on the postero-plantar calcaneus and the anterior hand on the dorsal forefoot. The foot and ankle are then passively plantarflexed to the first point of concordant pain (if present). Repeated movements or sustained holds are applied to determine if the symptoms increase or decrease. Differentiation of whole foot and midfoot can be made with hand placement changes. The clinician stabilizes the hindfoot and

Passive physiological dorsiflexion (whole foot, midfoot, forefoot) 11 passively applies a plantarflexion force on the midfoot.

A comparison of the patient s reaction to pain with the various positions implicates which anatomical region is the likely source of the pain hand on the

The foot and ankle are then passively dorsiflexed to the first point of concordant pain (if present).

2 Passive physiological dorsiflexion (whole foot, midfoot, forefoot) 11 passively applies a plantarflexion force on the midfoot. The same is true for the forefoot by stabilizing the midfoot and forcing the forefoot into plantarflexion. A comparison of the patient s reaction to pain with the various positions implicates which anatomical region is the likely source of the pain hand on the postero-dorsal calcaneus (over the calcaneal tendon) and the other hand on the palmar surface of the foot. The foot and ankle are then passively dorsiflexed to the first point of concordant pain (if present). Repeated movements or sustained holds are applied to determine if the symptoms increase or decrease. Differentiation of whole foot and midfoot can be made by stabilizing the hindfoot and promoting dorsiflexion of the midfoot. Differentiation of the forefoot from the midfoot is made by stabilizing the midfoot and applying a dorsiflexion force to the forefoot. 2

Passive physiological inversion (whole foot, midfoot) Passive physiological eversion (whole foot, midfoot) 12 13 hand on the calcaneus (fingers medially, thumb laterally) and the anterior hand on the

This movement occurs to the first point of pain and the process is repeated at end range as well. Behavior with repeated movements or sustained holds is recorded.

3 Passive physiological inversion (whole foot, midfoot) Passive physiological eversion (whole foot, midfoot) hand on the calcaneus (fingers medially, thumb laterally) and the anterior hand on the forefoot (fingers medially, and thumb laterally). The foot and ankle are then passively inverted as the clinician pushes the foot away from his or her body in a curvilinear fashion. This movement occurs to the first point of pain and the process is repeated at end range as well. Behavior with repeated movements or sustained holds is recorded. The midfoot is differentiated from the hindfoot by blocking the hindfoot and promoting an inversion movement at the midfoot. The forefoot can be differentiated by stabilizing the midfoot and promoting inversion at the forefoot. hand on the calcaneus (fingers medially, thumb laterally) and the anterior hand on the forefoot (fingers medially, and thumb laterally). The foot and ankle are then passively everted as the clinician pushes the foot away from his or her body in a curvilinear fashion. This movement occurs to the first point of pain and the process is repeated at end range as well. Behavior with repeated 3

Passive physiological first MTP flexion movements or sustained holds is recorded.

The forefoot can be differentiated by stabilizing the midfoot and promoting eversion at the forefoot. The patient is in supine.

4 Passive physiological first MTP flexion movements or sustained holds is recorded. The midfoot is differentiated from the hindfoot by blocking the hindfoot and promoting an eversion movement at the midfoot. The forefoot can be differentiated by stabilizing the midfoot and promoting eversion at the forefoot. The patient is in supine. The examiner grasps the distal metatarsal and proximal distal phalanx applying a perpendicular force in plantar direction Passive physiological first MTP extension The patient is in supine. The examiner grasps the distal metatarsal and proximal distal phalanx applying a perpendicular force in dorsal direction anterior to posterior passive accessory glide of the inferior tibiofibular 15 The patient assumes a sidelying position with the medial border of the foot placed on the plinth, the clinician is standing in front of the patient facing the foot. Resting symptom level is assessed. The clinician places one thumb on the anterior border of the distal fibula whereas the 4

posterior to anterior glide of the inferior tibiofibular caudal glide of the inferior tibiofibular 16 17 other hand stabilizes the tibia.

The movement is also repeated or sustained to assess the response of the movement on the concordant sign The patient assumes a sidelying position with the medial border of the foot placed on the

5 posterior to anterior glide of the inferior tibiofibular caudal glide of the inferior tibiofibular other hand stabilizes the tibia. The clinician performs a play movement by mobilizing the distal fibula directly posteriorly until the patient first reports concordant discomfort. The movement is then performed near end range. The movement is also repeated or sustained to assess the response of the movement on the concordant sign The patient assumes a sidelying position with the medial border of the foot placed on the plinth, the clinician is standing behind the patient facing the heel. Resting symptom level is assessed. The clinician places one thumb on the posterior shelf of the distal fibula whereas the other hand stabilizes the tibia. The clinician performs a play movement by mobilizing the distal fibula directly anteriorly until the patient first reports concordant discomfort. The movement is then performed near end range. The movement is also repeated or sustained to assess the response of the movement on the concordant sign The patient assumes a sidelying position with the medial border of the foot placed on a plinth. The clinician stands cephalically to the foot of the patient. The clinician performs a caudal glide of the fibula by inverting the hindfoot until the patient reports concordant discomfort. The movement is sustained or repeated to assess the outcome 5

cephalic glide of the inferior tibiofibular anterior to posterior glide of the talocrural posterior to anterior glide of the talocrural 18 19 20 of the technique.

The clinician performs a cephalad glide of the fibula by everting the hindfoot until the patient reports concordant discomfort.

hand on the distal tibia and fibula and the anterior hand on the head of the talus with the elbows pointing out away from each other.

6 cephalic glide of the inferior tibiofibular anterior to posterior glide of the talocrural posterior to anterior glide of the talocrural of the technique. The patient assumes a sidelying position with the medial border of the foot placed on a plinth. The clinician stands caudally to the foot of the patient. The clinician performs a cephalad glide of the fibula by everting the hindfoot until the patient reports concordant discomfort. The movement is sustained or repeated to assess the outcome of the technique. hand on the distal tibia and fibula and the anterior hand on the head of the talus with the elbows pointing out away from each other. With the tibia and fibula stabilized, an anterior to posterior force is exerted on the talus until the patient reports concordant pain. If the pain reported is concordant, the movement is repeated or sustained to determine the effect of the technique. The movement is then taken beyond the first point of pain toward end range. If the pain is concordant, the technique is repeated or sustained at end range hand on the head of the talus and the anterior hand on the distal tibia and fibular with the elbows pointing out away from 6

medial rotation of the talocrural lateral rotation of the talocrural 21 22 each other.

If the pain reported is concordant, the movement is repeated or sustained to determine the effect of the technique.

7 medial rotation of the talocrural lateral rotation of the talocrural each other. With the tibia and fibula stabilized, a posterior to anterior force is exerted on the talus until the patient reports concordant pain. If the pain reported is concordant, the movement is repeated or sustained to determine the effect of the technique. hand on the distal tibia and fibula and the anterior hand on the head of the talus with the elbows pointing away from each other. With the tibia and fibular stabilized, medial rotation of the talus is performed until the patient reports concordant pain. If the pain reported is concordant, the movement is repeated or sustained to determine the effect of the technique. hand on the distal tibia and fibula and the anterior hand on the head of the talus with the elbows pointing away from each other. With the tibia and fibula stabilized, lateral rotation of the talus is performed until the patient reports concordant pain. If the pain reported is concordant, the movement is repeated or sustained to determine the effect of the technique. 7

longitudinal distraction of the talocrural posterior to anterior glide of the subtalar anterior to posterior glide of the subtalar

The knee of the clinician is placed on the posterior thigh of the patient for stabilization.

on the head of the talus. The clinician lifts up with his or her body to distract the talocrural.

With the talus stabilized (anteriorly), a posterior to anterior force is exerted on the calcaneus until the patient reports

8 longitudinal distraction of the talocrural posterior to anterior glide of the subtalar anterior to posterior glide of the subtalar position with the knee flexed to 90 degrees. Resting pain is assessed. The knee of the clinician is placed on the posterior thigh of the patient for stabilization. The examiner places one hand under the foot, cupping the calcaneus and the other hand on the dorsum of the foot with the 5 th digit on the head of the talus. The clinician lifts up with his or her body to distract the talocrural. hand on the calcaneus and the anterior hand on the head of the talus with the elbows pointing out away from each other. With the talus stabilized (anteriorly), a posterior to anterior force is exerted on the calcaneus until the patient reports concordant pain. hand on the talus and the anterior hand on the anterior calcaneus with the elbows pointing out away from each other. The calcaneus is stabilized and the talus is mobilized anteriorly (from its posterior contact) until the patient reports concordant pain 8

medial rotation of the subtalar lateral rotation of the subtalar medial glide of the subtalar 26 27 28 hand on the calcaneus and the anterior hand on the head of the talus with the elbows pointing

With the talus stabilized, medial rotation of the calcaneus is performed until the patient reports concordant pain hand on the calcaneus and the anterior hand on the head of the talus with the

The patient assumes a sidelying position with the medial border of the leg placed on the clinician s forearm and the foot hanging off the mat, the clinician is standing facing the patient s foot.

9 medial rotation of the subtalar lateral rotation of the subtalar medial glide of the subtalar hand on the calcaneus and the anterior hand on the head of the talus with the elbows pointing out away from each other. With the talus stabilized, medial rotation of the calcaneus is performed until the patient reports concordant pain hand on the calcaneus and the anterior hand on the head of the talus with the elbows pointing out away from each other. With the talus stabilized, lateral rotation of the calcaneus is performed until the patient reports concordant pain. The patient assumes a sidelying position with the medial border of the leg placed on the clinician s forearm and the foot hanging off the mat, the clinician is standing facing the patient s foot. Resting symptom level is assessed. The clinician takes the hindfoot in the distal hand with the thenar eminence firmly placed against the lateral calcaneus and the proximal hand stabilizing the lower leg (from underneath) with the forefinger on the medial malleolus and talus. The clinician performs a medial glide toward the floor while an eversion movement is provided to prevent the motion from becoming an 9

lateral glide of the subtalar horizontal flexion of the forefoot 29 34 inversion curvilinear movement rather than a medial glide of the calcaneus on the talus.

10 lateral glide of the subtalar horizontal flexion of the forefoot inversion curvilinear movement rather than a medial glide of the calcaneus on the talus. The patient assumes a sidelying position with the lateral border of the leg placed on the clinician s forearm and the foot hanging off the mat, the clinician is standing facing the patient s foot. Resting symptom level is assessed. The clinician takes the hindfoot in the distal hand with the thenar eminence firmly placed against the medial calcaneus and the proximal hand stabilizing the lower leg (from underneath) with the forefinger on the lateral malleolus and talus. The clinician performs a lateral glide toward the floor while an inversion movement is provided to prevent the motion from becoming an eversion curvilinear movement rather than a lateral glide of the calcaneus on the talus. Examiner places both hands interlaced on the dorsum of the foot with both thumbs on the plantar surface. The thenar aspect of the thumbs perform a mobilizing movement in a plantar to dorsal direction while the fingers draw the rays around the thumbs to increase the horizontal arch until the patient reports concordant pain 10

horizontal extension of the forefoot posterior to anterior glide of the metatarsal phalangeal and interphalange al s anterior to posterior

The thumbs perform a mobilizing movement in a dorsal to plantar direction while the fingers draw the rays around the thumbs to decrease the

Using the thumb to generate the mobilizing force, a plantar to dorsal shearing movement is performed until the patient reports concordant

11 horizontal extension of the forefoot posterior to anterior glide of the metatarsal phalangeal and interphalange al s anterior to posterior glide of the MTP Examiner places both hands interlaced on the plantar surface of the foot with both thumbs on the dorsal surface. The thumbs perform a mobilizing movement in a dorsal to plantar direction while the fingers draw the rays around the thumbs to decrease the horizontal arch until the patient reports concordant pain that is to be assessed in the other hand. Using the thumb to generate the mobilizing force, a plantar to dorsal shearing movement is performed until the patient reports concordant pain. that is to be assessed in the other hand. Using the thumb to generate the mobilizing force, a dorsal to plantar shearing movement is performed until the patient reports concordant pain. 11

adduction of the MTP s abduction of the MTP s medial rotation of the MTP and IP s 38 39 40 that is to be assessed in the other hand.

12 adduction of the MTP s abduction of the MTP s medial rotation of the MTP and IP s that is to be assessed in the other hand. Using the thumb to generate the mobilizing force, an adduction movement is performed until the patient reports concordant pain. that is to be assessed in the other hand. Using the thumb to generate the mobilizing force, an abduction movement is performed until the patient reports concordant pain. that is to be assessed in the other hand. Using the thumb and forefinger to generate the mobilizing force, a medial rotational movement is performed until the patient reports concordant pain. 12

lateral rotation of the MTP and IP s compression and distraction of the MTP and IP s 41 42 that is to be assessed in

Using the thumb and forefinger to generate the mobilizing force, a lateral rotational movement is performed until the

13 lateral rotation of the MTP and IP s compression and distraction of the MTP and IP s that is to be assessed in the other hand. Using the thumb and forefinger to generate the mobilizing force, a lateral rotational movement is performed until the patient reports concordant pain. that is to be assessed in the other hand. Using the thumb and forefinger to generate the mobilizing force, a compressive movement is performed until the patient reports concordant pain. 13

Module Three: Interventions of the Foot/Ankle

Evidence-Based Treatment of the Foot Presented by Alexis Wright, PT, PhD, DPT, FAAOMPT Practice Sessions/Skill Check-offs Module Three: Interventions of the Foot/Ankle (75 minutes) Skilled Process a rearfoot