Section Three: The Leg, Ankle, and Foot Lecture: Review of Clinical Anatomy, Patterns of Dysfunction and Injury, and

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1 Section Three: The Leg, Ankle, and Foot Lecture: Review of Clinical Anatomy, Patterns of Dysfunction and Injury, and Treatment Implications for the Leg, Ankle, and Foot Levels I and II Demonstration and Practice: Treatment Protocols for the Leg, Ankle, and Foot 1. Assessment: Observation a. Alignment of toes, p.483 i. Hallux valgus? Hammer? Claw? b. Assessment of the longitudinal arch, p. 483 functional low arch will increase in heel lift c. Assessment of the Achilles, p.484 (Figure 10-17) does it bow in or out -and notice relationship to knee & hip 2. Motion assessment - in standing a. Active great toe extension, p.484 (Figure 10-18) essential for normal gait b. Passive great toe extension sharp pain under 1st MTP= possible early degeneration or capsular fibrosis c. Active dorsiflexion: reps., p.484 painless weakness = L4- to S-1 nerve roots also tests functional strength for ant. tibialis, extensor hallucis and digitorum longus d. Active plantar flexion/toe raises, pp painless weakness =L4-S2 also tests functional strength and involvement (tendinosis/itis) for soleus (lower post/med border), gastrocnemius 1

2 (medial calf), tibialis posterior, flexor hallucis and digitorum longus 3. Passive Motion assessment - supine a. Passive ankle dorsiflexion, p of dorsiflexion. Pain with dorsiflexion = joint (anterior impingement), plantar fasciitis, post. shin splint, gastrocnemius tendinitis b. Passive ankle inversion to assess for sprain of the anterior talofibular ligament, p.485 (Figure 10-19) Level I 1. MET and STM for the anterior and lateral compartments of leg a. MET #1 CR-MET for the tibialis anterior, p.488 (Figure 10-21) L4 b. MET #2 CR-MET for the peroneus longus and brevis, p.488 (Figure 10-22) S1 c. STM: 1 st series, release of the anterior and lateral compartments, pp i. stroke 1: Anterior crural fascia- longitudinal stroke (Figure 10-30) ii. stroke 2: anterior crural fascia - A-P stroke (Figure 10-31) iii. stroke 4: bent leg: anterior and lateral muscles - double thumb M-L (Figure 10-32) Level II 1. MET and STM for the anterior and lateral compartments of leg a. MET #6 CR-MET for the ext. hallucis longus, p.489 (Figure 10-26) L4/5 b. MET #7 CR-MET ext. digitorum longus, p.490 (Figure 10-27) L5 (brevis S1) 2

3 c. STM, 1 st series; release of muscle attachments in the anterior and lateral compartments, pp (Figure 10-53) (Anatomy 10-52) Client supine, knee bent, stroke in M- L direction i. Tibialis anterior attachments - lateral, proximal tibia ii. Ext. digit. long. - lateral condyle of tibia and ant. medial fibular iii. Ext. hall. long. - deep to tib. ant and ext. digit.long. and inferior iv. Peroneus longus & brevis - lateral fibula v. Comm. peroneal n. at the fibular neck. Level I 2. MET and STM for the posteromedial leg a. MET #3 CR-MET for the tibialis posterior, resist dorsiflexion and eversion: pp (Figure 10-23) L5 b. MET #8 CRAC in prone for soleus and to increase ankle dorsiflexion, p.490 (Figure 10-28) 3

4 c. STM 2 nd series, Release of the muscles and fascia of the posteromedial leg, pp i. 1 st stroke: side lying w/bottom leg straight, top leg bent I- S - soft fist (Figure 10-34) ii. 3 rd stroke: side lying w/bottom leg straight, top leg bent A-P - double thumb (Figure 10-35) Level II 2. (NEW) Release of attachments to posteromedial leg. Same as Level I except focus on deep adhesions (Figure 10-35) Level I 3. MET and STM for the posterior compartment and Achilles tendon 4

5 a. (Review) MET #3, (ch. 9, Knee, p.434) CRAC MET gastrocnemius (Figure 9-23) b. (Review) MET #8 CRAC for soleus & increase ankle dorsiflexion, p.490 (figure 10-28) c. STM 3 rd series, Prone release of the posterior compartment and the Achilles tendon, pp i. stroke 1: posterior compartment: Soft fist - I-S ii. stroke 3: posterior compartment: "part the midline" (Figure 10-37) i. stroke 4: Achilles tendon (foot off the table) 1) (Figure 10-38) M-L double thumb: body of tendon, 1-2 inches above, and on the heel 2) (Figure 10-39) A-P fingertips on either side of tendon 3) roll Achilles Level II 3. MET and STM for the posterior compartment 10-23) a. (Review) MET #3 tibialis posterior, p.488 (Figure b. MET #4 and #5, CR and PIR-MET for flexor digitorum longus and flexor hallucis longus, p.489 (Figure and 10-25) 5

6 Level II c. STM, 3 rd series; release of the muscles and attachments in the posterior compartments, pp client is prone (Fig 10-60) or supine (Fig 10-61) i. proximal posterior fibula: soleus, flex. hall. longus, tibialis posterior ii. center line/interosseous membrane: tib post and soleus iii. posterior tibia: proximal to distal: semi membranous, popliteus, soleus, flexor digitorum longus iv. Alt. position. Supine, knee bent - can mobilize fibular head in this position as well 6

7 Level I 4. STM and MET for the dorsum of the foot and ankle a. MET #6 CR-MET for the extensor hallucis longus, p. 489 (Figure 10-26) b. MET #7 CR for the extensor digitorum longus, p. 490 (Figure 10-27) c. (Review) MET #1 CR-MET for the tibialis anterior, p.488 (Figure 10-21) d. STM 4 th series, Release of the muscles of the foot and the ligaments of the ankle, pp i. (Figure 10-42) - tendon of tib. ant. ext. hal long, ext. dig. long at ankle joint- then extensor hallucis and digitorum brevis (ATF), ii. ligament release anterior- btw fib & talus 2. lateral-fibula to cal (CF) 3. medial mallelous to heel (deltoid) 7

8 iii. facing cauda: btw metatarsals: dorsal interossei: then on lateral meta and medial meta for inerossei, lumbricals and jt. capsule Level II 4. MET and STM for nerves and tendons crossing the ankle a. (Review) MET #4 and #5, for flexor digitorum longus and flexor hallucis longus, p.489 (Figure and 10-25) b. (Review) MET #3 CR-MET for tibialis posterior, p. 488 (Figure 10-23) c. (Review) MET #6 and 7 CR-MET for extensors hallucis longus and digitorum longus; and MET #1 for tibialis anterior (Figure 10-21; and 10-27) d. STM, 2 nd series; release of the tendons crossing the ankle and deep peroneal and posterior tibial nerves, pp ) Release anterior jt. capsule for anterior impingement. Release deep peroneal nerve under inferior ext. retinaculum- just lateral to ext. hal. longus (Figure 10-42) 8

9 2) Medial mallelous to heel = Post. tibial tarsal tunnel (Figure 10-56) 3) more posterior = calcaneal branch 4) under navicular= Plantar n. under abductor hall. (Figure 10-57) 5) lateral mallelous = Peroneal tendons. (Figure 10-58) Level I 5. STM and MET for the plantar fascia a. (Review) MET #3, (chapter 9, p.434) CRAC MET for gastrocnemius b. (Review) MET #8 CRAC for soleus and to increase ankle dorsiflexion, p.490 c. (Review) MET #10, (Ch. 8, Hip), CRAC for hamstrings d. STM 5 th series; release of the plantar fascia and the muscles of the first layer of the foot, pp i. Soft fist, toes to heel (figure 10-46) ii. release of three eminences (Figure and 10-48) 1) calcaneus -big toe - ab. Hal, flex hal. 9

10 2) middle foot - flex. digit. brevis, quad plantae 3) little toe - ab digiti mini., flex. digit mini., opponens 5. MET and STM on the heel Level II a. (Review) MET #3 (Ch. 9, Knee) CRAC-MET for gastrocnemius, p.434 b. (Review) MET #5 MET for flexor digitorum longus and brevis p.489 c. STM, 4 th series; release of the muscles and ligaments that attach to the calcaneus and heel spurs, pp (Anatomy figure and 10-63) i. Plantar surface of the heel ii. iii. Anterior and medial calcaneus - all around calcaneus - ab hal, flex digit brevis, quad. plantae, ab digit mini, long plantar ligament heel spurs Level I 6. MET and STM for the deep layers of the plantar surface of the foot a. (Review) MET #3 CR-MET for the tibialis posterior, p.488, b. (Review) METs #4 and #5, CR and PIR-MET for the flexor digitorum longus and brevis and the flexor hallucis longus and brevis, p

11 c. *MET for adductor hallucis, p. 501 (Anatomy figure 10-49) d. STM 6 th series; Release of the second, third, and fourth layers of the foot, pp i. A-P, and M-L planes of flexor digit and hal long tendons and lumbricals on medial side of flex. digit long tendons and deep to that: oblique head of adductor hallucis and flex. hal brevis (Figure 10-50) ii. Annular ligs of flexor tendons at MTP - P-A (heel to toe) at MTP joints iii. P-A (heel to toe) 5th meta - 1st: strokes for adductor hallucis transverse head (medial side of 5th-2nd and lateral side of 1st) 11

12 Level II 6. MET and STM to the MTP and IP joints of the toes a. (Review) MET #5, PIR-MET for flexor digitorum longus and flexor hallucis longus, p.489 b. STM 5 th series; release of the joint capsule and ligaments of the metatarsophalangeal and interphalangeal joints, and plantar digital nerve, pp ) A-P and M-L plantar surface of navicular, 1st cuneiform, and base of 1st metatarsal - tib ;post, tib ant., and peroneus long 2) base of 5th and cuboid release M-L - release ab digit mini, flex digit mini, peroneus brevis Sit on table facing cauda, pts foot on your thigh (Figure 10-66) 1) P-A Release interossei mm from either side of MTPs and transverse metatarsal ligament 2) M-L scoop plantar digital nerve from under bone to interspace between MTPs 12

13 Level I 7. Mobilization of the ankle and toes a. STM 6 th series, mobilization of the ankle and foot, pp i. Jt. cap. of great toe (Figure 10-69) brisk transverse M-L ii. Mob. 1 st. MTP. (Figure 10-70) iii. Shear each metatarsal. iv. Mob. each toe (Figure 10-71) - stabilize proximal, move distal Level II 7. Mobilization of the ankle and toes foot, pp a. STM 6 th series, mobilization of the ankle and i. MET to correct varus/valgus heel ii. Mobilization of ankle a. dorsiflex b. traction c. pronate/supinate 13

14 iii. Mobilize sesamoids - facing cauda, patient's foot on your thigh 1. flex great toe to slack (use your lateral hand) 2. index finger on lateral side of the great toe (use your medial hand) 3. pull great toe into extension 4. move great toe laterally as you move the sesamoid bones medially (or keep the sesamoid bones "in place" as you move the great toe) 14