ANKLE PLANTAR FLEXION Evaluation and Measurements By Isabelle Devreux 1
Ankle Plantar Flexion: Gastrocnemius and Soleus ROM: 0 to 40-45 A. Soleus: Origin: Posterior of head of fibula and proximal1/3 of its body. Soleal line & middle 1/3 of medial border of tibia. Tendinous arch between tibia and fibula. Insertion: Posterior surface of the calcaneum (w/ gastrocnemius). Nerve: Tibial nerve: L5, S1, S2 Action: Plantar flexes the ankle joint. 2
Ankle Plantar Flexion: Gastrocnemius and Soleus B. Gastrocnemius: Origin: Medial Head: Proximal & posterior of part of medial condyle of femur. Capsule of knee joint. Lateral Head: Lateral condyle and post. surface of femur. Capsule of knee joint. Insertion: Middle part of posterior surface of the calcaneum Nerve: Tibial nerve: L5, S1, S2 Action: Plantar flexes the ankle joint + assists in flexion of the knee joint. 3
Ankle Plantar Flexion: C. Plantaris muscle: Origin: Distal part of lateral supracondylar line of the femur + popliteal surface. Oblique popliteal ligament of the knee joint. Insertion: Posterior part of calcaneum. Nerve: Tibial Nerve: L4,L5, S1 Action: Plantar flexes the ankle + assists in flexion of the knee joint. 4
Ankle Plantar Flexion: ROM: +- 45 to 45 Limitation by: Tension of talofibular ligament. Tension of the dorsifexor ms. Contact of posterior portion of talus bone on the tibia. Accessory ms.: Tibialis posterior Peroneus longus Peroneus Brevis Flexor hallucis longus Flexor digitorum longus Forefoot & ankle joint plantar flexors Toe, forefoot & ankle joint plantar flexors 5
Ankle Plantar Flexion: Grade 3, 4, 5 Pt.: Standing on leg to be tested, knee straight. Therapist stands beside the patient. Grade 3:«Rise on your toes clearing your heel off the floor--- relax»(one time). Grade 4 & 5:»Same + repeat 4 to 5 times». Needs sufficient stabilization to the forefoot on the ground. Good = if patient has difficulty to complete the ROM or if he fatigues easily. Weight bearing Or Non Weight Bearing Tests 6
Ankle Plantar Flexion: Grade 3 Non Weight Bearing: Pt. is in prone with foot to be tested over end of the table. Ph.Th. stands beside foot. Proximal hand is placed on the L.L., proximal to the ankle to stabilize. «Pull the heel upward and push backwards with your toes---relax». 7
Ankle Plantar Flexion: Grade 4-5 Pt. Is in prone as in gr. 3. Therapist applies resistance: Proximal hand hods the sides of the heel. Distal hand is on plantar surface of the foot. Moderate ( gr. 4) and Maximal + hold ( gr. 5) push of resistance simultaneously at heel + forefoot through full ROM. 8
Ankle Plantar Flexion: Grade 2 1-0 Pt. in sidelying position:with lateral border of the foot to be tested resting on the table. Therapist is beside the foot, proximal hand grasps the lower leg just above the ankle joint to stabilize it. «Push your foot down through full ROM.» Grade 1: Palpation of the contraction of the ms. fibers and on tendon above calcaneum. 9
Ankle Plantar Flexion: Effects of weakness: Hyperextension of the knee. Nonweightbearing position in standing. Gastrocnemius limp: inability to rise on toes and to transfer weight normally forward. Effects of contracture & shortness: Equinus position( ankle joint plantar flexed) of the foot and flexion of the knee. Muscle shortness: restriction of the ankle dorsiflex. when knee is extended & a restriction of the knee extension when the ankle is dorsiflexed. 10
Foot/ Ankle Deformities Talipes calcaneus: ankle joint dorsiflexed. Talipes equinus: ankle joint plantar flexed 11
Inversion & Eversion 12
Talipes Valgus: Foot/ Ankle Deformities Foot is everted and accompanied by flattening of the longitudinal arch. Talipes Varus: Foot is inverted & accompanied by an increase in the height of the longitudinal arch. 13
ANKLE DORSI FLEXION AND INVERSION Evaluation and Measurements By Isabelle Devreux 14
Foot Dorsiflexion and Inversion: Tibialis Anterior Origin: Lateral condyle & prox. ½ of lateral surf. of tibia. Interosseus membrane, deep fascia and intermucular sceptum. Insertion: Medial and plantar surface of medial cuneiform bone. Base of first metatarsal bone. Nerve: Peroneal nerve: L4, L5, S1 Action: Dorsiflexes and assist in inversion of the ankle foot. 15
Foot Dorsiflexion and Inversion: Tibialis Anterior ROM : 20 Limited ROM by: Tension of the lateral tarsal ligament Tension of the peroneus longus and peroneus brevis ms. Contact between tarsal bones, medially. 16
Foot Dorsiflexion & Inversion: Tibialis Anterior - Testing Gr. 3 and 2 Pt. sits with legs over the edge of the table. Therapist sits on a stool near the affected leg. Proximal hand grasps around the ankle to stabilize the lower leg. «Pull your foot up and in; through full ROM ----relax». Grade 3: Full ROM. Grade 2: Partial ROM 17
Foot Dorsiflexion & Inversion: Tibialis Anterior - Testing Gr. 4 & 5 Pt. Position in sitting over the edge of the table. His heel is supported on the thigh of the therapist. Therapist : Proximal hand supports the lower leg above calcaneus, distal hand grasps the medial border if forefoot to give resistance. Resistance: pushing down the medial border of the foot. Pt. Should keep big toe flexed to avoid substitution by extensor hallucis longus. «Pull your foot up and in through full ROM.» 18
Foot Dorsiflexion & Inversion: Tibialis Anterior - Testing Gr. 1 & 0 Pt. In backlying, foot over the edge of the table. Therapist stands near the edge, distal hand supports the forefoot, the proximal hand palpates the tibialis anterior on its tendon on the medial volar aspect of ankle. «Try to pul your foot up and in----relax. 19
Foot Dorsiflexion & Inversion: Tibialis Anterior Effects of weakness: Decrease of the ability to dorsiflex the ankle and allows tendency towards the foot eversion. Substitution: The extensor Hallucis Longus which has the function of assisting the dorsiflex. + inversion may substitute to a weak tibialis anterior muscle. Pt should keep the toes relaxed. 20
Foot Inversion from Plantar Flexion 21
Foot Inversion from Plantar Flexion: Tibialis Posterior Origin: Most of interosseus membrane. Lat. posrtion of posterior surface of tibia. Prox. 2/3 of medial surface of fibula. Insertion: Tuberosity of navicular bone. By fibrous expansions to the sustentaculum tali of calcaneus three cuneiforms, cuboid and bases of 2 nd, 3rd, 4th metatarsal bones. Nerve: Tibial nerve ; L4, L5, S1. Action: Inverts the foot and assists in the plantar flexion of the ankle joint. 22
Foot Inversion from Plantar Flexion: Tibialis Posterior Accessory muscles: Flexor digitorum longus. Flexor Hallucis Longus. Gastrocnemius»medial head». Range of Motion: 35 But may be limited by: Tension of lateral tarsal ligaments. Tension of peroneal muscle group. Contact between tarsal bones medially. 23
Foot Inversion from Plantar Flexion: Tibialis Posterior- Grade 3 «Fair strength» Pt; is in sidelying, affected leg down, foot in plantar flexion & resting on lateral border. Therapist stands at the foot of the table, proximal holds ankle joint proximally to stabilize the L.L. «Raise up the medial border of your foot through full ROM.---relax. 24
Foot Inversion from Plantar Flexion: Tibialis Posterior- Grade 4-5 Pt. In sidelying, foot over the edge of the table. Therapist: Prox. hand supports the L.L. proximal to ankle, distal hand over the medial border of the foot + resistance. Gr.4: moderate resistance. Gr.5: maximal resistance + hold. 25
Foot Inversion from Plantar Flexion: Tibialis Posterior grade 2 1-0. Pt. in backlying with foot in plantar flexion over the edge of the table. Therapist stands at end + prox. hand grasps the leg posteriorly just above the akle joint. «Move your foot medially---- relax». Gr. 1: palpation at the tibialis posterior between medial malleolus and navicular bone; above the medial malleolus. 26
Foot Eversion from Plantar Flexion Evaluation and Measurements 27
Foot Eversion from plantar flexion: Peroneus longus & brevis. Peroneus Longus: Origin: Lateral condyle of tibia, Head of proxilmal 2/3 of lateral surface of fibula, intermuscular septa. Insertion: lateral side of base of 1st metatarsal and medial ccuneiform bone. Nerve : Peroneal nerve: L4, L5, S1. Action: Everts foot and assists in plantar flexion of the ankle joint. 28
Foot Eversion from plantar flexion: Peroneus longus & brevis. Peroneus Brevis: Origin: Distal 2/3 of lateral surface of tibia. Adjacent intermuscular septa. Insertion: Tuberosity at base of 5th metatarsal bone, lateral side. Nerve: Peroneal nerve: L4,L5,S1. Action: everts the foot and assits in plantar flexion of the ankle joint. 29
Foot Eversion from plantar flexion: Peroneus longus & brevis. Accessory muscles: Extensor Digitorum Longus Peroneus Tertius (evert.+dorsiflexion) ROM: 35 Limited ROM by: Tension of medial tarsal ligaments Tension of tibialis anterior and tibialis posterior muscles Contact of tarsal bones laterally. 30
Foot Eversion from plantar flexion: Peroneus longus & brevis. Test gr.3. Pt. In side lying, upper leg is the affected leg, foot over the edge of the bed and in plantar flexion; leg is resting on its medial border. Therapist: proximal hand supports the lower leg proximal to the ankle joint. «Pull your foot up through full ROM---relax.» 31
Foot Eversion from plantar flexion: Peroneus longus & brevis:grade 4-5 Pt. Position as in gr.3. Therapist grasps the forefoot to give resistance. Moderate (or maximal for gr.5) resistance against plantar surface of first (or all) metatarsal head. Extensor digitorum longus should be relaxed. «Raise up the lateral border of the foot through full ROM. 32
Foot Eversion from plantar flexion: Peroneus longus & brevis:grade 2,1,0. Pt. In sidelying with affected foot plantar flexed and resting on its medial border. Therapist stands at the foot of the table and proximal hand stabilizes the L.L. For GR. 1: palpation on the peroneus brevis at the joint proximal to the 5th metatarsal bone on the lateral border of foot. For peroneus longus: palpation under the head of the 1st metatarsal bone. 33
Foot Eversion from plantar flexion: Peroneus longus & brevis: EFFECTS Effects of Weakness: strength of eversion of the foot and plantar flexion of the ankle joint. Allows a varus position of the foot. the ability to rise on the toes. Decreases lateral stability of the foot. Weakness of Peroneus longus / brevis: =Talipes Equino Varus 34
Effects of Contracture: Contracture of peroneus longus & brevis: = Talipes Equino Valgus =Everted or valgus position of the foot. 35
THANK YOU 36