MusculoSkeletal Exam

(Kaltenborn, 1999; Magee,1997). If the end feel is hard it may be due to contact between the calcaneus and the sinus tarsi. Normal range of motion is 0–5 degrees (Figure 13.52) (American Academy of Orthopedic Surgeons, 1965).

Forefoot Inversion

Place the patient in the sitting position with the leg dangling over the side of the treatment table and the knee flexed to 90 degrees or in the supine position with the foot over the end of the treatment table. Make sure that the hip is at 0 degrees of rotation, and adduction and abduction. Place one hand under the calcaneus to stabilize the calcaneus and talus and prevent dorsiflexion at the talocrural joint and inversion of the subtalar joint. Place your other hand over the lateral aspect of the foot over the metatarsals with your thumb on the dorsal aspect facing medially and the other four fingers on the plantar surface. Move the foot medially. The normal end feel is abrupt and firm (ligamentous) because of the tension in the joint capsule and the lateral ligaments (Kaltenborn, 1999; Magee, 1997). Normal range of motion is 0–35 degrees (Figure 13.53) (American Academy of Orthopedic Surgeons, 1965).

Figure 13.53 Passive movement testing of forefoot inversion.

Forefoot Eversion

Place the patient in the sitting position with the leg dangling over the side of the treatment table and the knee flexed to 90 degrees or in the supine position with the foot over the end of the treatment table. Make sure that the hip is at 0 degree of rotation, and adduction and abduction. Place one hand under the calcaneus to stabilize the calcaneus and talus and prevent dorsiflexion at the talocrural joint and inversion of the subtalar joint. Place your other hand under the distal plantar aspect of the foot with your thumb on the medial aspect of the first metatarsophalangeal joint and the other four fingers around the fifth metatarsal. Move the foot laterally. The normal end feel is abrupt and firm (ligamentous) because of the tension in the joint capsule and the medial ligaments

(Kaltenborn, 1999; Magee, 1997). Normal range of motion is 0–15 degrees (Figure 13.54) (American Academy of Orthopedic Surgeons, 1965).

Flexion of the Metatarsophalangeal Joint

Place the patient in the sitting position with the leg dangling over the side of the treatment table and the knee flexed to 90 degrees or in the supine position with the foot over the end of the treatment table. Make sure that the metatarsophalangeal joint is at 0 degree of abduction–adduction. The interphalangeal joints

should be maintained at 0 degree of flexion–extension. If the ankle is allowed to plantarflex or the interphalangeal joints of the toe being tested are allowed to flex, the range of motion will be limited by increased tension in the extensor digitorum longus and extensor hallucis longus. Place one hand around the distal metatarsals with your thumb on the plantar surface and the fingers across the dorsum to stabilize the foot and prevent plantar flexion. The other hand holds the hallux between the thumb and index finger and flexes the metatarsophalangeal joint. The normal end feel is abrupt and firm (ligamentous) because of the tension in the capsule and the collateral ligaments (Kaltenborn, 1999; Magee, 1997). Normal range of motion is 0–45 degrees for the hallux (Figure 13.55) (American Academy of Orthopedic Surgeons, 1965).

Extension of the Metatarsophalangeal Joint

Place the patient in the sitting position with the leg dangling over the side of the treatment table and the knee flexed to 90 degrees or in the supine position with the foot over the end of the treatment table. Make sure that the metatarsophalangeal joint is at 0 degree of abduction–adduction. The interphalangeal joints should be maintained at 0 degree of flexion–extension. If the ankle is allowed to dorsiflex or the interphalangeal joints of the toe being tested are allowed to extend, the range of motion will be limited by increased tension in

Figure 13.55 Passive movement testing of flexion of the metatarsophalangeal joint.

the flexor digitorum longus and flexor hallucis longus. Place one hand around the distal metatarsals with your thumb on the plantar surface and the fingers across the dorsum to stabilize the foot and prevent dorsiflexion. The other hand holds the hallux between the thumb and index finger and extends the metatarsophalangeal joint. The normal end feel is abrupt and firm (ligamentous) because of the tension in the plantar capsule, the plantar fibrocartilaginous plate, the flexor hallucis longus, flexor digitorum brevis, and the flexor digiti minimi muscles (Kaltenborn, 1999; Magee, 1997). Normal range of motion is 0–70 degrees for the hallux (Figure 13.56) (American Academy of Orthopedic Surgeons, 1965).

Mobility Testing of the Accessory

Movements

Mobility testing of accessory movements will give you information about the degree of laxity present in the joint. The patient must be totally relaxed and comfortable to allow you to move the joint and obtain the most accurate information. The joint should be placed in the maximal loose packed (resting) position to allow for the greatest degree of joint movement. The resting position of the ankle and foot are as follows: talocrural joint, 10 degrees of plantar flexion and midway between maximal inversion and eversion; distal and proximal interphalangeal joints, slight flexion; meta-

Figure 13.56 Passive movement testing of extension of the metatarsophalangeal joint.

tarsophalangeal joints, approximately 10 degrees of extension (Kaltenborn, 1999).

Dorsal and Ventral Glide of the Fibula at the Superior Tibiofibular Joint

Place the patient in the supine position with the knee flexed to approximately 90 degrees. Sit on the side of the treatment table and on the patient’s foot to prevent it from sliding. Stabilize the tibia by placing your hand on the proximal ventral aspect. Hold the fibular head by placing your thumb anteriorly and your index finger posteriorly. Pull the fibular head in both a ventrallateral and dorsal-medial direction (Figure 13.57).

Ventral Glide of the Fibula at the Inferior

Tibiofibular Joint

Place the patient in the prone position with the foot over the end of the treatment table. Place a rolled towel or a wedge under the distal anterior aspect of the tibia, just proximal to the mortise. Stand at the end of the table facing the medial plantar aspect of the patient’s foot. Stabilize the tibia by placing your hand on the medial distal aspect. Using your hand on the posterior aspect of the lateral malleolus, push the fibula in an anterior direction (Figure 13.58).

The Ankle and Foot Chapter 13

Figure 13.57 Mobility testing of dorsal and ventral glide of the fibula at the superior tibiofibular joint.

Traction of the Talocrural Joint

Place the patient in the supine position so that the calcaneus is just past the end of the treatment table. Stand at the end of the table facing the plantar aspect

of the foot. Stabilize the tibia by placing your hand on the distal anterior aspect, just proximal to the mortise. Hold the foot so that your fifth finger is over the talus with your other four fingers resting over the dorsum of the foot. Allow your thumb to hold the plantar surface of the foot facing the first metatarsophalangeal joint. Pull the talus in a longitudinal direction, until all the slack is taken up. This produces distraction in the talocrural joint (Figure 13.59).

Traction of the Subtalar Joint

Place the patient in the supine position with the foot at 0 degrees of dorsiflexion so that the calcaneus is just past the end of the treatment table. Stand at the end of the table facing the plantar aspect of the foot. Maintain the dorsiflexion angle by resting the patient’s foot on your thigh. Stabilize the tibia and the talus by placing your hand over the anterior aspect of the talus and the distal anterior aspect of the tibia, just distal to the mortise. Hold the posterior aspect of the calcaneus and pull in a longitudinal direction, until all the slack is taken up, producing distraction in the subtalar joint (Figure 13.60).

Dorsal and Plantar Glide of the Cuboid-

Metatarsal Joint

Place the patient in the supine position with the knee flexed to approximately 90 degrees. Stand at the side of the treatment table facing the medial side of the

foot. Stabilize the cuboid on the lateral side with your second and third fingers on the dorsal aspect and your thumb on the plantar aspect. Hold the base of the fourth and fifth metatarsals with your second and

third fingers on the dorsal aspect and your thumb on the plantar aspect. Glide the metatarsals first in a dorsal direction taking up all the slack, and then in a plantar direction (Figure 13.61).

Dorsal and Plantar Glide of the First Cuneiform-

Metatarsal Joint

Place the patient in the supine position with the knee flexed to approximately 90 degrees and the foot on a wedge just proximal to the first cuneiform-metatarsal joint. Stand at the side of the treatment table facing the lateral side of the foot. Stabilize the first cuneiform on the medial side with your second and third fingers wrapping around from the dorsal to the plantar aspect. Hold the lateral aspect of the foot against your trunk for additional stabilization. Hold the base of the first metatarsal with your index and middle fingers from the medial side just proximal to the joint. Glide the first metatarsal in a dorsal direction taking up all the slack, and then in a plantar direction (Figure 13.62).

Dorsal and Plantar Glide of the Metatarsals

Place the patient in the supine position with the knee flexed to 90 degrees and the foot flat on the treatment table. Stand on the side of the table facing the dorsal aspect of the patient’s foot. Stabilize the second metatarsal from the medial aspect of the foot using your thumb on the dorsal aspect and wrapping your fingers around the first metatarsal toward the plantar aspect. Hold the third metatarsal with your thumb on the dorsal aspect and your fingers on the plantar aspect. Move the third metatarsal in a dorsal direction until all the slack is taken up, and then in a plantar direction. This test can be repeated by stabilizing the second meta-

tarsal and mobilizing the first metatarsal, by stabilizing the third metatarsal and mobilizing the fourth metatarsal, and by stabilizing the fourth metatarsal and mobilizing the fifth metatarsal (Figure 13.63).

Figure 13.63 Mobility testing of dorsal and plantar glide of the metatarsals.

Figure 13.64 Mobility testing of traction of the first metatarsophalangeal joint.

Traction of the First Metatarsophalangeal Joint

Place the patient in the supine position with the knee extended. Sit on the end of the treatment table on the lateral aspect of the foot and allow the patient’s leg to rest on your thigh. Stabilize the first metatarsal with your thumb on the dorsal aspect and your fingers wrapped around the plantar surface just proximal to the joint line. Hold the foot against your body for additional stabilization. Hold the first proximal phalanx with your thumb and index fingers. Pull the phalanx in a longitudinal direction until all the slack is taken up, creating traction in the first metatarsophalangeal joint (Figure 13.64).

Resistive Testing

Muscle strength of the ankle is tested in plantar flexion and dorsiflexion. Inversion and eversion of the foot occur at the subtalar joint and are also tested. The toes are examined for flexion and extension strength.

Chapter 13 The Ankle and Foot

In testing muscle strength of the foot and ankle, it is important to watch for evidence of muscle substitution. Observe the forefoot for excessive inversion, eversion, plantar flexion, or dorsiflexion. The toes should be observed for movement while testing the ankle. If the ankle muscles are weak, the patient will recruit the flexors or extensors of the toes in an effort to compensate.

Ankle Plantar Flexion

The primary plantar flexors of the ankle are the gastrocnemius and soleus muscles (Figure 13.65). Additional muscles that assist are the tibialis posterior, peroneus longus and brevis, flexor hallucis longus, flexor digitorum longus, and plantaris muscles. All of the ankle plantar flexors pass posterior to the ankle joint. It is imperative to observe for downward rotation of the calcaneus. Excessive toe flexion in an attempt to plantarflex the ankle is a result of substitution by the long toe flexors. Excessive inversion during attempts to plantar flex is due to substitution by the tibialis posterior muscle. Excessive eversion is due to substitution by the peroneus longus muscle. The

Posterior view of leg

Soleus

Gastrocnemius

Figure 13.65 Plantar flexors of the ankle.

Tibialis anterior

Figure 13.68 The dorsiflexor of the ankle.

Figure 13.69 Testing dorsiflexion.

Chapter 13 The Ankle and Foot

Ankle Dorsiflexion

The primary dorsiflexor of the ankle is the tibialis anterior muscle (Figure 13.68). Due to its attachment medial to the subtalar joint axis, the tibialis anterior also inverts the foot. This muscle is assisted by the long toe extensors.

•Position of patient: Sitting with the legs over the edge of the table and the knees flexed to 90 degrees (Figure 13.69).

•Resisted test: Support the patient’s lower leg with one hand and apply a downward and everting force to the foot in its midsection as the patient attempts to dorsiflex the ankle and invert the foot. Dorsiflexion can also be tested by asking the patient to walk on his heels with his toes in the air. Testing dorsiflexion with gravity eliminated is per-

formed by placing the patient in a side-lying position and asking him or her to dorsiflex the ankle. Observe the patient for substitution by the long extensors of the toes. You will see dorsiflexion of the toes if substitution is taking place (Figure 13.70).

Painful resisted dorsiflexion in the anterior tibial region can be due to shin splints at the attachment of the tibialis anterior muscle to the tibia, or an anterior compartment syndrome.

Weakness of dorsiflexion results in foot drop and a steppage gait. An equinus deformity of the foot may result (i.e., as in peroneal palsy).

Subtalar Inversion

Inversion of the foot is brought about primarily by the tibialis posterior muscle (Figure 13.71). Accessory muscles include the flexor digitorum longus and flexor hallucis longus.

•Position of patient: Lying on the side, with the ankle in slight degree of plantar flexion (Figure 13.72).

•Resisted test: Stabilize the lower leg with one hand. The other hand is placed over the medial border

of the forefoot. Apply downward pressure on the forefoot as the patient attempts to invert the foot. Testing inversion of the foot with gravity eliminated

is performed by having the patient lie in the supine position and attempting to invert the foot through the normal range of motion. Watch for substitution of the flexor hallucis longus and flexor digitorum longus during this procedure, as the toes may flex in an attempt to overcome a weak tibialis posterior (Figure 13.73).

Weakness of foot inversion results in pronation or valgus deformity of the foot and reduced support of the plantar longitudinal arch.