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OMM 20/21- Ankle and Foot
Functional Arches
• Lateral Longitudinal Arch (weight bearing arch)
– Calcaneus, Cuboid, 4th and 5th metatarsals (long plantar ligament)
• Medial Longitudinal Arch (spring arch)
– Talus, Navicular, Cuneiforms, 1st, 2nd, and 3rd metatarsals (plantar fascia and tibialis posterior muscle)
• Transverse Arch
– Cuboid, Cuneiforms, Navicular
• Metatarsal Arch (not a true arch)
– Articulations of the metatarsal heads with the phalanges
Fibularis longus: induces eversion of cuboid
Tibialis anterior: induces inversion of navicular
Tarsal SD: to diagnose, palpate the plantar surface for depressed bones
• Cuboid – medial plantar edge rotates laterally
• Navicular – lateral plantar edge rotates medially
• Cuneiforms – 2nd cuneiform glides directly inferior
Functional Ankle: Motions
Tibiotalar joint (true ankle mortise)
Dorsiflexion with posterior glide
Plantar flexion with anterior glide
Talocalcaneal joint, subtalar joint (shock-absorber) (Distributes forces for foot)
Posterolateral glide with foot inversion
Anteromedial glide with foot eversion
Pronation: DEA (Dorsiflexion, Eversion, Abduction)
Supination: PIA (Plantar flexion, Inversion, Adduction)
Lateral ligaments of the ankle
Anterior talofibular ligament (most commonly sprained)
Calcaneofibular ligament (2nd most commonly sprained)
Posterior talofibular ligament.
Medially the Deltiod ligament
Anterior Tibiotalar
Tibionavicular
Tibiocalcaneal
Posterior tibiotalar
Plantar calcaneonavicular or “spring” ligament also helps to maintain the medial arch.
Muscles
Fibularis longus
Talocrural joint: plantar flexion
Subtalar joint: eversion
Supports transverse arch of foot
Tibialis anterior
Talocrural joint: dorsiflexion
Subtalar joint: inversion
Tibialis posterior
Talocrural joint: plantar flexion
Subtalar joint: inversion
Supports longitudinal and transverse arches of foot
OMM 20/21- Ankle and Foot
Pes planus
– Longitudinal & transverse arches fall
– Talocalcaneal joint axis more horizontal
– Tarsal somatic dysfunction
– Navicular prominence on medial side of foot
– Subtalar axis more horizontal
– Plantar fasciitis may be from decreased ligamentous arch stability (flattened arches)
Pes cavus
– Arches rise
– Axis more vertical
– Navicular less prominent
Gait and Foot Mechanics
• Heel strike on outer 1/3 of heel: Heel wear pattern
• Bear weight on lateral longitudinal arch
• Transfer weight to 1st, 2nd, and 3rd metatarsals
• Push-off with great toe
Fibula
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Palpate the entire length of the tibia and fibula (Maisonneuve fracture associated with syndesmotic injury)
Plantar flex: fibular head posterior (distal head is anterior)
Dorsiflex: fibular head anterior (distal head is posterior)
The anterior and posterior tibio-fibular ligaments maintain the mortise joint – the intact mortise provides stability to the
ankle; when these ligaments are injured, the patient has suffered a “high ankle sprain”
Motions of the Ankle
• Dorsiflexion (20o)
– TA, TP, EHL, EDL
• Plantarflexion (50o)
– TP, Gastrocnemius, Soleus, Peroneus longus and brevis, FHL, FDL, TP
• Inversion (5o)
– Tibialis posterior, tibialis anterior
• Eversion (5o)
– Peroneal group (LBT), EDL
• Supination – Combination of inversion, forefoot adduction and flexion
• Pronation – Combination of eversion, forefoot abduction and extension
OMM 20/21- Ankle and Foot
Stability Testing
Anterior Drawer: tests anterior talofibular ligament
5-10 degrees plantar flexion, slide foot forward while stabilizing tibia
Abnormal exam would be an asymmetric increased motion or lack of endpoint
Talar Tilt Test: tests the integrity of the calcaneal fibular ligament
Right hand fingers monitor the space below the lateral maleolus and talus and calcaneous rotated medially
Reverse Talar Tilt Test: Tests the integrity of Deltoid ligament
Monitor medial malleolus; rotate the talus out laterally
External Rotation Test: detects high ankle sprains or injuries to the anterior or posterior tibio-fibular ligaments
Ankle at 90 degrees, stabilize leg, forcefully externally rotate the foot on the ankle
If affected side opens 15⁰ greater than normal side, positive test
Squeeze Test: for high ankle sprains
Compress tibia and fibula together mid-leg and pain is felt at mortise joint
Thompson Test: Squeeze the calf, plantar flexes the foot if Achilles tendon is intact
Done against gravity to increase sensitivity
Midfoot palpation: twist of midfoot injures ligaments (reproduces pain)
Manual Muscle Testing
Posterior tibialis: tests strength in plantarflexion and inversion
Fibularis: have patient plantar-flex and evert
Tibialis anterior: hold foot in dorsiflexion and resist plantar-flexed force
Gastroc/Soleus: Ask to stand on toes
First MTP joint: dorsiflexion; important for gait (pushoff) at least 60 degrees
Check extensor hallucis (L5) due to most common slipped discs L4/L5 and L5/S1
Pulses: posterior tibial artery, dorsalis pedis
Ankle sprain
Inversion occurs more frequently than eversion because of relative strength of Deltoid ligaments
Most common mechanism: Inversion, plantar flexion (A Talofibular): 80%
Edema, decreased ROM, pain, anterior drawer, positive swing test, late ecchymosis
OMM 20/21- Ankle and Foot
Red: ATF (Type 1)
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Blue: calcaneofibular (2)
Green: PTF (3)
1st Degree Sprain
– Ligament integrity
– Conservative care
2nd Degree Sprain
– Partial tearing (slight laxity)
– Usually no need for surgery
3rd Degree Sprain
– Complete rupture
– Immobilization
– Surgery rarely indicated
Traumatic Inversion sprains peroneus longus and brevis muscles
Shortening of those muscles pulls fibula inferiorly and posteriorly (posterior fibular head)
Motion issues secondary to trauma
• Shape of talus
– Inversion, plantar flexion puts narrow posterior talus in mortise joint
– Offers little stability; forces ligaments & muscle effort for stability
• Peroneal muscles
– Rapidly eccentrically loaded
• Talus jammed into joint
– Weight of body coming down ‘jams’ talus into crural (distal tib/fib) articulation
Talus inversion
ATF pulled tight, Pulls distal fibula anterior, Proximal fibula moves posterior – becomes locked
Fibular motion with gait: Motion is anterolateral to postero-medial
Relates biomechanics to motion deficits
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Fibular head moves posterior during ankle inversion
Fibular head moves anterior during ankle eversion.
OMM 20/21- Ankle and Foot
Shin Splints
Pain at the medial border of the tibia
Degeneration and micro-tearing of the tendons of the muscles that flex the toes and the forefoot- the flexor
digitorum longus, flexor hallucis longus and tibialis posterior.
By: Functional lowering of the longitudinal arch together with hyperpronation which is normally compensated
for by the tendons of those muscles; or through weakness and overloading of the muscle in front of the
shin, the tibialis anterior.
Achilles tendonitis (calcaneal):
Extension of the calf muscles into and around the heel, into the plantar fascia, extending to the ball of the foot.
Degenerative change in the tendinous region associated with microtears.
This is the result of a combination of faulty biomechanics and repetitive overload stress as occur in running.
NSAIDs, relax, do not run! (pool?)
Talar Dysfunction
• Commonly Plantar Flexed
– Restricted in dorsiflexion AKA Anterior dysfunction (posterior restriction)
• Usually due to traumatic inversion ankle injury
– Associated with plantar fasciitis; Chronically tight posterior calf muscles
• Pt may complain of:
– Anterior talar pain; Sense of ‘jamming’ with attempted dorsiflexion; Reduced calf stretch
Swing Test: for talar dysfunction
Foot parallel to the floor with knee flexed
Monitor with thumbs adjacent the anterior tendons at ankle joint
For dorsiflexion to occur, the talus must dorsiflex and glide posteriorly into the mortise
Anterior talus will cause foot to point plantar-ward at the barrier
Abnormal motion: “anterior dysfunction of the talus”
Can also place patient supine, examiner at feet, grasp metatarsal heads and dorsiflex feet bilaterally
Compare left and right for restrictions
Eversion= anteromedial shift talus
Inversion= posterolateral shift talus
Muscle control of the foot aides in proprioception and balance.
Muscular retraining and strengthening of the foot muscle should be the first step in gait training.
Increased tone and therefore improved arch function also takes “shock” strain off of other joints.(knees, Hips, Low Back)
OMM 20/21- Ankle and Foot
Lateral Arch: in walking the distribution of weight shifts
(1)from the heel to the lateral border of the foot
(2) then to the metatarsal heads
(3) finally to the hallux for push off
Plantar Fascia
Provides static support for the longitudinal arch of the foot and to assist with shock absorption during foot strike
During the heel-off phase of gait, tension increases on the plantar fascia, which acts as a storage of potential energy.
During toe-off, the plantar fascia passively contracts, converting the potential energy into kinetic energy and imparting
greater foot acceleration.
Plantar fasciitis This condition causes pain by inflammation of the insertion of the plantar fascia on the medial process
of the calcaneal tuberosity
Talus: tripod action that distributes weight to calcaneous, Med. Long Arch, Lateral Long arch
Distributor of “body weight”
Talus is relay station-covered by ligamentous attachments and articular surfaces
OMT
Goal: decrease pain, increase ROM, decrease edema, remove inflammatory mediators and waste products, increase
nutrient delivery, speed up recovery
HVLA: Talar Tug
Talus in plantar flexion (resists dorsiflexion)--Talus considered anterior
Patient supine, leg extended, operator at end of table
Grasp foot, interlock fingers around head of talus, thumb on plantar surface
Dorsiflex ankle to restrictive barrier
Maintain traction and short, quick pull on talus
OMM 20/21- Ankle and Foot
Articulatory with traction: Talocalcaneal SD
1. Patient is seated at end of table with their legs dangling
2. Operator grasps heel with one hand and dorsum of foot near ankle with other hand
3. Traction is exerted by a downward pull on the calcaneus while the other hand articulation the talocalcaneal joint
through it’s full range of inversion and eversion
Circular motions in both direction
4. Recheck
Eversion = anteromedial shift
Inversion = posterolateral shift
Foot supination: Cuboid, Navicular, Cuneiform (Supine-Direct Articulatory)
• Pt supine & doc at feet
• Doc wraps lateral hand around dorsum of foot
• With thumb find navicular and apply slight pressure
• Wrap fingers of medial hand around dorsum of foot and the fingers of your lateral hand
• Cross over lateral thumb to address cuboid
• Apply tension laterally through medial thumb & medially through lateral thumb
• Objective is to separate all components of the transverse arch
Navicular Findings:
Plantar glide & inverted
Plantar surface rotates medially (navicular inverts)
Midline edge of navicular is prominent and inferiorly displaced, often TTP: “Dropped”
Cuboid findings
Everts & rotates laterally
Midline edge is inferiorly displaced and TTP : “Dropped”
“Hiss Whip” cuboid, navicular, cuneiform SD
• Pt prone or standing at edge of table on side of dysfunction
• Have pt secure themselves with opposite hand (if prone, hang leg off of table)
• Operator grasps foot with dysfunction
• Place one thumb over specific bone to be treated (navicular, cuboid, or cuneiform)
• Reinforce with opposite thumb
• Interlace fingers on dorsum of foot