Ankle

1
Ankle Foot (3)
2

• Flexion Metatarsophalangeal Joint

3

• ? Range of motion
• Great Toe 0 45
• Lateral Four Toes 0 40
• ?Testing position
• Supine or sitting, ankle foot in 0 of
  dorsiflexion, plantar flexion, inversion,
  eversion. MTP in 0 abduction adduction. IP 0
  of flexion extension
• ?Stabilization
• Stabilize metatarsal to prevent plantar flexion
  of ankle inversion or eversion of foot. Do not
  hold MTP of other toes in extension, because
  tension in transverse metatarsal ligament will
  restrict the motion

4

• ? Goniometer Alignment
• Fulcrum
• Dorsal aspect of MTP joint
• Proximal Arm
• Dorsal midline of metatarsal
• Distal Arm
• Dorsal midline of proximal phalanx

5

• ? Alternative Goniometer Alignment For First
  Metatarsophalangeal Joint
• Fulcrum
• Medial aspect of the first MTP joint
• Proximal Arm
• Medial midline of the first metatarsal
• Distal Arm
• Medial midline of the proximal phalanx the first
  toe

6

• ? Patient Instruction
• Ask the patient to Bend their toe.

7

• ? Normal End Feel
• Firm, because of tension in
• Dorsal Joint capsule
• Collateral ligaments
• Extensor digitorum brevis

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Hallux Toe Metatarsophalangeal Flexion Muscles

• Lumbricales
• Flexor Hallucis Brevis

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Lumbricales

• Origin
• Tendons of Flexor digitorum longus 1st
  lumbricale
• 2nd-4th lumbricales

• Insertion
• Toes 2-5 (proximal phalanges dorsal expansions
  of tendons of Extensor digitorum longus)

Innervation Medial Planter Nerve (L5-S1) ? 1st
lumbricale Lateral Planter Nerve (S2-S3) ? 2nd
3rd 4th lumbricales
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Flexor Hallucis Brevis

• Origin
• Lateral head cuboid bone lateral cuneiform
  bone
• Medial head medial intermascular septum tendon
  of Tibialis
• posterior

Insertion Lateral Medial heads Hallux (
proximal phalanx on both sides of base) blend
with abductor hallucis

• Intervention
• Medial Planter Nerve (S1-S2)

11

• 1- Hallux MP Flexion (Flexor Hallucis Brevis)
• Test For Grades 5, 4, 3, 2, 1 and 0

? Patient Position The patient is short sitting
with legs hanging over the edge of the table. The
ankle is in a neutral position
? Therapist and Patient Instructions   The
therapist is seated on a stool in front of the
patient. The test foot rests on the examiner's
lap. The therapist stabilizes the dorsum of the
foot just below the ankle with one hand, and uses
the index finger of the other hand to resist
beneath the proximal phalanx of the great toe.
Ask the patient to, Bend your big toe over my
finger. Hold it. Dont let me straighten it.
12

• Test For Grades 5, 4, 3, 2, 1 and 0

Grade 5 (Normal) completes full range of motion
and holds against maximal resistance. Grade 4
(Good) completes available range of motion and
holds against strong to moderate
resistance. Grade 3 (Fair) patient completes
available range of MP flexion of great toe but
unable to hold against any resistance Grade 2
(Poor) completes only partial range of
motion. Grade 1 (Trace) therapist my note
contractile activity but no toe motion Grade 0
(Zero) no contractile activity
13

• 2- Toe MP Flexion (Lumbricales)
• Test For Grades 5, 4, 3, 2, 1 and 0

? Patient Position The patient is short sitting
with legs hanging over the edge of the table. The
ankle is in a neutral position
? Therapist and Patient Instructions   The
therapist is seated on a stool in front of the
patient. The test foot rests on the examiner's
lap. The therapist stabilizes the dorsum of the
foot just below the ankle with one hand, and uses
the index finger of the other hand to resist
beneath the MP joints of the four lesser toes.
Then patient actively flexes the toes at the MP
joints, keeping the IP joints neutral. Ask the
patient to, Bend your toes over my finger.
14

• Test For Grades 5, 4, 3, 2, 1 and 0

Grade 5 (Normal) completes full range of motion
and holds against maximal resistance. Grade 4
(Good) completes available range of motion and
holds against strong to moderate
resistance. Grade 3 (Fair) patient completes
available range of MP flexion of toes but unable
to hold against any resistance Grade 2 (Poor)
completes only partial range of motion. Grade 1
(Trace) therapist my note contractile activity
but no toe motion Grade 0 (Zero) no contractile
activity
15

• Extension Metatarsophalangeal Joint

16

• ? Range of motion
• 0 to 50-70
• ?Testing position
• Supine or sitting, ankle foot in 0 of
  dorsiflexion, plantar flexion, inversion,
  eversion. MTP in 0 abduction adduction. IP 0
  of flexion extension
• ?Stabilization
• Stabilize metatarsal to prevent dorsiflexion of
  ankle inversion or eversion of foot. Do not
  hold MTP of other toes in flexion, because
  tension in transverse metatarsal ligament will
  restrict the motion

17

• ? Goniometer Alignment
• Fulcrum
• Dorsal aspect of MTP joint
• Proximal Arm
• Dorsal midline of metatarsal
• Distal Arm
• Dorsal midline of proximal phalanx

18

• ? Alternative Goniometer Alignment For First
  Metatarsophalangeal Joint
• Fulcrum
• Medial aspect of the first MTP joint
• Proximal Arm
• Medial midline of the first metatarsal
• Distal Arm
• Medial midline of the proximal phalanx the first
  toe

19

• ? Patient Instruction
• Instruct the patient to extend their toe.

20

• ? Normal End Feel
• Firm, because of tension in
• Planter Joint capsule
• Planter pad
• Flexor hallucis brevis
• Flexor digitorum brevis
• Flexor digiti minimi

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Hallux Toe MP IP Extension Muscles

• Extensor Digitorum Longus
• Extensor Digitorum Brevis
• Extensor Hallucis Longus

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Extensor Digitorum Longus

• Origin
• Lateral condyle of tibia shaft of fibula
  fascia
• cruris interosseous membrabe intermascular
  septum

• Insertion
• Toes 2-5 (to each middle each distal phalanx,
  dorsal surface)

Innervation Deep Peroneal Nerve (L5-S1)
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Extensor Digitorum Brevis

• Origin
• Calcaneus lateral talocalcaneal ligament
• extensor retinaculum

• Insertion
• Ends in four tendons Hallux ( proximal phalanx,
  dorsal surface) toes 2-4 join tendons of
  extensor digitorum longus

Innervation Deep Peroneal Nerve (L5-S1)
24
Extensor Hallucis Longus

• Origin
• Shaft of fibula interosseous membrane

• Insertion
• Hallux (distal phalanx, dorsal aspect of base)
  expansion to proximal phalanx

Innervation Deep Peroneal Nerve (L5)
25

• 1- Hallux
• Test For Grades 5, 4, 3, 2, 1 and 0

? Patient Position The patient is short sitting
or supine. Ankle is neutral
? Therapist and Patient Instructions   The
therapist stabilizes the metatarsal area by
contouring hand around the plantar surface of the
foot with the thumb curving around the base of
the great toe. The other hand stabilizes the foot
at heel. For resistance, place the thumb over the
MP or IP joint. Ask the patient to, straighten
you big toe, hold it.
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• 2- Toes
• Test For Grades 5, 4, 3, 2, 1 and 0

? Patient Position The patient is short sitting
or supine. Ankle is neutral
? Therapist and Patient Instructions   The
therapist uses both hands to stabilize the
metatarsals with the fingers on the plantar
surface and the thumbs on the dorsum of the foot.
The other hand is used to give resistance with
the thumb placed over the dorsal surface of the
proximal phalanges of the toes. Ask the patient,
straighten you toes, hold it.
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• Test For Grades 5, 4, 3, 2, 1 and 0

Grade 5 (Normal) Grade 4 (Good) patient can
extend the toes fully against variable resistance
(which may be small) Grade 3 (Fair) Grade 2
(Poor) patient can complete range of motion with
no resistance (Grade 3), or can complete partial
range of motion (Grade 2). Grade 1 (Trace)
tendons of the Extensor digitorum longus can be
palpated or observed over dorsum of metatarsals.
Tendon of the Extensor digitorum brevis often can
be palpated on the lateral side of the dorsum of
the foot just in front of the malleolus Grade 0
(Zero) no contractile activity
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• Abduction Metatarsophalangeal Joint

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• ?Testing position
• Supine or sitting, foot in 0 of inversion
  eversion. MTP IP 0 of flexion extension
• ?Stabilization
• Stabilize metatarsal to prevent inversion or
  eversion of foot.

30

• ? Goniometer Alignment
• Fulcrum
• Dorsal aspect of MTP joint
• Proximal Arm
• Dorsal midline of metatarsal
• Distal Arm
• Dorsal midline of proximal phalanx

31

• ? Normal End Feel
• Firm, because of tension in
• Joint capsule
• Collateral ligaments
• Fascia of the web space between toes
• Addactor hallucis
• Planter interosseus muscles

32

• Adduction Metatarsophalangeal Joint

33

• Adduction is the return from abduction to the 0
  starting position, it is not usually measured

34

• Flexion IP Joint of First Toe PIP Joints of
  Four Lesser Toes

35

• ? Range of motion
• Great Toe 0 to 30 90
• Lateral Four Toes 0 to 35 65
• ?Testing position
• Supine or sitting, ankle foot in neutral
• ?Stabilization
• Stabilize metatarsal proximal to prevent
  dorsiflexion or planterflexion of ankle
  inversion eversion of foot. Avoid flexion
  extension of the MTP joint

36

• ? Goniometer Alignment
• Fulcrum
• Dorsal aspect of IP joint being tested
• Proximal Arm
• Dorsal midline of proximal phalanx
• Distal Arm
• Dorsal midline of the phalanx distal to the joint
  being tested

37

• ? Normal End Feel
• May be soft
• ? because of compression of soft tissues between
  the planter surfaces of the phalanges
• Sometimes it might be firm, because of tension
  in
• Dorsal Joint capsule
• Collateral ligaments

38

• Flexion DIP Joints of The Four Lesser Toes

39

• ? Range of motion
• 0 to 30
• ?Testing position
• Supine or sitting, ankle foot in neutral
• ?Stabilization
• Stabilize metatarsal ,proximal and middle phalanx
  to prevent dorsiflexion or planterflexion of
  ankle inversion eversion of foot. Avoid
  flexion extension of the MTP PIP joints of
  the toe being tested

40

• ? Goniometer Alignment
• Fulcrum
• Dorsal aspect of DIP joint being tested
• Proximal Arm
• Dorsal midline of middle phalanx
• Distal Arm
• Dorsal midline of the distal phlanx

41

• ? Normal End Feel
• Firm, because of tension in
• Dorsal Joint capsule
• Collateral ligaments
• Oblique retinacular ligament

42
Hallux Toe DIP PIP Flexion Muscles

• Flexor Digitorum Longus
• Flexor Digitorum Brevis
• Flexor Hallucis Longus

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Flexor Digitorum Longus

• Origin
• Shaft of tibia fascia over tibialis posterior

• Insertion
• Toes 2-5 (distal phalanges, planter surfaces
  bases)

Innervation Tibial Nerve (L5-S2)
44
Flexor Digitorum Brevis

• Origin
• Calcaneus plantar aponeurosis intermascular
  septum

• Insertion
• Toes 2-5 (by four tendons to middle phalanges,
  both sides)

Innervation Medial Plantar Nerve (S1-S2)
45
Flexor Hallucis Longus

• Origin
• Shaft of fibula interosseous membrane
  intermascular
• septum fascia over tibialis posterior

• Insertion
• Slip of tendon to Flexor digitorum longus
  hallux

Innervation Tibial Nerve (L5-S2)
46

• Test For Grades 5, 4, 3, 2, 1 and 0

? Patient Position The patient is short sitting
with foot on examiner's lap, or supine.
? Therapist and Patient Instructions   The
therapist is seated on a stool in front of the
patient. One hand grasps the anterior foot with
fingers placed across the dorsum of the foot
the thumb under the (PIP) or (DIP) or under the
IP of the hallux for stabilizaion . The other
hand applies resistance using the examiners four
fingers or thumb under the middle phalanges (for
the IP test) under the distal phalanges (for the
DIP test) with the index finger under the
distal phalanx of the hallux Ask the patient,
Curl your toes . Hold it. Curl your big toe .
Hold it.
47

• Test For Grades 5, 4, 3, 2, 1 and 0

Grade 5 (Normal) Grade 4 (Good) patient
complets range of motion of toes then hallux
resistance in bothe tests may be minimal Grade 3
(Fair) Grade 2 (Poor) patient can complete
range of motion with no resistance (Grade 3), or
can complete partial range of motion (Grade 2).
Grade 1 (Trace) Grade 0 (Zero) minimal to no
palpable contractile activity occurs. Tendon of
the Flexor hallucis longus may be palpated on the
planter surface of the proximal phalanx of the
great toe
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? Good Luck To You All ?