__Measurement_of_Joint_Motion__A_Guide_to_Goniometry_3rd_Edition

244 PART III LOWER-EXTREMITY TESTING talus. In inversion of the foot, the calcaneus slides later- ;1JHermr and middle porrions of the SUbLll;H ioint and is ally on a fixed talus. In eversion, the calcaneus slides rcinfurcl.'d hy rhl.:\" spring, hifun.:arl.' (Cl!C:Hll.'Ocuboid and medially on the talus. Gl!c.:lIlCOllJvicul:lrl. and d<lr\"31 raIOll;l\\'itular lig3ments (hg. IO-6l!). Capsular Pattern The capsular pattern consists of a greater limitation In The c,l!cln<.'(KUhoid join! is (Oll1posc...d of the shallow}' inversion. 3 anlCOIlV('X-COIlC;\\VL' surtacL',s 011 thL' aIHerior cl!C<lI1CUS Transverse Tarsal (Midtarsal) Joint rhe COI1V(.'X-COIH.:aVe SUrLKL'S 011 the posterior cuboid, Th~\" joint is enclosed in a clpsulc rlt:u is rc..:inforce:d by [h~,' Anatomy bifurc3te (calcaneocuboid :'Iml c;lk311CCHl;lvicular), dorsal cakancocuboiJ. plantar cakallL\"(KUbc)id, and long plan- The transverse mrsal, or midtarsal, joint is a compound tar liganH:nrs {Fig. 10-6el. joint formed by the talonavicular and calcaneocuboid joints (Fig. lQ-6A). The talonavicular joint is composed Osteokinematics of the large convex head of the talus and the concave posterior porrion of the navicular bone, The concavity is The joinr is cOllsidered to ha\\'(' t\\\\'o axes. one longitudi~-<' enlarged by the plantar calcaneonavicular ligament nal :1I1d one: oblique. Motions ;Hound both axes are (spring ligament). The joint shares a capsule with the rrirl:lIlar alld consist of inversion 31H.I ('version. The \" rr:lI1s\\\"{:rse: t:1fs,11 ioinr is the tr:lnsitioll:lliink berwccn the hindfoot and rhe fonJooL Talus Navicular \\- ----'''-:::c-_ _Talonavicular joint ~ Transverse tarsal 1 - - - - - - - - - t Calcaneocuboid joint ! (midlarsal) joint j Fitth Dorsal talonavicular ligament Talus metatarsal Navicular 1 / Ca!caneonavicular Cuboid Cafcaneus ligament A Dorsal talonavicular ligament Calcaneocuboid ligament ..... ----. / '---_/i Cuboid Calcaneus B r ( .- Plantar calcaneonavicular ligament (spring ligament) First metatarsal C Long plantar ligament FIGURE 10-6 (A) The two joints that make up the rr=tIlSVt'rsc tarsal joinr arl.: shown in ;l Iatcr;l! vicw of a left ankle, (B) The dorsal talonavicular ligament, rhe hi(un.:ar<.' lig:lIl\\l'nr {cak:\\neon:1Vil,;u!:H and (ah.:a- neocuboid ligaments), and the dorsal calcaneocuboid ligalllent in n bteral view of ;l I(.~ft ankle, iC) The long plantar ligamenr, the plantar calcaneonavicular ligamcnt, and the dorsal mionavi\\.:lllar ligamt:m in a medial view,

CHAPTER 10 THE ANKLE AND fOOT 245 inversion, the concave navicular slides medially and and the cuboid. The fifth metatarsal articulates with the Anr<a,llv on the convex talus. The calcaneus slides medi- cuboid. The first joint has its own capsule, whereas the second and third joints and the fourth and fifth joints toward the plantar surface. In eversion, the share capsules. Each joint is reinforced by numerous navicul'lt slides laterally and toward the plantar surface, dorsal, plantar, and interosseous ligaments. the talus the calcaneus slides laterally toward the Osteokinematics surface. The TMT joints are plane synovial joints that permit CaJ~sular Pattern gliding motions, including flexion-extension, a minimal amount of abduction-adduction, and rotation. The type capsular pattern consists of a limitation in inversion and amount of motion vary at each joint. For example, at (adIQu.cnon and supination). Other motions are full. the third TMT joint, the predominant motion is flexion- extension. The combination of motions at the various Joints joints contribures to the hollowing and flattening of the foot, which helps the foot conform ro a supporting five tarsometatarsal (TMT) joints link the distal surface. tarsals with the bases of the five meratarsals (Fig. 10-7). The concave base of the first metatarsal articulates with Arthrokinematics convex surface of the medial cuneiform. The base of The distal joint surfaces glide in the same direction as the second metatarsal articulates with the morrise formed shafts of the metatarsals. by the intermediate cuneiform and the sides of the medial and lateral cuneiforms. The base of the third metatarsal Metatarsophalangeal Joints articulates with the lateral cuneiform, and the base of the fourth metatarsal articulates with the lateral cunieform Anatomy .~ .- - Tarsometatarsal The five metatarsophalangeal (MTP) joints are formed joint proximally by the convex heads of the five metatarsals Cuboid and distally by the concave bases of the proximal Medial phalanges (Fig. 10-8A). The first MTP joint has two cuneifonn sesamoid bones that lie in two grooves on the plantar Navicular surface of the distal metatarsal. The four lesser roes arc interconnected on the plantar surface by the deep ttans- Intermediate verse metatarsal ligament (Fig. 10-8B). The plantar cuneiform aponeurosis helps ro provide stability and limits exten- Transverse SIOn. tarsal Osteokinematics joint The five MTP joints are condyloid synovial joints with 2 • \",Ult<.r. 10-7 The tarsometatarsal joints and transverse tarsal degrees of freedom, permitting flexion-extension and in a dorsal view of a left foor. abduction-adduction. The axis for flexion-extension is oblique and is referted to as the metatarsal break. The range of motion (ROM) in extension is greater than in flexion, but the total ROM varies according to the rela- tive lengths of the metatarsals and the weight-bearing status. Arthrokinematics In flexion, the bases of the phalanges slide in a plantar direcrion on the heads of the metatarsals. In abduction, the concave bases of the phalanges slide on the convex heads of the metatarsals in a lateral direction away from the second toe. In adduction, the bases of the phalanges slide in a medial direction towatd the second toe. Capsular Pattern The pattern at the first MTP joint is gross limitation. of extension and slight limitation of flexion. At the other

246 PART III LOWER-EXTREMITY TE$TING Distal interphalangeal joints ioillls (second (() fifth), the limitation is more restriction of flexion than extension. ; Distal phalanx Interphalangeal Interphalangeal Joints Middle phalanx joint Anatomy Proximal phalanx ;..-....,!---_ Metatarso- The- :\"rructurc of the ilHCrphalJllgcal (IPI joints of the feet A phalangeal is identical to that of the III joints of rhl: fingers. Each IP joint joint is composed of the concave hase of a dlsral phalanx and rht: COTlvex head of a proxirnJI plulanx {see Fig. I 0-8A i. Osteakinematics 'fhc IP joints arc synovial hinge joilHs \\virh 1 degree of frcL'i..lom. The JTlmiOT1S permiw:d afC flexion and Cxtcn~ SiOll in the saginal plane. Each joiiH is enclosed 10 a capsule and reinforced with collatcLl! ligaments. Arthrokinematics The conClVt: base of rhe distal phabnx slides on the convex head of till' proximal plulanx in the saille direc- tion as the sluft of the disul bOlle. The C(H1CavC base slides [(}ward rhe plantar surface of the fooI during ion Jll(.l toward the dorsum of the foot dUring Deep transverse ~ Research Findings metatarsal ligaments 'fables 10-1 and 10~2 provide ankk and toe 1\\0;\\1 B from v;lrious sourccs. ·fhe age, gendLT, ;l1}(.lllLilllber of subjccts who were measured to ohuill the FIGURE 10-8 (A) The metatarsophalangeal, interphalangeal, and distal interphalangeal joints in a dorsal view of a left foot. reported by rhe AIHericlll Association of (B) The deep transverse metatarsal ligaments and the plantar plates in a plantar view of a left foot. Surgeons (AAOSj!· (published in 1965) ;111(.1 the Al!I1Clcic:m \\tedical Associatioll (A\\1;\\)·\\ arc llnkno\\vn. The AAOS' edition includes RO,\\1 valucs from research stlldies, including the samc v~dLles from and Azen(' that arc included in Table 10- j as well as few v,llues from rhe 1065 edirion. Boone and Azen, TABLE 10-1 Ankle Motion: Values in Degrees from Selected Sources AMA = American Medical Association; MOS = American MTP 1 Association of Orthopaedic Surgeons; (SO) = standard deviation. 2 3 * Values represent visual estimation of arc of motion. 4 t Subjects were 109 males 1 to 54 years of age. $ 1P1 PIP 2-$ DIP 2-$ AMA American Medical A'>sociiltion; AAOS American Association of Orthopaedic Surgeons; DIP distal interpha- langeal; IP interphalangeal; MTP metatarsophalangeal; PIP proXimal interphalangeal.

.. /\" CHAPTER 10 THE ANKLE AND FOOT 247 TABLE 10-3 Effects of Age on Ankle Motion in Newborns and Children Aged 6 to 12 Years: Mean Values in Degrees using- a universal goniometer, measured active ROM on women ranging from 70 to 92 years of age. The mosr 'male subjects, rapid reducrion in ROM occurred for individuals in rhe ninth decade. Ankle dorsiflexion measured wirh the knee Effects of Age, Gender and Other Factors extended (a rest of the lengrh of rhe gastrocnemius muscle) showed rhe mosr marked change. The invesriga- ~!le tors suggested that shorteness of [he plantarflexor ~1ludy of Table 10-3 shows that newborns, infants, and muscle-tendon unit was due to connective tissue changes 2.year·olds have a larger dorsiflexion ROM than older associated with [he aging process. In another study that children. The mean values for dorsiflexion in rhe examined the effects of aging on dorsiflexion ROM, youngest age groups arc more than double the average Gajdosik, Vanderlinden, and Williams 13 used an isoki- ~4ult' values presented in Tables 10-1 and 10-4. netic dynamometer ro passively stretch [he calf muscles in HOlvever, between 1 and 5 years of age, dorsiflexion 74 females (aged 20 to 84 years). The older women (aged values decrease to within adult ranges (Table 10-3). 60 ro 84 years) had a significantly smaller mea'n dorsi· Newborns also have less plantarflexion ROM than flexion angle of 15.4 degrees rhan the younger women ,}4il!ts, bur they attain adult values in the first few weeks (aged 20 to 39 ye~rs), who had a mean of 25.8 degrees, pflife. According ro Walker,IO the persistence in infants and the middle-aged women, who had a mean of 22.8 of aJimited ROM in plantarflexion may indicate pathol- degrees, The decrease in dorsiflexion in the older women ogy;- was associated with a decrease in plantarflexor muscle- ': \"Table 10-4, provides evidence that decreases in both tendon unit extensibility. 'A~isiflexion and plantarflexion ROM occur with Nigg and associates14 found rhat age-relared changes ::-iricreases in age, However, the difference berween dorsi- fle~ion values in the oldest and those in the youngest in ankle ROM were motion specific and differed between , ''groups constirutes less than 1 standard deviarion (SD). males and females. The aurhors measured active ROM in ':R:?\"the other hand, plantarflexion values in the oldesr 121 subjects (61 males and 60 females) between rhe ages \"group are slightly more than 1 SD less than values for the of 20 and 79 years. For the whole group of subjects, 'yo~';gesr group. decreases in active ROM with increases in age occurred James and Parker 12 found a consistent reduction in in plantarflexion, inversion, abduction, and adduction but not in eversion and dorsiflexion ([es[ed in rhe sitting ,\"c: b~t~':~ctiv,e ~nd passive ROM wirh increasing age in all posirion with [he knee flexed). Plantarflexion decreased !sioint motions in a group of 80 active men and about 8 degrees from the youngest to the oldest group. TABLE 10-4 Effects of Age on Active Ankle Motion for Individuals 13 to 69 Years of Age: Mean Values in Degrees

248 PA R Till LOWER-EXTREMITY TESTING TABLE 100S Effects of Age and Gender on Dorsiflexion Range of Motion in Males and Females Aged 40 to 85 Years: Mean Values in Degrees 15.4 (4.3) 19.3 (3.2) ROM = Range of motion; (SO) = standard deviation. • A laboratory coordinate system ROM instrument was used to measure active HOM in ~ubj('cts !>illing with the knee:> flexed. t An electric computer-controlled torque motor system was used to produce' p<\"lSsrvc: HOtv1 in sllbjects positioned prone with the knee flexed. Gender 1lll,:Il . .I;\\lIIC$ :llld P:lrkl'r.l.~ who lllt'asun:d hOEh al.:ti\\'c and p:h~i\\'l' RO\\l, found thar thl\" only motion rh;lI showed a Gender effects on ROM are Joint specific and motion ~igflifil.';lm differellce hl'tweel) rlw gender:') W;lS ;mkle specific and are often related to age. Nigg and associ- pl:ult:lrflt:xioll Illl'aslln:d widl tilt k1li..T t:x!cllded, \\'('omen \", ates'\" found gender differences in ankle motion but :tlld Illcn h:ld ~illlilar l1lean valw..'s in rhl.' group herween \" determined that the differences changed with increasing 70 ,\\Ild 74 year~ of :tgi.:. bur rhl' n:ducrioll in RO\\;l over age. Only in the oldest group, did women have 8 degrees rhi.' cmin.:: ;lgl\" r:lll~e W;P; gre;w,:r for lllcn (25,2 percent) more plantarflexion than men (Table 10-5). The only (11:111 for \\\\'Ollll'll ( I 1,3 pen':('lH), High-hccled shoe wear gender differences noted by Boone, Walker, and Perry\" 11:15 h(,(,11 proposed by Nigg :1 lid ;ls~(l(.:i~Hl·;,;i'; as olle reason were that females in the 1-year-old to 9-year-old group why WOlll('1l 11;1\\'(' :1 gri.::Her RO\\·1 in pLtnrarfk'xion than and those in the 61-year-old to 69-year-old group had significantly more ROM in plantarflexion than their male mt'n. countcrpans. Three other studies also found that women In (.:olHr:1S{ w rht' findings !Iut WOOlen han..' greater had more plantarflexion than men. Bell and Hoshizaki!6 studied 17 joint motions in 124 females and 66 males RO\\1 than Illl'll in pl:llltarfkxioll, ;1 fe\\\\' investigators ranging in age from 18 to 88 years. Females between 17 ha\\'(: found rh:H tCllutes h:1\\'I.' less :lcti\\\"l' ,mel passive and 30 years of age had a greater ROM in plantarflexion dorsiflexion RO.\\! thall m:1ks,l-I·1 ;.IS III :1 !-{Ud~' by Nigg as well as dorsiflexion than males in the same age groups. Walker and colleagues!7 studied active ROM in 30 men :l1td associ:HCS,I,1 males in rhl..' old,,:sl group Iud a greater 'Yirpf and 30 women ranging in age from 60 to 84 years. ;h.·' i VI..' r,mgt' of Illmlon in dorsifkxion (8 tkgrccs) me:lS- ,:,. Women had 11 degrees more ankle plantarflexion than Ul't,'d with [he kn(,'e tlexl'll thall fcmales in dle same age ';', group (Llhlc 10-51. Femalcs, showcd a significan[::,';,/ dL'L\"fl'aSC in activt: dorsiflexioll ROM \\,.lith increasing age,',;); frol1l 26,0 dcgn:·(.:s III tht.' YOUl\\gL'S[ group [(I 18,5 degrees ' TABLE 10-6 Dorsiflexion Range of Motion Measured in Non-vVeight-8earing Positions with _ the Knee Extended in Male and Female Subjects Aged 20 to 85 Years: Mean Values in Degrees I t~l:~~'(s:~j'~~jt;p·8(4.~~Ji;-;,(r5.4:<5,ili!1~;\\-;\";( \"/;']8:'/;;<6.9) ROM = Range of motion; (SO) :::: standard deviation. in.. All measurements are of passive ROM in female subjects taken in the supine position with a universal goniomNer. t All measurements are of passive ROM in both genders taken the prone position with usc of a protractor ilnd with the applic.ltion of 12.0 f Nm of torque. ~ All measurements are of active assistive ROM in the prone position. § All measurements are of active ROM in the prone position with use of a footpli1te ilnd a potentiometer.

CHAPTER 10 THE ANKLE AND fOOT 249 TABLE 10-7 Comparison Between Dorsiflexion Range of Motion Measurements Taken with the Knee Flexed and Extended in Subjects Aged 8 to 87 Years: Mean Values in Degrees ROM = Range of motion; (SO) = standard deviation. • All measurements were taken in weight-bearing positions with use of an inclinometer. t All measurements were taken in weight·bearing positions with use of a leighton Flexometer (a type of gravity inclinometer). The flexed-knee testing position was greater than 90 degrees. *All measurements were taken by one tester using a masked goniometer. The testing position was not reported, but in the flexed-knee posi- tion, the knee was flexed to 90 degrees. § All measurements were taken in non-weight.becuing positions with use of an active assistive ROM technique t.v' flexed are used ro relax the gastrocnemius muscle so that its effect on the measurement of dorsiflexion ROM is in the oldest gtoup. Females a~:·showed a significant reduced. Positions in which the knee is extended gener- decrease in eversion of 5.8 deir~~s with increasing age. ally are used for testing the length of the gastrocnemius Males, on the other hand, had'f(i1e or no change in either muscle (Table 10-6). Dorsiflexion measurements taken ;, active dorsiflexion or eversion ROM from the youngest with the knee flexed genetally ate larger than measure- to the oldest group. Vandervoort and coworkers!S expe- ments taken with the knee in the extended position (Table tienced similar findings in a study measuting passive 10-7). Dorsiflexion measurements taken in the weight- dotsiflexion ROM with the knee flexed. The end of the ROM was defined as the maximum degree of dotsiflex- bearing position are usually greater than measurements ion possible before muscle contraction occurred, or when taken in the non-weight-bearing position\" (Tables 10-6 the subject felt discomfort, or when the heel lifted from a and 10-7). floor plate. Females in the srudy showed a dec tease in passive dorsiflexion ROM, from a high of 19.3 degrees in McPoil and Cornwall23 compared dorsiflexion ROM . the youngest group (aged 55 to 60 years) to a low of 12.1 measurements taken with rhe knee flexed with measure- degtees in the oldest group (aged 81 to 85 years) (Table mentS taken with the knee extended in 27 healthy young 10-5). In comparison, male subjects showed a decrease adults. As might be expected, the mean dotsiflexion of only 2.3 degrees in dorsiflexion from the youngest ROM (16.2 degtees) with the knee flexed was greater than the mean (10.1 degrees) with the knee extended group (mean = 15.4 degrees) to the oldest group (mean (Table 10-7). Baggett and Young\" campa ted measure- ments of dorsiflexion ROM taken in the non-weight- = 13.1 degrees). Males had greater passive elastic stiff- bearing supine position with those taken in the standing ness than females, with 10 degrees of dorsiflexion. .'_' , Grimsron and associates l8 measured active ROM in weight-beating position in 10 males and io female .,.--1- .;. 120 subjects (58 males and 62 females) ranging in age patients, aged 18 to 66 yeats. Both supine and standing \"_, it Arom 9 to 20 years. These authors found that females measurements were taken with the knees extended. The generally had a greatet ROM in all ankle motions than average dotsiflexion ROM in the supine position was 8.3 :males. Both males and females showed a consistent trend degrees, whereas the average dorsiflexion ROM in the toward decreasing ROM with increasing age, but females standing position was 20.9 degrees. Little correlation was had a larget decrease than males. found between measurements taken in the non-weight- beating position with those taken in the weight-bearing Testing Position position. Consequently, the authors recommended that examiners not use the non-weight-bearing and weight- ~i-:;,,;:t;- variety of positions are used to measure dorsiflexion bearing positions interchangeably. ·'~·ROM, including sitting with the knee flexed, supine with Lattanza, Gray, and Kante~6 measured subralar jo~nt 'Lthe knee either flexed or extended, prone with the knee eversion in weight-bearing and :;0either flexed or extended, and standing with the knee 7i;e't11er flexed or extended. Positions in which the knee is

250 PART III LOWER-EXTREMITY TESTING postures in 15 females and 2 males. Measurements of altl'fe-d in rhe fractured ;lnklc::> alld dur this re-flex activ. subralar joint eversion in a weight~bcaring posture \\vere found to be significantly greater than those in a ity acted as ;l prorectin' Illechanism to prevent Over. non-weight-bearing posture. The authors advocated ~(rctching of tilt: pblltarflL\"xor~ ;It\"rcr a period of measurement in both positions. inullobilizatiol1, Reynolds ;lIH.I C(lIIt.:;lgUt·S II found that in Nowoczenski, Baumjaucr, and Umbcrger27 measured rats, 6 WCL:'k~ of immohiliz;uioll of a healthy hind limb _ active and passive extension ROM of the MTP joint of the first toe in different positions in 14 women and 19 resulted in a signifie;ult (70 pen':<.:lni loss of dorsiflexion) men between the ages of 20 and 54 years. Active and passive roe extension measurements were taken with the 1\\0\\;1 when a fixcd torquc wa::> appliL'd, The authors.';': subject standing on a platform with toes extending over the edge. Passive measurements were taken in the suggeslt·d that loss of cxtensibility of dlt· lTlllSClll()[cndi~.': non-weight-bearing seated position and during heel rise in standing. Mean values in the weight-bearing position !lOUS unit \\1,/;lS prohably caused by tisslH: rt'modeling that~~ were 37.0 degrees for passive MTP extension and 44.0 degrees for active extension compared with a mean value m.:currcd during l:xtcnocd irnmohiliz;1tiun. of 57.0 degrees obtained in the non-weight-bearing I--Ia::.tings ;Jnd coworkcrs ;:.'. ~llldi(:d ;1 singlc patient with,,:., seated position and 58 degrees during heel rise in the standing position. Similar to the effects of different test- diab('te~ mellitus \\1,'110 !l;HJ n:L'i.:iveJ :1 t(;ndo-<lchille~;; ing positions on ankle ROM, the results showed that the posirions could not be used interchangeably, with the lengthening pl\"ol.'t:dun:, 'lhc opl'l\"atioll n:sulted in an) exception of the heel rise and seated non-weight-bearing positions. ill(re;l::\\(,: ill dorsiflexioil RO.M wirh th(: knee exrended. Injury/Disease t'rom ;I pn:ojJlT;Hiv(\" k\\'d 010 (k'grl\"Cs to ;1 7 month post;, opcrati\\'l' levd of I~ dcgn:c:-.. Plalltar prl'ssllrl' Juring gait- Wilson and Gansneder28 measured physical impairment measures (loss of passive ankle dorsiflexion, plantarflex- was cOllsidcr;lhly rt:dlJCl,d by 55 pn...·l·m wilt'll [h(' paticnr, ion ROM, and swelling), functional limitations, and .disability duration in 21 athletes with acute ankle W;lS Wt':lfillg shocs ;Illd thi.' p;nii.'llt\\ scores on thi/; sprains. Passive ROM measurements wefe taken with a universal goniometer, and ROM loss was obtained by pcrfol\"lllancl' of ;1 !lumher ut fUlk'riol1:l1 r;lsks was! subtracting the ROM total of the affected ankle from the passive ROM measurements taken on the unaffected illlprovt.:d by 24 PlTCt.'IlL \" ankle. The authors found that the combination of ROM loss and swelling predicted an acceptable estimate of Sali<.:h, \\ludlt'r, ;lIld S;lhrm;IlIn ~ > fouJld rhat patients- disability duration, accounting for one-third of the vari- ancc. Functional limitation measures alone provided a with diabetes nlt,llitus and periphvr:-d l1L\"lIrtlp;Hhy demon- better estimate of disability duration, accounting for 67 percent of the variance in the number of days the athletes strated It:ss dorsit\"It::xioll RU\\1 (t'xtt'llsibili[y of the were unable to work after the acute ankle sprain. fllllSClllotclldillOU~ unit) th;lIl a group of age matched,' Kaufman and associares29 tracked 449 trainees at a conrro! ~lIbjL\"(!s, S:tlich, Brown, alld \\ltH:lkr H fOlllld thai'0 Naval Special Warfare Training Center to determine whether an association existed between foot structure therc was a po::>itive relationship hetwecn body size and.:\" and the development of musculoskeletal overuse injuries p;lssiv(' pbnr;lI' flexor Illuscle stiffness, The lack of ~ of the lower extremities. Restricted dorsiflexion ROM was one of the five risk factors associated with overuse (orrl'lation hL\"rw('l'll stiffIH.'ss (L\"h;lngc.: in torque per unit Injury. L\"hangt' i:l joint anglc) and ;l L1cCrt',lSt' in RO,\\-t led the Cheswonh and Vandervoorr30 measured dorsiflexion ROM after ankle fracture. They found that large differ- ;lUrhors to ...:aurion examincrs ;lbollt llsing the term \"stiff::: ences occurred in the maximum passive dorsiflexion ROM between fractured ankles and the contralateral ness\" ro desL\"ribt' limitl:d joint motion. Limitations in uninvolved ankles. Maximum passive dorsiflexion was defined as that point just prior to the initiation of muscle jOint 1\\0\\1 m,\\~' he ClllS('d by tl'llsio[l e:>.:crred by a fulli' activity in the plantarflexor muscles. The authors hypoth- esized that the reflex length-tension relationship was is\"lL'ngthl'!ln! IIl1lst:!e at tilt' cnd of irs cnd-range which differcll{ dUll Illuscle :-:!lffnl'ss. The :1uthors suggested that oldcr patit,llts who L:ompbill of sriffncss may acru~\" ;llly bt' experit'lll\"ing strl'n:h inwkT;lllCl' which mar ha!.~ motion ('arly III the R():\\{ meastlrt'llle!H, ' Functional Range of Motion ,-\\n adt'lluate RO:\\tl at rht' ;lukic, foor. alld toes is ncces sary for llofllial g;lir. !\\t IC;lSt I() dcgret's of dorsiflcxio is nCn'5S;\\ry ill the Sl:\\Il(e phJSl' of g:llr so that ribi Cl.lll ~ldvallcc ov('[\" the foot Cfable 10-1-;) ,md ;H least 1 I(q~rec:s ot. pI;lnwrt'J('X\"IOIl IS llt.'ct'ss;lr)' .In prcs'wmg._~-3S; five dcgn:cs of eversion is nCCt'ssarv at IO;'lding response ro 1I1llc;ck tht' midt;lfs;t1 joint for· shoL\"k ;\\b;()rption.3~, \\,(!hcn tht' midt;lrsal joint is unloL\"kcd the foot is able ~9-' ;lC(OlTllllOd~ltt~ to v;Hinus surbn.'s by tilting lllcdially an', L.ltcLtlly, In normal w,tlking rhe first roc ('xtends at ever step and it Ius been estim:1tcd rhat this ;'vITP extension o(curs abuut 900 rimes ill w;llkill~ :1 mik.'10 Aboue 30 dl'grcl's of c:xrension is rt'quircd ;1£ ~ht' ~'ATr joints in [he tennin:ll st:ll1L\"C phase of gait. In pre-swing, extension at, the ~\\'lTP joints rL'<H.:hcs a maximulll of Jpproxima[c!Y 60;

CHAPTER 10 THE ANKLE AND FOOT 251 f!~UR£ 10-9 Standing on tipme requires a full range of AGURE 10-10 Descending stairs requires an average of 21 to motion in plamarflexion and 58 to 60 degrees of extension27 at 36 degrees of dorsiflexion..37 the first metatarsophalangeal joint. '~grees when the toes maintain contact with the floor oto 30 degrees of plantarflexion;1l these ROMs are simi- tier heel rise (Fig. 10-9). If the ROM at the MTP joints lar (Q the amount of motion required for stair ascent and 's.limited it will interfere with forward progression, and descent as shown in table 10-8. Descending srairs t!i~ step length of the conrralareral leg will be requires a maximum of between 21 and 36 degrees of ~C:'reased. JS dorsiflexion (Fig. 10-10). Another activity requiring maximum dorsiflexion is rising from a chair (Fig. 10-11). 'Running requires 0 to 20 degrees of dorsiflexion and ge of maximum mean angles observed during the activity. ....~_,.~ ~ ._~---c-~

252 PART III LOWER· EXTREMITY TESTING IllcaSLlrt:d fOf(.:foo(-n:arfoO[ fromal plan/: relationships in 2.)4 (I..\"ct ( 120 hl..'ahhy males and fl:Jl1alcs widl a mean age of lS.1 yens). :\\pproxil1l:Ht·!y X7 pl:f(l..'llr of rhe meas- ured tCl:t had (ordoO[ varus, 8.8 perct:1H had forefoot valgus :lllli 4.6 pCft.:\"l..'fI( had a neutral fordoor-rcarfoot rl:brlol\\ship. Reliability and Validity Rdiahilirr studies invoh\"ing one or mOfl\" motions at the ;mklc h:lve ht.:tll t:ondm:[(:d on ht:alrhy suhjcCtS...1- 49 ;111(1 Oil pa[!'('!lt popuIat'lons. \"'-Ii :\\1so, motI'ons at, the subt;tlar joi!lt. the subr:1lar ioinr llcutral position, and the forefoot posirion have ht.'ell illvesligarl'd . .1(,. 5!'-'i·1 SOI1)(;' joinr:\\ and motions call be mC<lsured more reli~ ahly than othi:rs. Boone and ;1ss()(:iarc:s+1 found that intr,l(est<.T reli~lhility for selected motions at the ankle was better rhan rh;H obtaincd for hip ,HId \\... rist motions, bur nor as good ,lS that obuillcd for sck:..:ted morions at d1(' shoulder, e1how, and knee. Clapper and \\X/oJf''; found th,H both rhe universal goniometer Jnd the Onhor,\\ngcr {Orrhorronics, Daytona Beach, Fl..} werc rcli,lhk insrrulllclHs for Illl'asuring dorsi- flL'xiofl ;Hld plalHarf!e;..:ion hut that the iu!raclass correIa· fion 1,,:(ldficicll[S {ICes) wcre higher for the universal j!;olliol1lcter. The ICC for l1leaSUrClllCIHS of acrivc dorsi· fk-xiol1 for rhe: ulliversal goniolllt:tt:r waS 0.92 in compar- ison with 0.80 for the Onhoranger. The ICC for the ~ol1iomt:t('f for pbnrarfln:iol1 was 0.96, whereas the ICC for rh<.' Orrhorallger was 0.93. Considering the f:lct that~; rhe Orrhorangcr, a tn'\" of pendulum goniomerer, costs <.:onsiderahly more th:Hl the univers:tl g.oniometer, the ',; FIGURE IG-tt Getting om of d chair may require a full ;turhors concluded that the :ldditiol1<l1 cost involved in dorsiflexion range of morian (ROM), depending on the height purchasing an Orrhor;H1~er to Ill<.':lsure: RO~\\'l could not of the chair sear. The lower the scat, the greater the ROM required. be justified. Mecagni and colleagues\" suggested that decreases Boh:mnon, Tiberio. and \\X/aters;H, in il srudy involving in dorsiflexion ROM constituted a risk factor for decreased balance and alteration of movement patterns [ [ malL,s and 1 I fcma!<'-s aged 21 to 43 years, invcstigated and Hastings and coworkers32 identified limited dorsi- flexion ROM as a risk factor for increased plantar pres- passi\\'(' RO\\.'{ for ankle dorsiflexion by mt:ans of differ- sures during walking and decreased functional ent goniomt:tt.·r alignrnt.'nrs. In ont: ;lli~nnH.'nt. rhe ;lrms of performance. the gOJ1iOllletcr wen.: arranged paralkl with tht: fibula Torburn, Perry, and Gronley·' found that when subjects assumed a relaxed, one-legged standing position and th<.· heel. The second alignlllent used the fibul;l and a in three trials, they stood with the reatloot in approxi- mately the same everted position (mean of 9.8 degrees). lillc parallel to rhe fifth mcrar:lrs;ll. These authors found The authors suggested that the position of the rearfoot that passive RO.\\·l I1lC~lSurcnH:nts for dOl':-iiflcxion ':: during one-legged standing could be used as an indica- tion of the maximum eversion ROM needed for the differed significantly ;h:l..\"ording to whil..\"h landmarks were} single support phase of gait. Garbalosa and associates·3 lIsed. ..' lknndl and I..\"ollcagul~s·ls conducted it srudy t'O deter- mine inrcrre$tcr and incrarcstl.'f reli;lhility lIsing the wcighr·hearing lunge Illl'thod for measuring dorsiflexion. Four t.:xamintrs llsed an Inclinollleter to meaSure the angle bl:twcl:n the anrcrior border and tht: venical border' of the ribi,l and ;1 rape measun: to dcrc:rminc thl' disrance of tht: lunging roc from the wall. Inrratcsrcr and inrcrrcsn.:r rdiahility was l';..:trl'lllt'iy hi~h (ICC = 0.97 to 0.99) for rhe tour eX::1Tllincrs with both methods of assess· Illcnt. Refer to 'rables 10-7 and 10-9.

CHAPTER 10 THE ANKLE AND FOOT 253 \" Intertester or intertester correlation coefficient, as noted; ROM = range of motion; SEM = sample evaluation method. .~ was extended in 87.7 percent of measurement sessions. ~- 1~\\:/ opson, McPoil, and Cornwall·' conducted four examiner in maintaining the foot and ankle in the desired position while holding the goniometer. smlic' clinical tests to measure extension of the first MTP Youdas, Bogard, and SumanSl used 10 examiners in a joinrin 20 healthy adult subjects between 21 and 45 study to determine the intra tester and imerresrer reliabil- W!Ys~ of age. All measurement techniques were found to ity for active ROM in dorsiflexion and planrarflexion. The authors compared measurements made by a univer- 1i'e'ireliable but not interchangeable. Nowoczenski, sal goniometer and those obtained by visual estimation ~urnjauer, and Umberger27 also used four clinical tests on 38 patients with orthopedic problems. A considerable :iJ~easure the first MTP joint extension: active and measurement error was found to exist when two or more therapists made either repeat,::d goniometric or visual ,. ,~sive ROM and heel rise in the weight-bearing posi- estimates of the ankle ROM on the same patient (Tables 10-9 and 10-10). The authors suggested that a single 'qiJ!Qn; and passive ROM in the non-weight-bearing posi· therapist should use a goniometer when making repeared '~Hn. 'Test values were compared with measurements of measurements of ankle ROM. ~MTPextensionduring normal walking. Active ROM in The subralar joint neutral position, which has been the the:weight-bearing position (44 degrees) and exrension subject of numerous studies, is nOt the same as the 0 starting position for rhe subtalar joint as used in this \"measured during heel rise (58 degrees) had the strongest book and many others, including those of the AAOS,2 the AMA; and Clarkson.55 The subtalar joint neutral posi- icirrelarions with motion of the MTP joint (42 degrees) tion is defined as one in which the calcaneus inverts twice '~uring normal walking (r = 0.80 and 0.87, respectively). as many degrees as it everts. According to Elveru and associates,S2 this position can be found when the head of Elveru and associatesSO employed 12 physical thera- the talus either cannot be palpated or is equally extended Q~ts using universal goniometers to measure the passive at the medial and lateral borders of the talonavicular aOkle ROM in 43 patients with either neurological or joint, This is the position usually used in the casting of :o~hopedic problems. The ICCs for intratester reliability foot orthorics, but it also has been used for measurement :;;f~~ inversion and eversion were 0.74 and 0.75, respec- of joint motion. However, Elveru, Rothstein, and Lambso \",~xely, and intertester reliability was poor (see Tables 0-9, 10-10, and 10-11). Intertester reliability also was ,poor for dorsiflexion, and patienr diagnosis affected the :/f~liability of dorsiflexion measurements. Sources of error ;;';Nere identified as variable amountS of force being exerted- by the therapist, resistance [0 movement in neurological patients, and difficulties encountered by the TABLE 10-10 Inlralesler and InlerleSler Reliabilily: Planlarflexion L

254 PART III LOWER·EXTREMITY TESTING lio,;eclicancj neul'olclgi\",,1 problems Inversion 0.62\" Eversion 0.74 t ICC = lntertester and inlratester correlation coefficient as noted . Inversion .. Referenced to subtalar joint neutral. Ever$ion 0.59\" t Not referenced to subtalar joint neutral. Inversion 0.75 t Eversion found that referencing passive ROM measurements for 111l,:;lSlIrcmtms of the sllht:t1ar loim llcutral position was , inversion and eversion to the subtalar joint neutral posi- ICC = 0.27 lor 00(' ICster and ICC = 0.0(, for th~ tion consistently reduced reliabiliry (see Table 10-11). odll.:r tester. IlHcrtt:Stcr fc.:liabiliq-· W~b 0.00. Intra\"' :.:, Based on the study of Elveru, Rorhstein, and Lambso and information from the following studies, we have decided teSta :\\l1d imt:rtt:ster fc.:liahility :llso we.:rt: poor foc; not to use the subtalar neultal position as defined by Elveru and associates52 in this text. c..: I(ls<:d· kiI\\cnutic.:-clu i n J1H.';lSl1 rl'fllL'nrs. PiccianQ-:l;~ Rowlands, :lIH.l \\vorrell'·J (unduded rhat slllHalar joint' Bailey, Perillo, and FormanS3 used tomography to study the subralar joint neultal position in 2 female and 1Il.::lltral ll1e:\\SllrCIlH.'mS takl'll by IllloXpL'J\"iCIH.:C.:d resters- 13 male volunteers aged 20 to 30 years. These authors found that the neutral subtalar joint position was quite wt,.'rt,: 11l1rtliablc; they rl'L:OIllIllClldcd th:n dlllici:1l1s should variable in relation to the total ROM, and that it was not always found at one·third of the total ROM from the practicL' taking [ll(:<lSun::lllCllls :lnd pertorming repeated maximally evened position. Funhermore, the neutral position varied not only from subject to subject but also lllc:1Slln:nH:IHS fO determine thcir OWll reliability tor these between right and left sides of each subject. lllCaSlln.:rnenrs. l'ow(,.'\\,('r, 'forhufll, Perry, :lnd Cronlcy42 suggcsH:d thar inaccilfacy of 1l1C;\\SUremenr tl'chniqllc with Picciano, Rowlands, and Worrells• conducted a study liSt.: of a universal goniollll'rt.:r rarher dUll rhe.: ability of-:-' ro determine the inrraresrer and inrertesrer reliability of measurements of open-chain and c1osed·chain subtalat ('x:lInincrs ro position the subt31ar ioim in rhe neutral joint neutral positions. Both ankles of 15 volunteet position might bL' rL'spol1sihk~ for poor rdiabiliry findings subjects (with a mean age of 27 years) were measuted by two inexperienced physical therapy students. The for suhtabr loim l1L'lHral positioning. Tilt.: ICC for students had a 2-hour training session using a universal goniomerer prior to data collection. The method of il1tLTt(,.'stcr reliability for.) c;';::1rllill(.'rs W;lS liCe: = 0,76) taking measurements was based on the work of Elveru and associates:\" Intratester reliability of open-chain for positioning the.: subr\"br joint in the.: Itcurral position. In rhis study, the CX<lmilll:rs palpared rhe ItcH.1 of the talus ill 10 subjects lying in thl\" pronc position whilc an c1ec- rrogoniolllt'rcr was lIsl..'d to rccord the position. In (ontras{ to r1k' low reliabilitv found in the ;1fore- llll'nt'ICJlll..'d studies, :vkPoil and C~)rnw~tll·l.; found high inrmtest(T reliability for both suhtabr invasion :1I1d t'vcrSlon meaSurClllC!ltS taken by twO tesrers (set: Table 10-1 I).

CHAPTER 10 THE ANKLE AND FOOT 25S : Range of Motion Testing Procedures: Ankle and Foot ''';f. .----- ------------

5;:' 256 PA RTill LOWER-EXTREMITY TESTING 0u..' zo ••• • • . . • dorsiflc.:xion I{O.\\l is usually greater chim non-weight~;: <u..:r: bearing Illeasurements, and dH..'sC posirions should not be~;.' :;2', i Z<:l Motion occurs in the sagittal plane around a medial- used illll,:rl.:hangl:ably. ,.'1. lateral axis, The mean dorsiflexion ROM according to 4 the both the AAOS5 and the is 20 degrees, The Testing Position AMA Place rh(: suhj(,:cr sitting, wirh rht knt'c flexed to 90- ~\" mean active dorsiflexion ROM in the non-weight-bear- degrees position. The foor in 0 tk'grccs of inversion and'; ing position is 12,6 degrees according to Boone and everSion, ::l' Azen,6 Refer to Tables 10-1 through 10-7 for additional ;: QL.U j information. Stabilization U Dorsiflexion ROM is affected by the testing position Stabilize rhl' ribi:l ;lfld fibub ro pr('\\Tm knt.'t' motion and' '.,\" ;~,: (knee flexed or extended) and by whether the measure- hip rotation. \"\"'!i'ii: '\"', ment is taken in the weight-bearing or non-weight-bcar- Testing Motion ing position, Dorsiflexion ROM measured with the knee ,\", i= flexed is usually greater than that measured with the knee Use one k1l1d fO I1lOVt.' rhe fom imo dorsiflexion by push-.\" . ing on rhe bortol1l of rhe foot (Fig. 10-14). Avoid pres~:::';:; :,,) ~ extended, Knee flexion slackens the gastrocnemius sure on rhe LHeral border of rht.' foor undt:1\" rhe fifth'\" '~~i,0ii1, passive tension in the muscle does not inter~ metar;Hs<11 and rhe toes. ,.\\ considaablt.· amounr of force muscles so dorsiflexion, Knee extension stretches the is necessary CO overcome rill.' passi\\'c tension in the soleus fere with i=~- gastrocnemius muscle, and ROM measured in this posi- ~,: tion represents the length of the muscle. Weight-bearing u.;;C; ;.\"O:i FIc;UIlE 10-14 Tht.' subjt.'Cl·S left :lIlklc at rh(: end of dorsi· flexion range of motion. Tht: eX:J.tllincr holds rllt' distal, portion ot ~h{' lower leg widl one hand 10 prevent knee morioll :'Illd uses h(:r olht.·r h:lIld to push on [he palmar surlal.:C: of rhe foor to mailH:lin dorsiflexion.

i:d Achilles musculotendinous unit. Often, a compari- CHAPTER 10 THE ANKLE AND fOOT 257 ~of the active and passive ROMs for a particular indi- 'ual helps to determine the amount of upward force 2. Align the proximal arm with the lateral midline of ;ii~ceSsary to complete the passive ROM in dorsiflexion. rhe fibula, using the head of the fibula for refer- 'The end of the ROM occurs when resistance to further ence. Yilotion is felr and arrempts to produce additional motion 3. Align rhe distal arm parallel to rhe lareral aspect of -'use knee extension. the fifth merararsal. Although it is usually easier to palpate and align the distal arm parallel to the fifth 'J'Normal End·feel mecatarsal, an alternative method is to align the distal arm parallel to the inferior aspect of the ,'~fhe end-feel is firm because of tension in the posterior calcaneus. However, if the latter landmark is used, the total ROM in the sagittal plane (dorsiflexion j&i~t capsule, the soleus muscle, rhe Achilles tendon, the' plus plantarflexion) may be similar to the total ,;posterior portion of rhe deltoid ligament, rhe posrerior ROM of the preferred technique, but the separate ~talofibular ligament, and the calcaneofibular ligament, ROM values for dorsiflexion and plantarflexion will differ considerably. ';:-(.,'j. - Goniometer Alignment Xs~e Figures 10-15 and 10-16, j:' - L Center the fulcrum of the goniometer over the }/ lateral aspect of the lateral malleolus. FIGURE 10-15 In the starting position for measuring dorsiflexion range of motion the ankle is positioned so that the goniometer is at 90 degrees. This goniometer reading is transposed and recorded as 0 degrees. The examiner sits on ;1 stool or kneels in order to align the goniometer and perform the readings at eye level.

5.o.... ' 258 PA RTill LOWER-EXTREMITY TESTING Three Alternative Positions for Measuring strength ~md balnncc necessary to ;lSS11l1lt' tht wcighr_ bearing position. Dorsiflexion ROM Alternative Position (or Measuring Dorsiflexion ROM: The supine and prone posltlons arc twO alternative Supine non-weight-bearing positions that can be used to meas- ure dorsiflexion ROM. Standing is an alrcrnarivc wcighr- Place rhe subject in supine with the knee flexed ro 30 bearing position for this measurement. Measurements taken in different non-weight-bearing positions may not degrees and supported by a pillow. Coniometer align- be the same; tberefore, tbese positions should not be used interchangeably. Also, measurements taken in the ment is the same as that for the scated position. weight-bearing position differ considerably from those taken in non-wcight-bcaring positions and therefore Alternative Position for l\\1casuring Dorsifll.:xion ROM:\\~'\" should not be used interchangeably. Measurements taken in the weight-bearing posirion compared with tbose Prone \" taken in the non-weight-bearing position may be able to provide the examiner with informacion that is more rele- Position the suhject prone with the knee on rhe side vant to the performance of functional activities such as being res red flexed [() 90 degrees. Posirion the foot in O\"'~ walking. However, it may be difficult to control substi- degrees of inversion and eversion (Fig. I0--17). tute motions of the hindfoot and forefoot in the weight- bearing position. Also, some subjects may nor have the Alternative Position for Measuring Dorsiflexion ROM: ,;- Standing . Position the subject standing on rhe leg to be tcsn.:d with· the knee flexed (Fig. 10-1 S). FIGURE 10-16 At the l,:nd of dorsit\"lt.:xion r:lnge of: motion, till: l.:xaminer lISt'S one hand w align the proximal goniomcrcr i!TIll whitl.: rhl.: other hand 11l:1inr:lins dorsiilex· ion and alignment of the dist;'ll goniOlllt'H:r arm

CHAPTER 10 THE ANKLE AND FOOT 259 FIGURE 10-17 Goniometer alignment'H the end of dorsi· flexion range of motion. The subject is in an alternative prone position with the knee flexed to 90 degrees. \"rJ'u'Jt<.t 10-18 Goniometer alignment at the end of dorsi~ \"~i.~:~:~~_~r:a.~n,~gc~:ofmotion. The subject is in an alternative ,?f position with the knee flexed.

5 260 PA RT III LOWER· EXTREMITY TESTING o u.. . . • • .. Stabilization oz <: Stabilize the tibia and fibula to prevent knee flexion and .w...r Morion occurs 10 the sClgittal plane around a medial· hip rotation. lateral axis. The ROM is 50 degrees according ro the z~ AAOS,2 40 degrees according ro the ;\\MA; and 56.1 Testing Motion according ro Boone and Azen.6 The ROM is affected by <: Push downward with one hand on the dorsum of the subject's foot to produce planrarflexion (Fig. 10-19). Do rhe testing position (knee flexed or extended) and not exert any force on the subject's roes and be careful to avoid pushing the ankle into inversion or eversion. The whether or not the measurement is taken in a end of the ROM is reached when resistance is felt and attempts to produce additional planrarflexion result in non-wcight-bearing versus a weight-bearing position. . knee flexion. Please rcler to Tables 10-1 through 10-4 for addI- tional informacion regarding effects of age and gender. Testing Position Place thc subject sitting with the knee flexed to 90 degrees. Position the foot in 0 degrees of inversion and oz everSion. § ~ ou..:' w~.. <: '\" :! I I FIGURE 10-19 The subject's left ankle at the end of planrarflexion range of motion.

CHAPTER 10 THE ANKLE AND FOOT 261 Normal End-feel Goniometer Alignment \\'!~~aIlY, the end-feel is firm because of tension in the See Figures 10-20 and 10-21. i:'ferior joint capsule; the anterior portion of the deltoid 1. Center the fulcrum of the goniometer over the lateral aspect of the lareral malleolus. ligament; the anterior ralofibular ligament; and rhe 2. Align the proximal arm with the lateral midline of tibialis anterior, extensor hallucis longus, and extensor the fibula, using the head of the fibula for refer- ence. iligilorum longus muscles. The end-feci may be hard 6~c.ause of contact between the poscerior tubercles of the t,jl\"s and the posterior margin of the tibia. FIGURE 10-20 Goniometer alignment in the starting position for measuring plantarflexion range of motion.

oo 262 PART III LOWER-EXTREMITY TESTING u.. . 3. Align the distal atm parallel tn the lateral aspect of tarflexion) mal' be similar to the toral ROM of the preferred technique, bur rhe separare ROM values the fifth metatatsal. Although it is usually easier to fOt dorsiflexion and plantatflexion will diffet considerably. Measurements taken with the alter- palpate and align the disral arm parallel ro rhe fifth native landmark should not be used interchange_ ably wirh those raken using rhe fifth metatarsal metatarsal, as an alternative, the distal arm can he landmatk. aligned parallel to rhe inferior aspect of the calca- neus. If the alternative landmark is used, the toral ROM in the sagittal plane (dorsiflexion plus plan- FIGURE 10-21 At the end of the plantarflcxion range of motion, the examiner uses one hand to main- tain plantarflexion and ro align the distal goniometer arm. The examiner holds the dorsum and sides of the subject's fooc to avoid exerting pressure on the meso She lIses her mher hand to stabilize the tibia and align the proximal arm of the goniometer.

CHAPTER 10 THE ANKLE AND FOOT 263 ,iGURE (0;'22 .An'imterio~'vie;v of the subjec\\'sJeft ;;~kle 'ytcli.~;~iliJf~~~+~~~:!_{fmY;\\ia~_9P;~rks 'i' tp,.'i_~~i:cai:~_~\"'g~p.{ci~abr' ~ig~mc;nt iii measuring myel-sian ~ndiveision .range._ af.-;-:\" -}motion.-;--;o/.:o' ',,;';< - -- \"-'--', ,;'; I -.- '(' .,,;',::\" ,~: ;--.\",c. ::':-'::;}'f(~

',;;:::: PART III LOWER-EXTREMITY TESTING .oo.. 264 o-z.: INVERSION: TARSAL JOINTS This motion is a combination of supination, adduction, ell<: \"llpporling .. llrf.1L·c. PO,>ltIOIl dll\" hll' ill 0 dq;rl:cs of \"\"-~' and planrarflexion occurring in varying degrees at the rot;uion, addll~tloll•.llltl Jhdlh..::i(lil. :\\hLTll.ll ivt:ly, it is .<- z-.: subralar, transverse tarsal {ralocalcanconavicular and \\)(l'>:.ihlc to pl.ll':l· lill' '>uhin.':l ill tilL' ,>upilll' p(hiriol1, with calcaneocuboid}, cuboidconavicular, cuneonavicular, rill\" toOl O\\\"l'r Ihl' l:ll~t\" Ili dll' '>uppllnillg '>Ud:1Cl'. \" inrcrcunciform, cuneocuboid, rarsomcrarsal (TMT), and Stabilization inrermetatarsal joints. The functional ability of the foot SClhilil.e the rihi.1 ;1I1d the fihllb [0 I'IT\\'l'lI{ IIlL:dial to adapt to the ground and to absorb contact forces lioll ;111<.1 e,tcl1sion 01 lhl' klll'l' ;IlH.l ].Ill·r.d fot;aio!l ahduction of [he hip depends on the combined movement of all of these joints, Because of the uniaxial limitations of the goniometer, Testing Motion inversion is measured in the frontal plane around an Push the fOl'l:foot dOWllW,lrd llHn pLlrH;lI\"t'k:\\ioll, anterior-posterior axis. !vlcrhods for measuring inversion ;llly into ;Hldlll:tioll. :llld [Urn dw sole of the tom ,111)' into supin:ltioll to produce im\"n,>ioll (hg.. 10-24). of the rea door and forefoot are included in the sections Tht.: end of rht..' RO\\l OL'(Ur~ whell rL·si~E:llh,:t· is fclr and arrcmprs at flln!lcf Illorio!l pro\\,.hu.'l' IIlnli:t1 roration of on the subtalar and transverse tarsal joints. rht kncc :llld/or !aEcral rO(;\\tioll :1111..1 .lhdlldioll ;H rhe hip. oz Testing Position § Place the subject irt the sitting pOSItIOn, with the knee flexed to 90 degrees and the lower leg over the edge of .::.E. o \"\",' I \", FIGURE 10-2-4 Th\\,.· suhin.:t's left foot alld .Inkk .II the cud of silnlvhjelr's~iro'sndris:rlan~'iCl of morinl!. Thl' cxaminer ll:-l':' Oil\\'\" h:lIld 011 the ow t:r kg EO pn:VclH klll'c ,)!ld hip I\\lotion whik hn othl'r hand m:)inuillS inversion,

CHAPTER 10 THE ANKLE AND FOOT 265 Normal End-feel Goniometer Alignment The end-feel is firm because of tension in rhe joint See Figures 10-25 and 10-26, capsules; the amerior ilnd posterior ralofibular ligament; 1. Center rhe fulcrum of the goniometer over the ante- the calcaneofibular ligament; the anterior, posterior, rior aspect of the ankle midway be,ween ,he malle- lateral, and interosseous talocalcaneal ligaments; the oli. (The flexibiliry of a plascic goniome,er makes , dorsal calcaneal ligaments; the dorsal calcaneocuboid this instrument easier to use for measuring inver- ';'ligament; the dorsal talonavicular ligament; the lateral sion than a metal goniometer.) ';band of the bifurca,e ligament; the transverse metatarsal 'ligament; and various dorsal, plantar, and interosseous 2, Align the proximal arm of the goniometer with the ligaments of the cuboideonavicular, cuneonavicular, anterior midline of the lower leg, using the tibial tuberosity for reference, ..::':'i'rltcrcuneiform, cuneocuboid, TMT, and intermetatarsal 3, Align the distal arm with the anterior midline of the 'joints; and the peroneus longus and brevis muscles. second metatarsal. FlGURE 10-25 Goniometer alignment in the starting position FIGURE 10-26 At the end of the range of motion, the exam- ':,.roc measuring inversion range of motion. iner uses her one hand to maintain inversion and to align the distal goniometer arm.

'ij ~ I -~ ! - : - : - , - - - - - - - - - - - - - - - - - - 0O;~' 266 PART III LOWER·EXTREMITY TESTING L.I..o fi :s IoZ ~lA EVERSION: TARSAL JOINTS abduction, Testing Position This motion is a combination of pronation, Place the subject in the sitting position, with the knee Is2 ~ and dorsiflexion occurring in varying degrees at the flexed to 90 degtees and the lower leg over the edge of the supporting surface. Position the hip in 0 degrees of ~ subtalar, tran~vcrse tar,sal (ral?calcaneonavicu!a: and roration, adduction, and abduction. Alternatively, it is possible to place the subject in the supine position, with i<..f.l E, calcaneocubOid), cubOldconavlcular, cuneonavicular, the foot ovet the edge of the supporting sutface. ~ inrercuneiform, cuneocuboid, TMT, and intermerararsa[ Stabilization :J ti joints. The functional ability of the foot to adapt ro the Stabilize the tibia and fibula to prevent lateral rotation and flexion of the knee and medial rotation and adduc- @~J ground and to absorb contact forces depends on the tion of the hip. U~N'8cuonmiabxiinael dlimmoitvaetmioennst of all of these joints. Because of the , of the goniometer, this motion is ( Q..: rl measured in the frontal plane around an anterior-posrc- ( ~'M rior axis. 1vlethods for measuring eversion isolated to the I il1= rcarfnor and the forefoot are included in the sections on tnI- \"~ the subtalar and transverse tarsal joints. t t 81,.0,.'1 1 < ,j I 0, ~ I w§ I zO;;2ii'!. B I ~ I Ql I ~ I il j mi~1 1 § i ill ! § I ~ I I ~~ m ?V, I I M N);, mq ! I! j I 1 I,~ i ~ FIGURE 10~27 The left ankle and foot at the end of the range of motion in eversion. The examiner uses one hand on the subject'S ~ distal lower leg to prevent knee flexion and lateral rotation. The examiner's other hand maintains eversion. ~1 Im

CHAPTER 10 THE ANKLE AND FOOT 267 mrr~5!ing Motion metatarsal ligament; various dorsal, plantar, and the forefoot laterally into abduction and upward interosseous ligaments of the cuboideonavicular, cuneo- int~_ dorsiflexion, turning the forefoot into pronation so navicular, inrercunciform, cuneocuboid, TMT, and inrcr- metatarsal joints; and the tibialis posterior muscle. ii the lateral side of the foot is higher than the medial Goniometer Alignment stae to produce eversion (Fig. 10-27). The end of the See Figures 10-28 and 10-29. J(D.M occurs when resistance is fele and 3ncmprs at 1. Center the fulcrum of the goniometer over the ante- further motion cause lateral rotation at the knee andioe rior aspect of the ankle midway berween the malle- '~aial rotation and adduction at the hip. oli. (The flexibiliry of a plastic goniometer makes this instrument easier to use than a metal goniome· Normal End-feel ree for measuring inversion.) ~11i~ end-feci may be hard because of contact between the 2. Align the proximal arm of the goniometer with the ;rf~~I~ancus and the floor of the sinus tarsi. In some cases, anrerior midline of the lower leg, using rhe ribial ;/iheend-feel may be firm because of tension in the joint tuberosiry for reference. . 'Capsules; the deltoid ligament; the medial talocalcaneal 3. Align the distal arm with the anterior midline of the f,::lig~ment; the plantar calcaneonavicular and calca- second metatarsal. F~ ,,:eocuboid ligaments; the dorsal calonavicular ligament; emedial band of the bifurcated ligament; the transverse jeer's FIGURE 10-28 Goniometer alignmem in the sraning position for measuring eversion range of morion.

PA RTill lOWER. EXTREMITY TESTING FIGURE 10-29 At the end of the eversion range of morion, the examiner's left hand maintains eversion and keeps the distal goniometer arm aligned with the subject's second metatarsal.

CHAPTER 10 THE ANKLE AND FOOT 269

270 PART III LOWER-EXTREMITY TESTING :,;' INVERSION: SUBTALAR JOINT . 5tablizotion (REARFOOn St3hilize dlt' rihia and fihui:l lO I'revl.:rH Motion is a combination of supination, adduction, and krl('c rot:lIioll ;lJ1d hip ;U..ldlldilill. plancarflcxion. Because of the uniaxial limitations of the goniometer, this motion is measured in the fromal plane Testing Motion around an amerior-posterior axis. The ROM is abom 5 degrees_ 2 Hold the subjl.'u\\ lower kg with Olll: haw! alld usc th~e' orher hand III pull ria: sllbie~r\\ ....:aicllli.:us medially int6 Testing Position adduction alld to rotale it infO 'iupill;uion, thereby producing rt.::trfoo[ sllbr3L1r iflHTSio[l (rig. 10-32). Place the subject in the prone position, with the hip in 0 Avoid pllshin~ 011 rhe: tordoor. The e:nd of tht ROM is degrees of flexion, extension, abduction, adduction, and reached Whl.:ll rl.:SiStallL\"C ro fllrrher l1lorion is felt and roration. Position the knee in 0 degrees of flexion and attempts at ()vcrL\"oilling the rl.:SiSralH:l: produce later extension. Position the foot over the edge of the support- rotation ar rhL' hip or knee. ing surface. FIGURE lo-.n ·fhe I,.:il lower exm:miry at the end of subral rcufoot inversion r;lIl,!!.l: of I1lmio!l.

Normal End-feel CHAPTER 10 THE ANKLE AND FOOT 271 The end-feel is firm because of rension in the lateral joint capsule; the anterior and posrcri.or talofibular ligaments; 1. Cemer the fulcrum of the goniometer over the the calcaneofibular ligament; andthe lateral, posterior, posterior aspect of the ankle midway between the anterior, and interosseous talocalcaneal ligaments. malleoli. Goniometer Alignment 2. Align the proximal arm with the posterior midline of the lower leg. t See Figures 10-33 and 10-34. 3. Align the distal arm with the posterior midline of the calcaneus. 1 I, In:GURE 10-33 Goniometer alignment in the starting position for measuring 5ubralar rearfocit inversion range of morion. FIGURE 10-34 At the end of subralar (rcarfoor) inversion, the Normally, the examiner's hand would be holding the distal examiner's hand maintains inversion and keeps the distal liar goniometer arm. but for the purpose of this photograph, she goniomercr arm in alignment. has removed her hand.

272 PART III LOWER-EXTREMITY TESTING EVERSION: SUBTALAR JOINT Position rht., knn: in 0 dl.·~rtT'\" ill f1n:illll :Ind extension. REARFOO PI:H.:t (h •.: fOOl over lilt: t:d~l..' ot thl' ~llPP(lrring :'>urfacc. Motion is a combination of pronation, abduction, and Stabilization dorsiflexion. Because of the uniaxial limitations of the goniometer, this motion is measured in the frontal plane 5rahilizt: rhl.,.' {ihi:l :111<..1 tibub to prc\\'<.:1H around an anterior-posterior axis. The ROM is about 5 kntt ftH,Hioll ,JilL! hip ahdu\".'[ioll. degrees.' Testing Motion Testing Position Pull the cakallt:lls brcra!ty Into ahdlll.:rion alld rOtate it Place the subject prone, with the hip in 0 degtees of flex- inro proll;lfion (() ,?rOdUlt: subIa h r t:vcrSi(JlI (rig. 10-35). ion, extension, abduction, adduction, and rotation. The (:nd of rhe !U ).\\,{ O(l,,:ur .... wht.:/1 rl.~:-.i:-.lalh..:t: w FIGURE 10-35 The kIt town <:xtfClllitv ;\\1 the end of sllhrJlar-~;j (n.::lrf(HI(j .... t·t:rSi(11\\ r:tll~\"\" (lllllnrioll. ()I;l' ,:;111 lll\\~l'rv .... rh:u this subiect's l.'\\'l'l':;io!l i\" quill' limi[('l1. The l'x~l!l\\il1n':'I IWllJ lluin· I:lith suhr:ILlf .... versioll hy Jlullil1f:'. die <:;tk:.llll.:lIS LHl:r;III~·.

CHAPTER 10 THE ANKLE AND fOOT 273 i'\"\"nv<:m\"nt is fclt and additional attempts to move the Goniometer Alignment dca\"e\"s result in medial hip or knee rotation. Sec Figures 10-36 and 10-37. >i~ Norm'11 End-feel end-feel may be hard because of contact between the I. Ccnrcr the fulcrum of the goniometer over the posterior aspecr of the ankle midway between rhe . iY~alcanleus and the floor of the sinus tarsi, or it may be malleoli . because of tension in the deltOid ligament, the 2. Align the proximal arm with the posterior midline U!iiirll\"lial talocalcaneal ligament, and the tibialis posterior of the lower leg. 3. Align the distal arm with the posterior midline of the calcaneus. FIGURE 10-36 Goniometer alignment in the starring position FIGURE 10-37 At the end of sllbtahu eversion, the examiner's for measuring subralar (rcarfom) eversion. hand maintains cvc::rsion <lod keeps {he distal goniometer arm aligned.

274 PA RT III LOWER-EXTREMITY TESTING • .. Goniometer Alignment Most of the motion in the midfoot and fotefoot occurs at Sec Figu,,'s 10-3~ and 10-40. the talonavicular and calcaneocuboid joints, Some addi- I. Ccnrtr rhe fulcrulll of [Ill,' gonl0JllCtLT Over the anrcrior asp<:l:t ot the ankle slightly disral to a tional motion occurs at the cuboideonavicular, cuneo- poinr midw;ly between the malleoli. ~, navicular, intercuneiform, cuneocuboid, and TMT joints. 2. Align rhl: proximal ilrTll with rhe ;l!Ht:rior midline Motion is a combination of supination, adduction, of the lowlT leg, using th<.' tibial ruhLTosirr for .,~'\" , ::-::, reference. and plantarflexion. Because of the uniaxial limitation of 3. :\\lign thl: disr;d arm with rhe anterior midline of I the goniometer, this motion is measured in the frooml rhe second metatarsal. l plane around an amerior-posterior axis. The normal i ROM ranges from 30 to 37 degrees for the forefoot,',· Alternative Goniometer Alignment ~. ' See Figures 10-41 and 10-42- £ ' :;', \\.:l. Testing Position ',;,./' ,', z,:'''~'~, I. Place rhe fulcrum of the goniometer ;H rhe lareral Place the subject sitting, with the knee flexed to 90 aspect of the fifrh meratarsal h e a d . ' , 2. Align rht: proxim,tl arm parallel ro the anrcrior .'.< ;;, ; tn', degrees and the lower leg over the edge of the supporting Illidlirlt.' of rhe lower leg. 1.l\",,1: 3. Align the distal arm wirh the plantar aspc<.:t of the U ....: surface, The hip is in 0 degrees of rotation, adduction, first through rhe fifth metatarsal h('ads, 1;/· Z} and abduction, and the subtalar joint is placed in the 0 * 0; ,I, \"\"'0-' starting position. Alternatively, it is possible to 'place the il ~. of the supporting surface. subject in the supine position, with the foot over the edge r1-11I' 0':' w· Stabilization ~~.~pi ~:::;:;~::::~\"\":;~h:O\"%~I::'iO~:;';''';O\" of the 1i ,,''.'i:'''. Grasp the metatarsals rather than the toes and push the forefoot slightly into plantarflexion and medially into 'Ii ./ adducrion. Turn the sole of foot medially into supination, being careful not to dorsiflex the ankle (Fig, 10-38), The end of rhe ROM occurs when resistance is felt and attempts at further motion cause dorsiflexion and/or subtalar enversion. Normal End-feel The end-feel is firm because of tension in the joint capsules; the dorsal calcaneocuboid ligament; rhe dorsal ralonavicular ligament; the lateral band of the bifurcated ligament; the transverse metatarsal ligament; various dorsal, planrar, and inrerosseous ligaments of the cuboideonavicular, cuneonavicular, intercuneiform, cuneocuboid, TMT, and intermerararsal joims; and the peroneus longus and brevis muscles. FIGURE -10-38 The leh lower cxrrcmitv ar th<.' t.'nd 01 (1':1115- VcrSL' tarsal inversion range of motion (Ii()~'1). Th.: examiner's hand stabilizl:s the: t:akanclis ro prevent subtal;tr inn.. rsion. Norkt thilt the ROM for the trJnSVt:rsc carsal jOilH is k:-is than !I\\;tt of all of the [;\\rs;1l jOllUs comhined.

CHAPTER 10 THE ANKLE AND FOOT 275 FIGURE 10-40 At the cnd of transverse ta rSil I inversion, one of the examiner's hands releases the calcaneus and aligns the proximal goniometer arm with rhe lower leg. The examiner's other hand maintains invcrsion and holds the distal goniometer arm aligned with the second metatarsal. GURE 10-41 Goniomctcr alignment in the altcrnativc start- FIGURE 10-42 At the end of thc transverse tarsal inversion \" g position for measuring transverse tarsal inversion range of range of motion, the examiner lIses her hand to m:lintain inver- sion and to keep the distal goniometcr arm aligned. orion places the goniomcrcr .H 90 degrees, which is the 0 arting position. Therefore, rhe goniometer reading should be ansposed and recorded as starting at 0 degrees.

276 PA RTill LOWER·EXTREMITY TESTING EVERSION: TRANSVERSE TARSAL JOINT SUhjL'U in tk: ~llpint..· po,itloll, with thl: foot (lVL'r tht edge Motion is a combination of pronation, abduction, and of tht supporting surLH.:e. dorsiflexion. Because of the uniaxial limitations of the goniometer, this motion is measured in the frontal plane Stabilization around an anrerior-posterior axis. The normal ROM for forefoot eversion ranges from 15 to 21 degrees.4,6 Sr;1hili:t.L' the CdL\\II11:lI~ :tlld [,llllS 10 pn.:\\'CIH pbnrarflex:~ ion (Ii the anklt: :lIlt.! eversion of the Stlbt;llar jt,inr. Testing Position Testing Motion Place the subject sitting, wirh the knee flexed to 90 degrees and the lower leg over the edge of the supporting Pull the fordoot' later,tlly into ahduction and upward',< surface. Position the hip in 0 degtees of rotalion, adduc- into L!orsiflo:iol1. Turn thl' !ordo()[ into pronation so:;\": tion, and abduction, and the subtalar joinr in the 0 start· thai tht: Iari:Lll sidt' of tht loor i... higher than tht.' medial' ing posilion. Alternatively, ir is possible to place the side (Fig. 10-4.;). The end of ,he I((li'vl occurs when roisr:llKl: is fdr and ;\\nt.:lllprs [() prodUCt: ;1Clditional nH)rion cause: phtnrarfi<:xioll ;,ll1d/or sllinabr <.:\\'crsion. FIGURE to~,l The tnd (If lr;lllSVt.:rSl..' (;lrs;,! t.'\\'l'r::;i'lI\\ r;lngc ot l\\lnriOll, Thl' t.:x;llllinn's h:lIH.I stahilizt.'s Ill{\" ,,:a!':;1I1l'lIS ((l pn:vcnr Stll1t;lbr <.'\\'OSIOI\\. As ,::11\\ Ill' \"l'l'll ill the ph(ltll~r;lph, only :1 S111~111 ;111l01111t of motioll is aV;lilabk ;H tlH: transverse join! ill rhis slIhjl'I.:r.

CHAPTER 10 THE ANKLE AND FOOT 277 Normal End-feel Goniometer Alignment end-feel is firm because of tension in the joint See Figures 10-44 and 10-45. capsules; the deltoid ligament; the plantar calcaneonavic- 1. Center the fulcrum of the goniometer over the ante- and calcaneocuboid ligaments; the dorsal talonavlc- tior aspect of the ankle slightly distal to a point ligament; the medial band of the bifurcated midway between the malleoli. the transverse metatarsal ligament; various 2. Align the proximal arm with the anterior midline plantar, and interosseous ligaments of the of the lower leg, using the tibial tuberosity for reference. cuneonavicular, intercuneiform, cune()cl'bc)lQ, TMT, and intermetatarsal joints; and the 3. Align the distal arm with the anterior midline of the <,u\"~,,,, posterior muscle. second metatarsal. I,:,. ',' FIGURE 10-45 At the end of the transverse tarsal eversion range of motion, onc of the examiner's hands releases the calca- :CURE\" 1~4 Goniometer alignment in the starting position neus and aligns the proximal goniometer arm with the lower leg. The examiner's other hand maintains eversion and align- - measuring transverse tarsal eversion range of motion. ment of the distal goniometer arm.

i~ Align rhe proxirn;ll ;Ifill pacllkl to the ;llHtrior midlillL: 01 rhe 10\\\\,,('[ Itg. I 3. .-\\Iign rhl' distal ;lflll with till' plalHar a~pt.T[ from rhe first to rhl.\" tilth IlH:t,Har:-.al hl.:ads. ~ 1-·1\"O~ \":2\":7\":8--p-A-R-r-I-I-I--l-O-W-E-R-.E-X-r-R-E-M-I-r-Y-r-E-s-r-I-N-C IO....~! ~ Alternative Goniometer Alignment I<0: See Figures 10-46 and ]0-47. I:~~:.:I- 1. Place rhe fulcrum of the goniomerer at rhe medial aspect of the first metatarsal head. <II I«'-:' ::;) C 1'-'. Uo «: \"- .' .' , -, '. FIGURE 10-46 Goniometer alignment in the alrcrn:ltive SC3rt· FIGURE 10-47 At rhl' end of th\" r:1rlgc of morioll. th(' C:I:;lm- ing position (or measuring transverse tarsal eversion range of iner uses ol1e hand to ll1;1int;lin c\\'l.'rsioll whilL· her orhl.'t hand morion. aligns rhl' gOlliomcH:r. lkcHls(' till' suhjl,.·cr is sining on <.1 (:lblc. the examiner sits 011 ;) low srool ro align till: goniomcter and to read rhe lllcasurcmCIHS at eye level.

CHAPTER 10 THE ANKLE AND FOOT 279 r Distal phalanx --f-f',1 Proximal phalanx ---,h':: lstmetalarsal --r-\"7~ AB FIGURE 10-48 (A) Surface anacomy landmarks for measuring flexion and extension at [he first meta[ar~ sophabngeal (MTP) joint and first iI)rcrphalangeal OP) joint in a medial \\'iew of the subject'S left foot. (8) Bony anaromicallandmarks for measuring flexion and extension at the first .MTP and IP joines. am- 1st metatarsal and hIe, ;ito Proximal phalanx. Distal phalanx ~+-'\\' AB FIGURE 10-49 (A) Surface anatomy landmarks for goniometer alignment for measuring flexion ;lnd extension range of motion at the first and second MTP and IP joints and abduction and adduction at the firSt MTP joint. (8) Bony anacomicallandmarks for flexion and extension at the first and secondMTP and IP joints and abduction and adduction at the first MTP joint.

1 1-1.~ - , - : - - - - - - - - - - - - - - - - .0onn 280 PART III LOWER·EXTREMITY TESTING u.._:~ cd FLEXION: METATARSOPHALANGEAL ph;lbnx :l1Id l:;llIsin!!- intl..·rph;lbn~l:al fl:xioll. Tht end of ~i JOINT rhe I{O.\\I i':'o rl'~lchl..'d when rCSiQ:\\1Kt: i.. felt and :H[l'l1lprs ~.L~ ;H funhef l1\\(lIiOIl 1.:allSC pblll:lrtln:ioll ;H Ihe :lIlklc. :;:2-fi J\\1otion occurs in the sagittal plane around a mcdial v !~Z J Normal End·feel lateral axis. Flexion ROM at the fist MTP joint ranges Thl' c:.:nd-f<,'cl is firm hCL:\\llSC of tension ill lilt: dor~:ll joint between 30 degrees\" and 45 degrees.\" Sec Table 10-2 for L;lP~llk' :111d the (:(lILHeral lig:lllH:1H:-.. li.'llsioll in the l'Xh.:tbor digiwrulll hrL'\\'i~ nlllsde may (olHrihurt: to the ~ .;1 additional information. finll i..'nd-fccl. cdw .•-·}! Testing Position Goniometer Alignment Scc h~url'S 10-.5 I :\\1ld 10-52. ~;i Place rhe subject in the supine or sining position, \\virh the it&>:::1 ankle and foot in 0 degrees of dorsiflexion, plantarflex- I. Ct:lIELT the fulcrulll of Ihe gOlliolllch.:r (wer the c.. ion, inversion, and eversion. Posicion the MTP joint in 0 dorS:ll :lSpl'Cr of the ~.'ITI) joint. ~il degrees of abduction and adduction and the IP joints in 0 1. Align the pl'oxinul arm (H'l..'f rhe dors;1] midline of i=.n degtees of flexion and extension. (If the ankle is plan- {he 11\\(,:(<1(;1 rsa I. ~n mtflexed and the IP joints of tbe toe being tested ate 3. Align the disr;ll arm 0\\'(:( rhe dllr~al midline of the ~-:\"':'i~ flexed, tension in the extensor hallucis longus or extensor proximal ph;lbnx. O:~ digirofUITI longus muscle will restrin the motion.) Alternative Goniometer Alignment for First Metatarsophalangeal Joint I. , § Stobilization I. C.:nrer {he t'ukrulll of rill' goniol1\\C'[er nn:r (he :1 .::;. i Stabilize the metamtsal to prevent plantarflexioo of the Illtdi;\\1 aSpcL't of the firsr .\\ITP joinI. .,'('. 0-] Jnklc and inversion or eversion of the fOOL Do not hold 2, .\\lign the prtlximJI ;1r1ll with [h(: medial midline of _. 1oU.:1 the .MTP joints of rhe other roes in extension, because rhe first Illt'{ararsal. .!I'(~I :~~s:~~t:~nthe transverse metatarsal ligament will restrict 3, :\\Iig!: rhl' disral ;Hm wirh rht Illl.\"dialmidlillc of rhe proxim;ll phalanx of rhc firsr [Ot:, :1· -'.; ~~ Testing Motion 'I:'I--{~ ·\"1 Pull rhe great toe downward roward the plantar surface X il into flexion (Fig. 10-50). Avoid pushing on the disml ~,,; -o~ , ;Jt1 !l!! J i }I FIGURE 10-50 The leh first mCI3tarsophalangea) (~ITP) ]oilll at rht: ('Jill of lht: fln.:ion r;Ill!!-l\" of lIl(llJOll. The subject is supine, with her foot and ankle placed over d1l' edJ:.:C.' of rht' supporting surfat.:\\\"', HOWl'\\'l'r, [he subject's (oor could rest on the supporting Surta ...T, TI1l' t'X;llllilltT liSt'S her thumb ;k'ross tht: memrarsals to 'prevent ankle plantarflexion, The examiner's orhl'[ hand lllai1H~lins chr.: first ~lTP joint in flexion.

CHAPTER 10 THE ANKLE AND FOOT 281 FIGURE 10-51 Goniometer alignment in the starting position for measuring metatarsophalangeal flex~ ion range of motion. The arms of this goniometer have been cut short to accommodate the relative short~ ness of the proximal and distal joint segments FIGURE 10-52 At the end of the range of motion, the examiner uses one hand to align the goniometer while her other hand maintains metatarsophalangeal flexion.

iii o1-2-S-2--P-A-R-T-I-'-'--L-O-W-E-R-.E-X-T-R-E-M-'-T-Y-T-E-S-T-'-N-C ~I 'EXTENSION: METATARSOPHALANGEAL is felt and anemprs at further marion cause.: dorsiflexion i. . i~ JOINT at the ankle. ,,>,~:,,\";:,I mcdial~ :). Motion occurs in the sagittal plane around a Normal End-feel .~'II ~:s:;:~C;~::t:::able 10-2 for additional information. >~.J lateral axis. The ROM ranges between 50 degrees\" and The end-feel is firm because of tension in the plantar joint capsule, the plantar pad (plantar fibroCHtibgillolis I@ The resting position is rhe same as that for measuring plate), and the flexor hallucis brevis, flexor digirorum U~ flexion of the MTP joinr. (If the ankle is dorsiflexed and brevis, and flexor digiti minimi muscles. the IP joints of the toe being tested ate extended, tension Goniometer Alignment '.':>:: c.. in the flexot hallucis longus or flexor digirorum longus .•..:. ~.'.;.'.' muscle will restrict the morion. If the IP joints of the toe See Figures 10-54 and 10-55. ',:,: ~\";' being rested are in extreme flexion, tension in the lumbri- 1. Center the fulcrum of the goniometer Over the dorsal aspect of the 1v1TP joinr. '?'~ ~:.:\" \"I·.: calis ~~d io.rC[Osseus muscles may restrict rhe motion.) 1. Align the proximal arm over the dorsal midline of ri .. ~. StabilizatIOn the metatarsaL ~ ~ Stabilize the metatarsal (0 prevent dorsiflexion of the 3. Align the distal arm over the dorsal midline of the o ankle and inversion or eversion of the foor. 'Do not hold proximal phalanx. I ::!: the MTP joinrs of the other toes in extreme flexion, Alternative Goniometer Alignment for Extension at the First Metatarsophalangeal Joint t' O' because tension in the transverse mcrararsalligamem will I. Center the fulcrum of the goniometer t L<.o.JU' restrict the Jnmjon. medial aspect of the first IVITP joint. ~-';~ 2. Align the proximal arm with the medial midline !F ·i.· ~\" Testing Motion the first metatarsal. ,;,,(;:1;; .,' '~•.'] Push the proximal phalanx toward the dorsum of the 3. Align the distal arm with the medial midline of the foot, moving the MTP joinr into extension (Fig. 10-53). proximal phalanx of the first roe. Ii\"'.\".;\" Avoid pushing on the distal phalanx, which causes IP ~ -, extension. The end of the motion Occurs when resistance ~. I'; ~ ~-;, y. 5:- :~~' ;l ~. ·f' ~, ilf. ~i.~.: ,;_ .~_., '.;.'.- 1•~ , FIGURE 10-53 The left first mcratarsophalangeal joinr ;H rhe end of extension range of motion. The examiner places her digits on the dorsum of the subject's foot ro prevent dorsiflexion and lIses the thumb on her other hand to push the proximal phalanx into extension.

CHAPTER 10 THE ANKLE AND fOOT 283 FIGURE 10-54 Goniometer alignment in the starting position for measuring extension at the first metatarsophalangeal joint. FIGURE·I0-55 At the end of metatarsophalangeal extension, the examiner maintains goniometer align- ment with one hand while using her the index finger of her other hand to maintain extension.

284 PART III LOWER·EXTREMITY TESTING ABDUCTION: METATARSOPHALANGEAL Testing Motion JOINT . Pull rhL' proximal phalanx of rhl' 11K' I.IfL'r:llly .tway from the midline ()( thl' foot lnw ,1hdlli.:(lOIl !Fig. 10-56). Motion occurs in the transverse plane around a vertical :hoid pushing on tht: distal ph;danx. which places a axis when the subject is in anacornical position. str~ljll Oil rhe II' !oint. Tht: end of rhe RO.\\l ()n.:ur~ when I\"CSiSLllh:C is ft.,]t ;uh.l ,l((l'lllprS at furr!lcr motlun cause Testing Position either invcrsiol) or eversion of rlH: fOOL Place the subject supine or sitting, with the foot in 0 degrees of inversion and eversion. Position the MTP and Normal End·feel IP joims in 0 degrees of flexion and extension. Tht.' t:nd-ftd is firlll bl'GllIsl' ot {l'Il~i(JlI ill rill' joint ClpSll!t.', rhe (oll:llt'ral liyJlI1lCIH ..... rill' Lhl..\"i;1 o! tht\" web Stabilization SpJ((' betw('('!1 rhe ((J{:S, alld rllt' ;Iddll([or hallu(is ;lnd Stabilize the meratarsal [0 prevent inversion or eversion of the foot. plallt:lI' illterOSSt'llS lllLlSl'!eS, FIGURE 10-56 The stlbil.'l.:r's riltlll firs! we ;It rill.' tlld of ;lhdul.:lilln r~l1lgl.' 01 motion, Thl' I.':\\;ullillcr lISeS (Jnl: rhurnb to prt:v('1lt rr;U\\S\\\"l;rs(' urs;:ll inversioll. She llS('~ the inde:\\ finger ;l1ld rhumb 01 her OIlter halld [U pull dll~ pro,illl:ll ph:lbnx illlO ;lhdu(riuJI,

CHAPTER 10 THE ANKLE AND FDOT 285 Goniometer Alignment 2. Align the proximal arm wirh the dorsal midline of ».m Sec Figures 10-57 and 10-58. the mcta£arsal. 1. Center rhe fulcrum of rhe goniometer over rhe 3. Align the distal arm with the dorsal midline of the dorsal aspecr of the MTP joint. a proximal phalanx. en 1St Ill[ ·eb nd FIGURE 10-57 Goniometer alignment in the starting position FIGURE 10-58 At the end of metatarsophalangeal (MTP) measuring metatarsophabngeal abduction range of morion. abduction, the ex:unincc's hand maintains alignmcnr of the distal goniometer arm while keeping the MTP in abduction.

PA RTill LOWER-EXTREMITY TESTING ADDUCTION: METATARSOPHALANGEAL Stabilization OINT - Srabilizl: rhe rn('[;ll<lrS;ll ;lJld pro.,inl<ll phal~lllx to prevent Motion occurs in the transverse plane around a vertical dOfsifli::\\!(l[J Of plJlltarflcxioll of rhe ;mklc ;111£1 inversion axis when the subject is in anatomical position. or eversion of rhc foor. Avoid flexion and exrension Adduction is the retum from abduction to the 0 starting the l\\rrp joint. position and is not usually measured. Testing Motion Motion occurs In the sagittal plane around a medial- lateral axis. The ROM is between 30 degrees4 and 90 Pull the disf;ll plubnx of the first [()e or til(: degrees for the fitst toe2 and 35 degtees and 65 degrees phalan:\\ of the lesser !Ot:S dowll toward the fot the fout lesset toes.' surface of the foor. 'rhc end of tht RO\\I OCCurs resistance is telt ,1I1d ,Htelnprs ,H further fkxion Testing Position plantarflexion of rhe anklt: or flc'\\ion ,H the \\tTP joint. Place the subject supine or sitting, wirh the ankle and foot in 0 degrees of dorsiflexion, planrarflexion, inversion, Normal End-feel and eversion. Position the MTP joint in 0 degrees of flex- ion, extension, abduction, and adduction. (If the ankle is The elh.!-ft:el for f!e:\\lOll of rhe II' joinr of tht: big toe and positioned in planrarflexion and the MTP joint is flexed, the proxilll~lI intcrphaLl11gt:JI (PIP) joint's of the tension in the extensor hallucis longus or extensor digi- toes 111'-1)' be soft bCCIUSC of comprt:ssion of soft torum longus muscles will restrict the motion. If the MTP betwct:ll thc phntar surf,lees of the joint is positioned in full extension, tension in the lumbri- SOlllerimc-s, thc ('nd-fec! is firm hCl..';lllSC of tension in the calis and interosseus muscles may restrict the motion.) dorsal joint capsule 'llld rhe ,,:()llatcr;l! Iig'lI11ClltS. Goniometer Alignment I. Center rhl' fukTulll of rhe gO!liomeH.:r over the dors'll ;lspect of the illterplubl1geal joint being ('(:sted_ 2. :\\Iign the pro:\\imal ,1rlll O\\-cr rllt: dors,ll midline of [he prn:\\illla! plubn:\\, 3. Align the dist;ll ,ll\"1Tl (}v(.T the dorsal midline of the phaLlll'\\ dist';ll [() the joint heing ('(.'sted.

';,'/·,'· CHAPTER 10 TnE ANKLE AND fOOT 287 }~~. ':;.; Normal End-feel 1,-' ;\" The end-feel is firm because of rension in rhe dorsal joint 4 capsule, rhe collareral ligaments, and rhe oblique rerinac- '-~ ular ligament. ¢ Goniometer Alignment Morion occurs in rhe sagittal plane around a medial lareral axis. Usually rhis morion is not measured because 1. Center rhe fulcrum of rhe goniomerer over the it is a return from flexion to the zero starring position, dorsal aspect of rhe distal interphalangeal (DIP) joint. Morion occurs in rhe sagittal plane around a medial- lareral axis. Flexion ROM is 0 w 30 degrees.5 2. Align rhe proximal arm over the dorsal midline of rhe middle phalanx. Testing Position Place rhe subjecr supine or sitting, wirh rhe ankle and foor 3. Align rhe distal arm over the dorsal midline of the in 0 degrees of dorsiflexion, planrarflexion, inversion, distal phalanx. and eversion. Position rhe MTP and PIP joints in 0 degrees of flexion, extension, abduction, and adduction. • •• Stabilization lVlotion occurs in the sagirral plane around a medial- Srabilize rhe merararsal, proximal, and middle phalanx w lateral axis. Usually this motion not measured becuase it prevent dorsiflexion or planrarflexion of rhe ankle and is returned from flexion to the zero starting position. inversion or eversion of the foot. Avoid flexion and exrension of rhe MTP and PIP joints of rhe roe being rested. Testing Motion Push rhe distal phalanx wward rhe plantar surface of rhe foot. The end of rhe morion occurs when resistance is felr and 3rrcmprs to produce further flexion cause flexion at rhe MTP and PIP joints and/or plantarflexion of rhe ankle.

288 PA RT III LOWER·EXTREMITY TESTING Muscle length Testing Procedures: posirion, lilt, dor... iflc\"ioll lirnicHioli i\" dlll.: [(I \"hortncss of The Ankle and Foot the oIlL·-joiIH \"oleu.,; lIlu,>clc Of orhl..T joim srrUCHIres. GASTROCNEMIUS Normal valu<:\" for dor:-.ifkxioll ot rht, ~lllkh.: with the The gastrocnemius muscle is a rwo·JOInr muscle char kncr.: ill l:xI(:lI:-.ioll v;lry (sl\"e \"!:\\hk·s 10-(1 ;llld 10-7). ii, ;;;hg crosses the ankle and knee, The medial head 01 the Starting Position gastrocnemius originates proximally from the posterior aspect of the medial condyle 01 the lemur, whereas the PhH.:t: the sUhj{:L£ :-llpillC:, widl tht: knt:l: l'Xlt'l\\dl'd and the lateral head of the gastrocnemius originates lrom the foor in 0 dq~rn:s of in\\'asioll and evtTsion. ',:\"\"';'i;.':1 posterior lateral aspect 01 the lateral condyle (Fig, Stabilization F/\"C;!~I 10-59). Both heads join with the tendon 01 the soleus >:V}~iI muscle to lorm the tendocalcaneus (Achilles) tendon Hold rill: knee in full extensiun. Usually, rhl' weighr of the ({,'/i ;::~J which inserts distally into the posterior surlace 01 the limb alld lund prC:~~llrc: oll lhe ~Inrcri{lr leg can maintai~ ;;1Wj'~11 calcaneus. \\'Qhen the gastrocnemius contracts, it plan- an n:(Clldc:d knL'\\.' positioll. ,\" tarflexes the ankle and flexes the knee. Femoral <, A short gastrocnemius can limit ankle dorsiflexion and condyles ;-;:~f:1 knee extension. During the test lor the length 01 the gastrocnemius the knee is held in lull extension. A short gastrocnemius results in a decrease in ankle dorsiflexion \"'/i.Ul\"! ROM when the knee is extended, II, however, ankle _\"\"'_\"\" dorsiflexion ROM is decreased with the knee in a flexed Medial 'H-I--- Lateral head of ---ffi head 01 gaslronemius gastroncmius Achilles +--+ tendon - Calcaneus -\\;_\\_ FIGUHE IO-S'.l ;\\ posterior \"in\\, of ;1 ri~lll Inwa l'x[rcmiry<. shows ill\\.' ,lIfadltlu'!lt:- of thl\" g;lslrOdH.:llIius 1ll1lSd...,.

CHAPTER 10 THE ANKLE AND FOOT 289 ~;J~!II!J'~ Motion felt from tension in the posterior calf and knee and further ankle dorsiflexion causes the knee to flex. the ankle to the end of the ROM by pushing across the plantar surface of the metatarsal heads Normal End-feel The end-feel is firm owing to tension in the gastrocne- and Fig. 10---61). Do nOt allow the foot to mius muscle. and move into inversion or eversion. The end of motion occurs when considerable resistance is FIGURE l()...QO The subject'S right ankle at the end of the «sting motion for rhe length of the gastroc- nemius muscle. \" --....- ~,1;~ FIGURE 10-61 The gastrocnemius muscle is screeched over the extended knee and dorsi flexed ankle. , ,1 R !f '. :~ 1....

.. 290 PA R Till LOWER·EXTReMITY TESTING Goniometer Alignment Testing Motion Sec Figure 10-62. The patient dorsi flexes the ankle by leaning the body forwatd (Fig. 10-63). The end of the testing motion 1. Center the fulcrum of the goniometer over d1C occurs when the patient feels tension in the posterior calf lateral aspec£ of the Iarc[almallcolus. and knee and further ankle dorsiflexion causes the knee to flex. 1. Align the proximal arm with rhe lateral midline of the fibula, using rhe head of rhe fibula for rder- Coniometcr Alignment ence. See Figure 10-64. 3. Align the distal arm parallel [0 the lateral aspect of rhe fifth meratarsal. 'I. Center the fulcrum of rhe goniometer Over the lareral \"spect oi rhe lateral malleolus. Alternative Testing Position: Standing 2. Align the proximal \"rm with the lateral midline oi Place rhe subject in the sranding posirion~ with the knee the iibula, using the head of the fibula ior refet- ;: extended and the foor in 0 degrees of inversion and ever- enec. sion. The foot is in line (sagi[{al plane) with rhe lower leg and knee. The subject stands facing a wall or examining 3. Align the diStal arm paral1el to the lateral aspect of :' rabIe, which can be used for balance and supporr. the fifth metatarsal. Stabilization lvlainrain the knee in full extension, <'Iud the heel remains in total contact with the floor. The examiner may hold the heel in conmer with rhc floor. nCURE 10-61 Goniometer alignmcnt ~1t (he end of rhe t(:sting motion for d1C length of rhe gasrrlH.:nc- millS muscle.

CHAPTER 10 THE ANKLE AND FOOT 291 FIGURE !lHi3 The subjecr's right ,nkle \"' rhe end of the FIGURE 10-64 Goniometer alignment in the alternative test- ,.wcighr·bcaring resting motion for the length of the gasrrocnc- '. mius muscle. ing position. l. l.evangic) PK, and Norkin. CC: Joint Structure 3nd Function: A 7. Waugh, KG, et al: Measurement of selected hip, knee :md :lnkle Comprehensive Analysis, cd 3. FA Davis, Philadelphia, 200t. joint motions in newborns. Phys Ther 63:1616,1983. Americ:lll J\\cademy of Orthopaedic Surgeons: Joint Motion: Method of Measuring and Recording. 1\\A05, Chicngo, 1965 8. Wanambc, H, et al: The r:lnge of joint motion of the extremities Cyriax, jM, :lnd Crriax, PJ: lIIusrr;tted M:lOual of Orthopaedic Medicine. Buncrwonhs, London. 1983. in healthy japanese people: The differences according [0 age. American Mcdicnl AssociMion: Guides to the EV:llu:uion of Pcrmnncm lmpairmcnc. cd 3 (revised), AMA, Chic:lgo, 1988. Nippon Seikeigcka Gakkai Znsshi 53:275, 1979. (Cited in Creene, \\'(IB, and Heckman, JO (Eds): The Clinical MC:lsurcl1lcnr of Joint Ivlorion: American Academy of Orthopaedic Surgeons, Walker, JM: Musculoskeleral development: A review Phys Thcr Chicago, -1994. 71,878,1991.) noone, DC, and then, SP: Normal range of mofion of joints in 9. Boone, DC: Techniques of measurement of joint marion. male subjects. J Bone Joint Surg Am 61: 756, 1979. (Unpublished supplement [0 Boone, DC, :lncl then, SP: Normnl range of morion in male subjects. J Bone joint Surg Am 61:756, 1979.) to. Walker, jM: Musculoskeletal development: A review. Phys Ther 71,878,1991. 11. Boone, DC, Walker, JM, and Perry, J: Age and sex differen~cs in lower extremity joint motion. Presellted at the Nomonal

292 PA RTill LOWER-EXTREMITY TESTING Confcrence, American Physical Therapy i\\sS(lCi:1t ion, Il,·.... iii .. ~)l>I,·,-:'· \":ltl lii\"!'I'!'\" .111\\! PI·r:~'h<'1.1f lWlI\"'I'.llh:- \\','r'1I5:1n W~lshing(Ort, DC. 1981. .I;:r ':'.11 ... 1:\"'1 ~\"Ilip.lr!'-\"n .('.roul'. J'I;\\, Ibn .'\\tl; ;\\~. ~UtHJ. t2. James, B, :lnd Parker, 1\\\\'(/: Active and passivc mobility of lower J-L ....Il,:,!:. (,I;. ]'.:\",','.11. \\1 ..In'! \\lul'lIn. \\11: I{Ci,t;i\":biliP !:t'[Wttn limb joints in elderly Illen 3nd womell. Am J Phys Med Reh3bil p!.l;;!.,rrk'\\.,r 11Ili\"h: \"l;!IHI·'''. 'lfl'l~~:[h .HI,i l.lrTt:,· \"j rnoll!>11 ill \"lil'i\",I\" \\\"111; ,!I.:h·!,\".; ~l.. np!:\\·!.t! r:~·:ir,'p,l;i,:. ,\"rllp.lfnltu ;J!;e- 68:162,1989. !H.lhI1C,l ,\"llir;,i\". Il hlll\"P \\j\"ll'\" I'h\\\" I hn ~li; ·I-~. ;000. Ll. G:lidosik RL, V:lIIderLind(,r1, OW, :lnd \\,(lilli3IllS, AK: Iniluence of 35. 1'.llh\"l.:w'l\"i,,;:.. ;\"\"n h,' .Iltd I'h·... l...d rhl·r.lp~ [)~P!: ( li,'oI':' .)1)( !ILl! ( ,.I'~ .\\ II,d, 'I·. ni ·1. 1:\\ RIt. !\\'I:I, h,,, I l\" ;\\mlgoS age on lengrh and passive cbstic stiffnl'ss: Cn:uactcristics of ehe calf musclc·tcndoll unit of \\vomen. Plws Ther 79:827,1999. .\"'.Il:';!:.!! ]{,·!:.d'lbr.l\\H,n (ellkl. 11'.·.·.11,· ... (.-\\. :'ihll. 14. Nigg, tHv!, et ;11: Range of morion of r1~c foor 35 a funcrion of age. 36. \\h,rf.t~. \\11': ( .. ll~.h.l 1.... :1 p.ll:,·lil ,.1,,1(.\\, nWll,_ .\\lli 11'h:--...\\\\cd Foot Anklc 613:336, 1992. R\"~ub:! ·ik2·JO. 1'Ii'. . '. IS. Vandcrvoon, AA, Ct al: Age :Hld Sex effects on thc mobility of the 37 I 1'.I!i.~:'.(,,):. 1\\. '>i'··.'·lhi'lI . .i.\\I .. \\1'1,1 (l!nl','.• \\1: '>1.1I1,ii!lIhlll~: kine- human ankle. J Gerontol 476:M 17, 1.992. m.\"r\" \"ll '>i.ltl\" ,'I dlt!nrrl;: dtt]lCll..llllh. :\\r.-h I·in ... \\h-d f<d1abil -L ,'IS. 1\"\"1. 16. !kll, RO, :md Hoshilaki, TB: Relationships of age 3nd sex with 31\\. \\l'~-,I.\\,k'l. hI. 'I,~d \\'\\11:11':. [)\\. :\\r~ lilk,.::-.I[l·~l h,,'ml;..:h.tnical range of motion of seycllteen joint actions in hum:lOs. Can J Appl .111,\\1\\-\"1\" \"I :1i,fllU; \"l.llr .h~l·;lt .;I1<i ;,1l'\"-,~'·11:. I h!,.ml·\"'l 21:733, SPOrt Sci, 6:202, 19101 I. !\"S:->. 17. Walker, JM, et al: :\\cli\\le mobility of rhe extremities of older .3'.1. {1 ..ln\"k •. 1'\\.\\1:.\\ \".nq'.ln ..\"n ,.1 1.'•• 11, ~h.i:-.ld;:tl\"'I, .. II: ,<l\\llI!;;lnd subjects. Phys Ther 64:919,1984. ,.1,1 'ilhW,i ... l·h·... 1LC'I ·~·h. i-. \\\"e;.\\. IS. Grimsron, St<, et a!: Differences in ;lJ\\kle joim complex range o( -;0. (.ldil'·;' R: 1\"r'I.ln,i :\\n\\.k. ~,l '. ,-:\\ 1).l'I\".I'hll.I,ll'i!'hl.l. 1'1')7. motion as:l (unction of age. foot Ankle 14:215,1993. 4 1. .\\1,1'\"d. I (\" ,HI,i l \"11l\\\\·.d1. \\l\\\\': .\\:'ph,·d ~i'\"r{'o !'H'iI\\,·.:h;lllics in 19. ~....1oscley. AN, Crosbie., J, and Adams, R: Normative data for lvh.:!':I!] \\,1,01: 1't:I'ilH:~·.. h /.kh.lIl··.·..·,,~1. 1l. \\l,I~·.n·. Dl. l~wi!(·n. \\\\\" ,1,1,,;: :\\ddl'li, bllufll'\" ,un! 1':<,b.lhdtI.HllJ'L. p:lssivc plantarflexion~dorsiflexion f1exibilit),. Clin Biomcch (Bristol, Avon) 16: 514, 20tH. ....l:tll,!\\·r\", I'hil.hklph:.i. I ')'il>. 20. Jonson, SR, and Gross, MT: Intr3ex;uniner reliability, imerexam· -12. !\"rblll'i!. 1 . !·ar'. I..11\"i (.r..nln. j ..\\I'\\: .\\\"\"l\"o\"1il,·IH ill•• [llllt; 1'.\\\\.. 11,· pO'IIIl';;l1i..~. ,'Ill' II';' ~:\\'J 'Ll:!lhll~:. (_~.ll!. iner reliability and IIlC;lI\\ values for nine lower extremiry skeletal l:li l\":hSS. I·g,s. measures in healthy midshipmen. J Orrhop Sports f'hys Ther 43. (,.lrb,I;,,...l.l{ .1', .11: TiJ, t~\"1H.I[ rLI:ll' r..-i.lt:olhhll' I,t lh,' i\"rdoot 2S:253. 1997. \". the' \",'.11\",.,,: ii' .(ii .!\"\\::i!'lpiri,Hi, i'''!'··d,l:ron. ! ()n!\\l'J' Sports .2.1. Bt.'nncll, K. et :11: Hip :lJ\\d :lllkic range of motion :md hip muscle 1'!II\" 1h\"r ~U:.![!!i. 1-';»·:. strength ill young fem:l1e b:lllet dancers and controls. 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Testing of the Spine and Temporomandibular Joint Objectives ON COMPLETION OF PART III, THE READER WILL BE ABLE TO: 1. Identify: adequate stabilization of the proximal joint appropriate planes and axes for each spinal componem and jaw motion correct determination of rhe end of the range of motion expected normal end-feels structures that limit the end of the range of correct identification of the end-feel palpation of the correcr bony landmarks motion accurate alignment of the goniometer correct reading and recording 2. Describe: testing positions for motions of the spine and 5. Perform an assessment of the range of motion of the cervical spine, using each of the follow- Jaw ing methods: a tape measure, dual inclinome- goniometer alignments ters, and the cervical range of motion capsular patterns of restrictions (CROM) device. range of morion necessary for functional tasks 6. Perform an assessment of the range of motion 3. Explain: of the thoracic and lumbar spine, using a tape how age and gender may affect the range of measure and dual inclinometers motion 7. Perform' a~ evaluation of the temporo- how sources of error in measurement may mandibular, joim using a ruler affect testing results 8. Assess theinrratester and illterrester reliability of measurements of the spine and temporo- 4. Perform an assessment of the cervical, mandibular joinr thoracic, and lumbar spine, using a universal goniometer including: a clear explanation of the testing procedure placement of the subject in the appropriate testing position Chapters 11 through 13 ptcsent common clinical techlliquesJor measuring gross motions of the ceryi, cal, rhoracic, and lumbar spine and [he tcrnporomandibular.,ioint. Evaluation of the range of. motion: and end-feels of individual facer joints of the spine, are not included.