392 The Ankle and Foot Chapter 13 Extensor digitorum brevis Figure 13.25 Palpation of the extensor digitorum brevis. fingers to travel anteriorly along the lateral aspect of the plantar aspect of the foot. The cuboid may be the foot until you feel an indentation. You will be tender to palpation, especially when it has dropped along the cuboid. To check your location, follow a secondary to trauma. little more distally and you will palpate the articu- lation with the fifth metatarsal (Figure 13.28). The Fifth Metatarsal groove that you have palpated is for the tendon of Continue distally from the cuboid and you will pal- the peroneus longus as it passes to its attachment on pate the flare of the fifth metatarsal base, its styloid Lateral malleolus Figure 13.26 Palpation of the lateral malleolus.
Chapter 13 The Ankle and Foot 393 Peroneus tubercle Figure 13.27 Palpation of the peroneus tubercle. process. You can continue along the lateral aspect of Soft-Tissue Structures the foot and palpate the shaft of the fifth metatarsal until you come to the fifth metatarsophalangeal joint Anterior Talofibular Ligament (Figure 13.29). The peroneus brevis attaches to the Place your fingers over the sinus tarsi and you will lo- base of the fifth metatarsal. A fracture here is known cate the anterior talofibular ligament as it passes from as a Jones fracture. the lateral malleolus to the talar neck (Figure 13.30). Cuboid Fifth metatarsal Figure 13.28 Palpation of the cuboid. Figure 13.29 Palpation of the fifth metatarsal.
394 The Ankle and Foot Chapter 13 Anterior Calcaneofibular talofibular ligament Figure 13.31 Palpation of the calcaneofibular ligament. ligament Peroneus Figure 13.30 Palpation of the anterior talofibular ligament. brevis Peroneus longus The ligament is not distinctly palpable. However, in- creased tension can be noted under your finger when Figure 13.32 Palpation of the peroneus longus and brevis. the patient inverts and plantarflexes the foot. This lig- ament becomes vertically oriented in plantar flexion and is therefore the most commonly ruptured in ankle injuries. Edema and tenderness will be found over the sinus tarsi following a sprain of this ligament. Calcaneofibular Ligament Place your fingers between the lateral malleolus and the lateral aspect of the calcaneus and you will find the tubular cord of the calcaneofibular ligament (Figure 13.31). The ligament becomes more distinct as you ask the patient to invert the ankle. This ligament can also be torn during inversion injuries of the ankle and, coupled with injury to the anterior talofibular ligament, creates lateral instability of the ankle. Posterior Talofibular Ligament The posterior talofibular ligament runs from the lat- eral malleolus to the posterior tubercle of the talus. The ligament is very strong and deep. It is not palpable. Peroneus Longus and Brevis Tendons Place your fingers posterior and slightly inferior to the lateral malleolus. You will find the tendons of the peroneus longus and brevis. The brevis is closer to the malleolus and the longus is just posterior to the malle- olus. The tendon is made more distinct by asking the patient to evert the foot (Figure 13.32). You can visu- alize the tendon of the peroneus brevis distally to its
Chapter 13 The Ankle and Foot 395 attachment on the base of the fifth metatarsal. A ten- Achilles tendon (Figure 13.34). Tenderness may be der thickening that is palpable inferior to the lateral noted if the patient has overused the muscle and has malleolus may be indicative of stenosing tenosynovitis developed a tenosynovitis. Swelling may be noted and of the common peroneal tendon sheath. Painful snap- crepitus can be perceived with movement. The tendon ping of the tendons can occur if they sublux anteriorly can be ruptured secondary to trauma. Discontinuity to the lateral malleolus. of the tendon can be tested clinically (see pp. 417, 423, Figure 13.92). Palpation of the disruption of Posterior Aspect the tendon may be difficult because of the secondary swelling. The patient will be unable to actively plan- Bony Structures tarflex the ankle. Calcaneus Retrocalcaneal Bursa The large dome of the calcaneus is easily palpable The retrocalcaneal bursa separates the posterior as- at the posterior aspect of the foot. You will notice pect of the calcaneus and the overlying Achilles ten- that the calcaneus becomes wider as you approach don. It is not normally palpable unless it is inflamed the base (Figure 13.33). Excessive prominence of the from increased friction (Figure 13.35). superior tuberosity of the calcaneus often occurs in women who wear high heels and has been called a Calcaneal Bursa pump bump. The calcaneal bursa separates the distal attachment of the tendocalcaneus and the overlying skin. This bursa Soft-Tissue Structures is not normally palpable (Figure 13.36). Tendocalcaneus (Achilles Tendon) If thickness, tenderness, or edema is noted in the Place your fingers at the posterior aspect of the cal- posterior calcaneal area, the patient may have bursi- caneus and move them proximally to the lower one- tis. The calcaneal bursa is often irritated by wearing third of the calf. Palpate the thick common tendon improperly fitting shoes that rub against the posterior of the gastrocnemius and soleus, referred to as the aspect of the foot. Calcaneus Achilles Figure 13.33 Palpation of the calcaneus. tendon Figure 13.34 Palpation of the tendocalcaneus (Achilles tendon).
396 The Ankle and Foot Chapter 13 Achilles feel a flattened area that is not very distinct. You can tendon confirm your location by abducting the great toe and palpating the attachment of the abductor hallucis. If Retrocalcaneal you move medially, you will feel the attachments of bursa the flexor digitorum brevis and the plantar aponeuro- sis (Figure 13.37). The medial tubercle bears weight and is the site of the development of heel spurs. If a spur is present, the tubercle will be very tender to pal- pation. The most common cause of a spur is chronic plantar fasciitis. Figure 13.35 Location of the retrocalcaneal bursa. Sesamoid Bones Find the lateral aspect of the first metatarsophalangeal Plantar Surface joint and allow your fingers to travel to the inferior Bony Structures aspect. You will feel two small sesamoid bones when Medial Tubercle of the Calcaneus you press superiorly on the ball of the foot. These Place your fingers on the plantar surface of the calca- sesamoid bones are located in the tendon of the flexor neus and move them anteriorly to the dome. You will hallucis brevis and help to more evenly distribute weight-bearing forces (Figure 13.38). The sesamoid bones will also facilitate the function of the flexor hallucis brevis, especially during toe off. Metatarsal Heads Allow your fingers to travel slightly proximally from the inferior portion of the first metatarsophalangeal joint until you feel the first metatarsal head. Move laterally and palpate the heads of metatarsals two Achilles tendon Calcaneal bursa Figure 13.36 Location of the calcaneal bursa. Medial tubercle of calcaneus Figure 13.37 Palpation of the medial tubercle of the calcaneus.
Chapter 13 The Ankle and Foot 397 Sesamoid bones Transverse arch Flexor hallucis brevis tendon Figure 13.38 Palpation of the sesamoid bones. through five (Figure 13.39). You should feel that the Figure 13.40 Transverse arch of the foot. first and fifth metatarsal heads are the most promi- nent because of the shape of the transverse arch of the neuroma and is usually found between the third and foot (Figure 13.40). Sometimes you will notice a drop fourth metatarsals. of the second metatarsal head, which will increase the weight-bearing surface. You will also palpate in- Soft-Tissue Structures creased callus formation in this area. Tenderness and swelling between the metatarsals may be indicative of Plantar Aponeurosis (Plantar Fascia) a neuroma. Morton’s neuroma is the most common The plantar aponeurosis consists of strong longitudi- nal fibers that run from the calcaneus and divide into five processes before attaching onto the metatarsal heads. The plantar aponeurosis plays an integral part in the support of the medial longitudinal arch (Figure 13.41). Focal tenderness and nodules on the plantar surface may be indicative of plantar fasciitis. Under normal circumstances, the plantar surface should be smooth and without any nodules. It should not be tender to palpation. Figure 13.39 Palpation of the metatarsal heads. Toes Under normal circumstances, the toes should be flat and straight. The great toe should be longer than the second. If the second toe is longer, it is referred to as a Morton’s toe (Figure 13.42) and is due to a short first metatarsal. Observe the toes for alignment, callus or corn formation, color, and temperature. Calluses
398 The Ankle and Foot Chapter 13 Morton's toe Plantar aponeurosis Figure 13.41 Palpation of the plantar aponeurosis (plantar Figure 13.42 Morton’s toe. fascia). Claw toes and corns can be found on top of the joint surfaces, beneath the toes, and between them. Figure 13.43 Claw toes. Claw Toes The patient will present with hyperextension of the metatarsophalangeal joints and flexion of the proxi- mal and distal interphalangeal joints (Figure 13.43). The patient will often have callus formation over the dorsal aspect of the toes. This is caused by rubbing from the patient’s shoes due to decreased space that results from the deformity. Calluses will also be noted at the tip of the toes because of the increased amount of distal weight-bearing. Patients with pes cavus often develop claw toes. Hammer Toes The patient will present with hyperextension of the metatarsophalangeal joint, flexion of the proximal in- terphalangeal joint, and hyperextension of the distal interphalangeal joint (Figure 13.44). The patient will often have callus formation over the dorsal aspect of the proximal interphalangeal joint secondary to in- creased pressure from the top of the shoe.
Chapter 13 The Ankle and Foot 399 Hammer for dorsiflexion, plantar flexion, inversion, and ever- toes sion. Then have the patient bring up the toes, curl them, and spread them apart. This will check for toe extension, flexion, abduction, and adduction (Figure 13.46). Passive Movement Testing Figure 13.44 Hammer toes. Passive movement testing can be divided into two ar- eas: physiological movements (cardinal plane), which Active Movement Testing are the same as the active movements, and mobility testing of the accessory movements (joint play, com- Active movement tests should be quick, functional ponent). You can determine whether the noncontrac- tests designed to clear the joint. They are designed to tile (inert) elements are causative of the patient’s prob- help you see if the patient has a gross restriction. You lem by using these tests. These structures (ligaments, should always remember to compare the movement joint capsule, fascia, bursa, dura mater, and nerve from one side to the other. If the motion is pain free root) (Cyriax, 1979) are stretched or stressed when at the end of the range, you can add an additional the joint is taken to the end of the available range. overpressure to “clear” the joint. If the patient expe- At the end of each passive physiological movement, riences pain in any of these movements, you should you should sense the end feel and determine whether continue to explore whether the etiology of the pain is it is normal or pathological. Assess the limitation of secondary to contractile or noncontractile structures movement and see if it fits into a capsular pattern. The by using passive and resistive testing. capsular patterns of the foot and ankle are as follows: talocrural joint—greater restriction of plantar flexion Active movements of the ankle and foot should be than dorsiflexion; subtalar joint—greater restriction performed in both weight-bearing and non-weight- of varus than valgus; midtarsal joint—most restriction bearing (supine or long sitting) positions. In the in dorsiflexion, followed by plantar flexion, adduc- weight-bearing position, instruct the patient to stand tion, and medial rotation; first metatarsophalangeal and walk on the toes to check for plantar flexion and joint—greater restriction of extension than flexion; toe flexion, and to stand and walk on the heels to test interphalangeal joints—greater restriction of exten- for dorsiflexion and toe extension. Then instruct the sion than flexion (Magee, 2002; Kaltenborn, 1999). patient to stand on the lateral border of the foot to test for inversion, and then the medial border of the Physiological Movements foot to test for eversion (Figure 13.45). You will be assessing the amount of motion available In the non-weight-bearing position, instruct the pa- in all directions. Each motion is measured from the tient to pull the ankle up as far as possible, push it anatomical starting position. In the talocrural joint down, and turn it in and then out. This will check this is when the lateral aspect of the foot creates a right angle with the longitudinal axis of the leg. In addition, a line passing through the anterior superior iliac spine and through the patella must be aligned with the second toe. The starting position for the toes is when the longitudinal axes through the metatarsals form a straight line with the corresponding phalanx. Dorsiflexion You can measure dorsiflexion with the patient either in the sitting position with the leg dangling over the side of the treatment table or in the supine position.
400 The Ankle and Foot Chapter 13 Plantarflexion Dorsiflexion Inversion Eversion Figure 13.45 Active movement testing for inversion and eversion. This motion takes place in the talocrural joint. Place your other hand with the palm flattened over the dor- the patient so that the knee is flexed at 90 degrees sal surface of the foot directing your fingers laterally. and the foot is at 0 degree of inversion and eversion. Push the foot in a caudal direction avoiding any in- Place one hand over the distal posterior aspect of the version or eversion. The normal end feel is abrupt leg to stabilize the tibia and fibula and prevent move- and firm (ligamentous) because of the tension in the ment at the knee and hip. Place your other hand with anterior capsule and the anterior ligaments (Magee, the palm flattened under the plantar surface of the 2002; Kaltenborn, 1999). A hard end feel may result foot directing your fingers toward the toes. Bend the from contact between the posterior talar tubercle and ankle in a cranial direction. The normal end feel is the posterior aspect of the tibia. The normal range abrupt and firm (ligamentous) because of the tension of motion is 0–50 degrees (Figure 13.48) (American from the tendocalcaneus and the posterior ligaments Academy of Orthopedic Surgeons, 1965). (Magee, 2002; Kaltenborn, 1999). The normal range of motion is 0–20 degrees (Figure 13.47) (American Inversion Academy of Orthopedic Surgeons, 1965). Place the patient in the sitting position with the leg Plantar Flexion dangling over the side of the treatment table and the knee flexed to 90 degrees or in the supine po- You can measure plantar flexion with the patient sition with the foot over the end of the treatment either in the sitting position with the leg dangling table. Make sure that the hip is at 0 degree of over the side of the treatment table or in the supine rotation, and adduction and abduction. Inversion, position. This motion takes place in the talocrural which is a combination of supination, adduction, and joint. Place the patient so that the knee is flexed at plantar flexion, takes place at the subtalar, trans- 90 degrees and the foot is at 0 degree of inversion verse tarsal, cuboideonavicular, cuneonavicular, in- and eversion. Place one hand over the distal poste- tercuneiform, cuneocuboid, tarsometatarsal, and in- rior aspect of the leg to stabilize the tibia and fibula termetatarsal joints. Place one hand over the distal and prevent movement at the knee and hip. Place medial and posterior aspect of the leg to stabilize the
Chapter 13 The Ankle and Foot 401 (a) (b) (c) (d) (e) (f) (g) (h) Figure 13.46 Active movement testing in non-weight-bearing of: (a) Plantar flexion, (b) Dorsiflexion, (c) Inversion, (d) Eversion, (e) Toe extension, (f) Flexion, (g) Abduction, and (h) Adduction.
402 The Ankle and Foot Chapter 13 normal end feel is abrupt and firm (ligamentous) be- cause of the tension in the joint capsules and the lateral ligaments (Magee, 2002; Kaltenborn, 1999). The normal range of motion is 0–35 degrees (Figure 13.49) (American Academy of Orthopedic Surgeons, 1965). Figure 13.47 Passive movement testing of dorsiflexion. Eversion tibia and fibula and prevent movement at the knee Place the patient in the sitting position with the and hip. Place your hand over the distal lateral aspect leg dangling over the side of the treatment table of the foot with your thumb on the dorsal surface and the knee flexed to 90 degrees or in the supine and the other four fingers under the metatarsal heads. position with the foot over the end of the treat- Turn the foot in a medial and superior direction. The ment table. Make sure that the hip is at 0 degree of rotation, and adduction and abduction. Eversion, which is a combination of pronation, abduction, and dorsiflexion, takes place at the subtalar, trans- verse tarsal, cuboideonavicular, cuneonavicular, in- tercuneiform, cuneocuboid, tarsometatarsal, and in- termetatarsal joints. Place one hand over the distal lat- eral and posterior aspect of the leg to stabilize the tibia and fibula and prevent movement at the knee and hip. Place your hand under the distal plantar aspect of the foot with your thumb on the first metatarsal and the other four fingers around the fifth metatarsal. Turn Figure 13.48 Passive movement testing of plantar flexion. Figure 13.49 Passive movement testing of inversion.
Chapter 13 The Ankle and Foot 403 the foot in a lateral and superior direction. The nor- mal end feel is abrupt and firm (ligamentous) (Magee, 2002; Kaltenborn, 1999) because of the tension in the joint capsules and the medial ligaments. The nor- mal range of motion is 0–15 degrees (Figure 13.50) (American Academy of Orthopedic Surgeons, 1965). Subtalar (Hindfoot) Inversion Fibula Place the patient in the prone position with the foot Tibia over the end of the treatment table. Make sure that the hip is at 0 degree of flexion–extension, abduction– Figure 13.51 Passive movement testing of subtalar (hindfoot) adduction, and rotation, and that the knee is at 0 inversion. degree of extension. Place one hand over the mid- dle posterior aspect of the leg to stabilize the tibia and fibula and prevent motion in the hip and knee. Place your other hand on the plantar surface of the calcaneus, grasping it between your index finger and thumb. Rotate the calcaneus in a medial direction. The normal end feel is abrupt and firm (ligamen- tous) because of the tension in the joint capsule and the lateral ligaments (Magee, 2002; Kaltenborn, 1999). Normal range of motion is 0–5 degrees (Figure 13.51) (American Academy of Orthopedic Surgeons, 1965). Subtalar (Hindfoot) Eversion Place the patient in the prone position with the foot over the end of the treatment table. Make sure that the hip is at 0 degree of flexion–extension, abduction– adduction, and rotation, and that the knee is at 0 de- gree of extension. Place one hand over the middle pos- terior aspect of the leg to stabilize the tibia and fibula and prevent motion in the hip and knee. Place your other hand on the plantar surface of the calcaneus, grasping it between your index finger and thumb. Ro- tate the calcaneus in a lateral direction. The normal end feel is abrupt and firm (ligamentous) because of the tension in the joint capsule and the medial liga- ments (Magee, 2002; Kaltenborn, 1999). If the end feel is hard, it may be due to contact between the cal- caneus and the sinus tarsi. Normal range of motion is 0–5 degrees (Figure 13.52) (American Academy of Orthopedic Surgeons, 1965). Figure 13.50 Passive movement testing of eversion. Forefoot Inversion Place the patient in the sitting position with the leg dangling over the side of the treatment table and the knee flexed to 90 degrees or in the supine position
404 The Ankle and Foot Chapter 13 Tibia Fibula Figure 13.53 Passive movement testing of forefoot inversion. Figure 13.52 Passive movement testing of subtalar (hindfoot) and prevent dorsiflexion at the talocrural joint and eversion. inversion of the subtalar joint. Place your other hand under the distal plantar aspect of the foot with your with the foot over the end of the treatment table. thumb on the medial aspect of the first metatarsopha- Make sure that the hip is at 0 degree of rotation, langeal joint and the other four fingers around the and adduction and abduction. Place one hand un- fifth metatarsal. Move the foot laterally. The nor- der the calcaneus to stabilize the calcaneus and talus mal end feel is abrupt and firm (ligamentous) because and prevent dorsiflexion at the talocrural joint and of the tension in the joint capsule and the medial inversion of the subtalar joint. Place your other hand ligaments (Magee, 2002; Kaltenborn, 1999). Nor- over the lateral aspect of the foot over the metatarsals mal range of motion is 0–15 degrees (Figure 13.54) with your thumb on the dorsal aspect facing medi- (American Academy of Orthopedic Surgeons, 1965). ally and the other four fingers on the plantar surface. Move the foot medially. The normal end feel is abrupt Flexion of the Metatarsophalangeal Joint and firm (ligamentous) because of the tension in the joint capsule and the lateral ligaments (Magee, 2002; Place the patient in the sitting position with the leg Kaltenborn, 1999). Normal range of motion is 0–35 dangling over the side of the treatment table and degrees (Figure 13.53) (American Academy of Ortho- the knee flexed to 90 degrees or in the supine po- pedic Surgeons, 1965). sition with the foot over the end of the treatment table. Make sure that the metatarsophalangeal joint Forefoot Eversion is at 0 degree of abduction–adduction. The interpha- langeal joints should be maintained at 0 degree of Place the patient in the sitting position with the leg flexion–extension. If the ankle is allowed to plan- dangling over the side of the treatment table and the tarflex or the interphalangeal joints of the toe being knee flexed to 90 degrees or in the supine position tested are allowed to flex, the range of motion will be with the foot over the end of the treatment table. limited by increased tension in the extensor digitorum Make sure that the hip is at 0 degree of rotation, longus and extensor hallucis longus. Place one hand and adduction and abduction. Place one hand un- around the distal metatarsals with your thumb on der the calcaneus to stabilize the calcaneus and talus the plantar surface and the fingers across the dorsum to stabilize the foot and prevent plantar flexion. The other hand holds the hallux between the thumb and
Chapter 13 The Ankle and Foot 405 Figure 13.54 Passive movement testing of forefoot eversion. index finger and flexes the metatarsophalangeal joint. cause of the tension in the plantar capsule, the plan- The normal end feel is abrupt and firm (ligamentous) tar fibrocartilaginous plate, the flexor hallucis longus, because of the tension in the capsule and the collateral flexor digitorum brevis, and the flexor digiti min- ligaments (Magee, 2002; Kaltenborn, 1999). Normal imi muscles (Magee, 2002; Kaltenborn, 1999). Nor- range of motion is 0–45 degrees for the hallux (Figure mal range of motion is 0–70 degrees for the hallux 13.55) (American Academy of Orthopedic Surgeons, 1965). Extension of the Metatarsophalangeal Joint Figure 13.55 Passive movement testing of flexion of the metatarsophalangeal joint. Place the patient in the sitting position with the leg dangling over the side of the treatment table and the knee flexed to 90 degrees or in the supine position with the foot over the end of the treatment table. Make sure that the metatarsophalangeal joint is at 0 degree of abduction–adduction. The interphalangeal joints should be maintained at 0 degree of flexion– extension. If the ankle is allowed to dorsiflex or the interphalangeal joints of the toe being tested are al- lowed to extend, the range of motion will be limited by increased tension in the flexor digitorum longus and flexor hallucis longus. Place one hand around the distal metatarsals with your thumb on the plantar surface and the fingers across the dorsum to stabi- lize the foot and prevent dorsiflexion. The other hand holds the hallux between the thumb and index fin- ger and extends the metatarsophalangeal joint. The normal end feel is abrupt and firm (ligamentous) be-
406 The Ankle and Foot Chapter 13 (Figure 13.56) (American Academy of Orthopedic prevent it from sliding. Stabilize the tibia by placing Surgeons, 1965). your hand on the proximal ventral aspect. Hold the fibular head by placing your thumb anteriorly and Mobility Testing of the Accessory your index finger posteriorly. Pull the fibular head Movements in both a ventral–lateral and dorsal–medial direction (Figure 13.57). Mobility testing of accessory movements will give you information about the degree of laxity present in the Ventral Glide of the Fibula at the Inferior joint. The patient must be totally relaxed and com- Tibiofibular Joint fortable to allow you to move the joint and obtain the most accurate information. The joint should be Place the patient in the prone position with the foot placed in the maximal loose packed (resting) posi- over the end of the treatment table. Place a rolled tion to allow for the greatest degree of joint move- towel or a wedge under the distal anterior aspect of ment. The resting position of the ankle and foot are the tibia, just proximal to the mortise. Stand at the as follows: talocrural joint, 10 degrees of plantar end of the table facing the medial plantar aspect of flexion and midway between maximal inversion and the patient’s foot. Stabilize the tibia by placing your eversion; distal and proximal interphalangeal joints, hand on the medial distal aspect. Using your hand on slight flexion; metatarsophalangeal joints, approxi- the posterior aspect of the lateral malleolus, push the mately 10 degrees of extension (Kaltenborn, 1999). fibula in an anterior direction (Figure 13.58). Dorsal and Ventral Glide of the Fibula at the Traction of the Talocrural Joint Superior Tibiofibular Joint Place the patient in the supine position so that the Place the patient in the supine position with the knee calcaneus is just past the end of the treatment table. flexed to approximately 90 degrees. Sit on the side Stand at the end of the table facing the plantar aspect of the treatment table and on the patient’s foot to Figure 13.56 Passive movement testing of extension of the Figure 13.57 Mobility testing of dorsal and ventral glide of the metatarsophalangeal joint. fibula at the superior tibiofibular joint.
Chapter 13 The Ankle and Foot 407 Figure 13.58 Mobility testing of ventral glide of the fibula at the inferior tibiofibular joint. of the foot. Stabilize the tibia by placing your hand on foot. Stabilize the cuboid on the lateral side with your the distal anterior aspect, just proximal to the mortise. second and third fingers on the dorsal aspect and your Hold the foot so that your fifth finger is over the talus thumb on the plantar aspect. Hold the base of the with your other four fingers resting over the dorsum of fourth and fifth metatarsals with your second and the foot. Allow your thumb to hold the plantar surface third fingers on the dorsal aspect and your thumb of the foot facing the first metatarsophalangeal joint. on the plantar aspect. Glide the metatarsals first in a Pull the talus in a longitudinal direction, until all the dorsal direction taking up all the slack, and then in a slack is taken up. This produces distraction in the plantar direction (Figure 13.61). talocrural joint (Figure 13.59). Traction of the Subtalar Joint Place the patient in the supine position with the foot at 0 degree of dorsiflexion so that the calcaneus is just past the end of the treatment table. Stand at the end of the table facing the plantar aspect of the foot. Main- tain the dorsiflexion angle by resting the patient’s foot on your thigh. Stabilize the tibia and the talus by plac- ing your hand over the anterior aspect of the talus and the distal anterior aspect of the tibia, just distal to the mortise. Hold the posterior aspect of the calcaneus and pull in a longitudinal direction, until all the slack is taken up, producing distraction in the subtalar joint (Figure 13.60). Dorsal and Plantar Glide of the Cuboid–Metatarsal Figure 13.59 Mobility testing of traction of the talocrural joint. Joint Place the patient in the supine position with the knee flexed to approximately 90 degrees. Stand at the side of the treatment table facing the medial side of the
408 The Ankle and Foot Chapter 13 the lateral side of the foot. Stabilize the first cuneiform on the medial side with your second and third fingers wrapping around from the dorsal to the plantar as- pect. Hold the lateral aspect of the foot against your trunk for additional stabilization. Hold the base of the first metatarsal with your index and middle fin- gers from the medial side just proximal to the joint. Glide the first metatarsal in a dorsal direction tak- ing up all the slack, and then in a plantar direction (Figure 13.62). Figure 13.60 Mobility testing of traction of the subtalar joint. Dorsal and Plantar Glide of the Metatarsals Dorsal and Plantar Glide of the First Place the patient in the supine position with the knee Cuneiform–Metatarsal Joint flexed to 90 degrees and the foot flat on the treat- ment table. Stand on the side of the table facing the Place the patient in the supine position with the knee dorsal aspect of the patient’s foot. Stabilize the sec- flexed to approximately 90 degrees and the foot on a ond metatarsal from the medial aspect of the foot wedge just proximal to the first cuneiform–metatarsal using your thumb on the dorsal aspect and wrapping joint. Stand at the side of the treatment table facing your fingers around the first metatarsal toward the plantar aspect. Hold the third metatarsal with your thumb on the dorsal aspect and your fingers on the plantar aspect. Move the third metatarsal in a dorsal direction until all the slack is taken up, and then in a plantar direction. This test can be repeated by stabi- lizing the second metatarsal and mobilizing the first metatarsal, by stabilizing the third metatarsal and mo- bilizing the fourth metatarsal, and by stabilizing the fourth metatarsal and mobilizing the fifth metatarsal (Figure 13.63). Traction of the First Metatarsophalangeal Joint Place the patient in the supine position with the knee extended. Sit on the end of the treatment table on the lateral aspect of the foot and allow the patient’s leg to rest on your thigh. Stabilize the first metatarsal with your thumb on the dorsal aspect and your fingers wrapped around the plantar surface just proximal to the joint line. Hold the foot against your body for ad- ditional stabilization. Hold the first proximal phalanx with your thumb and index fingers. Pull the phalanx in a longitudinal direction until all the slack is taken up, creating traction in the first metatarsophalangeal joint (Figure 13.64). Resistive Testing Figure 13.61 Mobility testing of dorsal and plantar glide of the Muscle strength of the ankle is tested in plantar flex- cuboid–metatarsal joint. ion and dorsiflexion. Inversion and eversion of the
Chapter 13 The Ankle and Foot 409 1st Metatarsal 1st Cuneiform Figure 13.62 Mobility testing of dorsal and plantar glide of the first cuneiform–metatarsal joint. foot occur at the subtalar joint and are also tested. The eversion, plantar flexion, or dorsiflexion. The toes toes are examined for flexion and extension strength. should be observed for movement while testing the ankle. If the ankle muscles are weak, the patient will In testing muscle strength of the foot and ankle, it recruit the flexors or extensors of the toes in an effort is important to watch for evidence of muscle substi- to compensate. tution. Observe the forefoot for excessive inversion, Figure 13.63 Mobility testing of dorsal and plantar glide of the Figure 13.64 Mobility testing of traction of the first metatarsals. metatarsophalangeal joint.
410 The Ankle and Foot Chapter 13 Ankle Plantar Flexion Figure 13.66 Testing ankle plantar flexion. The primary plantar flexors of the ankle are the gas- trocnemius and soleus muscles (Figure 13.65). Addi- tional muscles that assist are the tibialis posterior, per- oneus longus and brevis, flexor hallucis longus, flexor digitorum longus, and plantaris muscles. All the an- kle plantar flexors pass posterior to the ankle joint. It is imperative to observe for downward rotation of the calcaneus. Excessive toe flexion in an attempt to plantarflex the ankle is a result of substitution by the long toe flexors. Excessive inversion during attempts to plantar flex is due to substitution by the tibialis posterior muscle. Excessive eversion is due to substi- tution by the peroneus longus muscle. The foregoing information is important when the patient is unable to perform normal plantar flexion in a standing position due to weakness of the gastrocsoleus muscle group. r Position of patient: Standing upright on the foot to be tested (Figure 13.66). r Resisted test: Ask the patient to stand up on the toes. Resistance is supplied by the body weight of the patient. Testing plantar flexion of the ankle with gravity eliminated is performed with the patient in a side- lying position and the ankle in neutral position. The Posterior view patient attempts to plantarflex the foot downward. of leg Observe the patient for substitution by the subtalar invertors/evertors and toe flexors (Figure 13.67). Painful resisted plantar flexion can be due to Achilles tendinitis or strain of the gastrocnemius or soleus muscle. Pain behind the heel during resisted plantar flexion can be due to retrocalcaneal bursitis. Weakness of plantar flexion results in an abnor- mal gait, as well as difficulty with climbing stairs and jumping. Hyperextension deformity of the knee and a calcaneus deformity of the foot may be noted in cases of paralysis (i.e., spina bifida). Soleus Ankle Dorsiflexion Gastrocnemius The primary dorsiflexor of the ankle is the tibialis Figure 13.65 Plantar flexors of the ankle. anterior muscle (Figure 13.68). Due to its attachment medial to the subtalar joint axis, the tibialis anterior also inverts the foot. This muscle is assisted by the long toe extensors. r Position of patient: Sitting with the legs over the edge of the table and the knees flexed to 90 degrees (Figure 13.69). r Resisted test: Support the patient’s lower leg with one hand and apply a downward and everting
Chapter 13 The Ankle and Foot 411 Figure 13.67 Testing plantar flexion with gravity eliminated. Tibialis anterior Figure 13.68 The dorsiflexor of the ankle. Figure 13.69 Testing dorsiflexion.
412 The Ankle and Foot Chapter 13 force to the foot in its midsection as the patient r Resisted test: Stabilize the lower leg with one attempts to dorsiflex the ankle and invert the foot. hand. The other hand is placed over the medial Dorsiflexion can also be tested by asking the border of the forefoot. Apply downward pressure patient to walk on his heels with his toes in the air. on the forefoot as the patient attempts to invert the Testing dorsiflexion with gravity eliminated is per- foot. formed by placing the patient in a side-lying position Testing inversion of the foot with gravity elimi- and asking him or her to dorsiflex the ankle. Observe the patient for substitution by the long extensors of nated is performed by having the patient lie in the the toes. You will see dorsiflexion of the toes if sub- supine position and attempting to invert the foot stitution is taking place (Figure 13.70). through the normal range of motion. Watch for sub- Painful resisted dorsiflexion in the anterior tibial stitution of the flexor hallucis longus and flexor digi- region can be due to shin splints at the attachment of torum longus during this procedure, as the toes may the tibialis anterior muscle to the tibia, or an anterior flex in an attempt to overcome a weak tibialis poste- compartment syndrome. rior (Figure 13.73). Weakness of dorsiflexion results in foot drop and a steppage gait. An equinus deformity of the foot may Weakness of foot inversion results in pronation or result (i.e., as in peroneal palsy). valgus deformity of the foot and reduced support of the plantar longitudinal arch. Subtalar Inversion Painful resisted foot inversion can be due to a Inversion of the foot is brought about primarily by tendinitis of the tibialis posterior muscle at its at- the tibialis posterior muscle (Figure 13.71). Accessory tachment to the medial tibia, known as shin splints. muscles include the flexor digitorum longus and flexor Pain can also indicate tendinitis of the tibialis poste- hallucis longus. rior or flexor hallucis longus posterior to the medial r Position of patient: Lying on the side, with the malleolus. ankle in slight degree of plantar flexion Subtalar Eversion (Figure 13.72). The evertors of the foot are the peroneus longus and peroneus brevis muscles (Figure 13.74). They are Figure 13.70 Testing dorsiflexion with gravity eliminated.
Chapter 13 The Ankle and Foot 413 Tibialis Figure 13.73 Testing subtalar inversion with gravity eliminated. posterior Posterior view of leg Plantar view of foot Figure 13.71 The invertors of the foot. Peroneus longus Peroneus brevis Figure 13.72 Testing subtalar inversion. Plantar view of foot Figure 13.74 The evertors of the foot.
414 The Ankle and Foot Chapter 13 Figure 13.75 Testing subtalar eversion. assisted by the extensor digitorum longus and per- r Position of patient: Supine (Figure 13.78). oneus tertius muscles. r Resisted test: Apply an upward pressure to the r Position of patient: Lying on the side with the bottoms of the patient’s toes as he or she attempts ankle in neutral position (Figure 13.75). to flex them. The flexors of the great toe may be r Resisted test: Stabilize the lower leg of the patient examined separately. Inability to flex the distal phalanx of the toes results with one hand. The other hand is used to apply a from dysfunction of the long flexors. downward pressure on the lateral border of the Painful resisted toe flexion may be due to tendinitis foot. Ask the patient to raise the lateral border of of the long flexors. the foot. This maneuver is more specific for the peroneus brevis. Testing foot eversion with gravity eliminated is per- formed by having the patient lie in the supine position and attempting to evert the foot through a normal range of motion. Observe for extension of the toes, as this signifies substitution (Figure 13.76). Painful resisted foot eversion can be due to tendini- tis of the peroneal tendons posterior to the ankle or at the attachment site of the muscles to the fibula. An inversion sprain of the ankle can result in stretching or tearing of the peroneal tendons and painful resisted foot eversion. A snapping sound may be heard as the tendons pass anteriorly over the lateral malleolus. Weakness of foot eversion may result in a varus position of the foot and cause reduced stability of the lateral aspect of the ankle. Toe Flexion Figure 13.76 Testing subtalar eversion with gravity eliminated. The flexors of the toes are the flexor hallucis brevis and longus and the flexor digitorum brevis and longus (Figure 13.77).
Chapter 13 The Ankle and Foot 415 Flexor Flexor Extensor digitorum digitorum hallucis longus longus longus Extensor hallucis Posterior Flexor longus view digitorum of leg brevis Extensor digitorum brevis Plantar view Figure 13.79 The extensors of the toes. of foot Toe Extension Figure 13.77 The flexors of the toes. The extensors of the toes are the extensor hallucis brevis and longus and the extensor digitorum brevis and longus (Figure 13.79). r Position of patient: Supine (Figures 13.80 and 13.81). Figure 13.78 Testing toe flexion. Figure 13.80 Testing toe extension.
416 The Ankle and Foot Chapter 13 ity of the Achilles tendon will also result in loss of an ankle jerk. The ankle jerk is easily elicited when the patient is relaxed (Figure 13.82). Have the patient sit on the edge of the table with the knees flexed to 90 degrees. Support the ball of the patient’s foot gently upward with one hand while asking him or her to relax and try not to assist in dorsiflexion of the foot. Take the reflex hammer and gently tap the Achilles tendon to elicit a plantar flexion response at the ankle. The test can also be performed with the patient prone with the feet off the edge of the table. In this position, the Achilles tendon is tapped with the reflex hammer. Always compare findings bilaterally. Figure 13.81 Testing great toe extension by the extensor Sensation hallucis longus. Light touch and pinprick sensation should be ex- r Resisted test: Apply a downward pressure on the amined following the motor examination. The der- distal phalanx of the great toe, as the patient matomes of the lower leg are L3, L4, L5, S1, and S2 attempts to extend the toe, to test the extensor (Figure 13.83). Note the location of the key sensory hallucis longus. Resistance can be applied to the areas for the L4, L5, and S1 dermatomes. The periph- middle phalanges of the other toes together to test eral nerves providing the sensation to the leg and foot the extensor digitorum longus and brevis. are shown in Figures 13.84–13.86. Weakness of toe extension may result in decreased Referred Pain Patterns ability to dorsiflex the ankle and evert the foot. Walk- ing barefoot may be unsafe, due to increased risk of Pain in the leg and foot may be referred from the falling as the toes bend under the foot. lumbar spine, sacrum, hip, or knee (Figure 13.87). Neurological Examination Special Tests Motor Special Neurological Tests The innervation and spinal levels of the muscles that function in the ankle and foot are listed in Table 13.1. Tests for Nerve Compression Reflexes Peroneal Nerve Compression The ankle jerk primarily tests the S1 nerve root. It will The common peroneal nerve can be injured where it be diminished or lost in patients with S1 radiculopa- wraps around the head of the fibula and is close to thy or sciatic or tibial nerve damage. Loss of continu- the skin (Figure 13.88). Tinel’s sign may be elicited inferior and lateral to the fibular head by tapping with a reflex hammer. The patient will note a tingling sensation down the lateral aspect of the leg and onto the dorsum of the foot. The patient will have a foot drop. Tarsal Tunnel Syndrome Entrapment of the posterior tibial nerve underneath the flexor retinaculum at the tarsal tunnel may also occur (Figure 13.89). Tinel’s sign may be obtained
Chapter 13 The Ankle and Foot 417 Table 13.1 Movements of the ankle and foot: the muscles and their nerve supply, as well as their nerve root derivations, are shown. Movement Muscles Innervation Root levels Plantar flexion (flexion) of ankle 1 Gastrocnemius Tibial S1, S2 Dorsiflexion (extension) of ankle 2 Soleus Tibial S1, S2 Inversion 3 Flexor digitorum longus Tibial L5, S1, S2 4 Flexor hallucis longus Tibial L5, S1, S2 Eversion 5 Peroneus longus Superficial peroneal L5, S1 Flexion of toes 6 Peroneus brevis Superficial peroneal L5, S1 7 Tibialis posterior Tibial L4, L5, S1 Extension of toes Abduction of great toe 1 Tibialis anterior Deep peroneal L4, L5 2 Extensor digitorum longus Deep peroneal L4, L5, S1 3 Extensor hallucis longus Deep peroneal L5, S1 4 Peroneus tertius Deep peroneal L4, L5, S1 1 Tibialis posterior Tibial L4, L5, S1 2 Flexor digitorum longus Tibial L5, S1, S2 3 Flexor hallucis longus Tibial L5, S1, S2 4 Extensor hallucis longus Deep peroneal L5, S1 5 Tibialis anterior Deep peroneal L4, L5 1 Peroneus longus Superficial peroneal L5, S1 2 Peroneus brevis Superficial peroneal L5, S1 3 Extensor digitorum longus Deep peroneal L4, L5, S1 4 Peroneus tertius Deep peroneal L4, L5, S1 1 Flexor digitorum longus Tibial L5, S1, S2 2 Flexor hallucis longus Tibial L5, S1, S2 3 Flexor digitorum brevis Tibial (medial plantar) L5, S1 4 Flexor hallucis brevis Tibial (medial plantar) L5, S1 5 Flexor digit minimi Tibial (lateral plantar) S1, S2 1 Extensor digitorum longus Deep peroneal L4, L5, S1 2 Extensor hallucis longus Deep peroneal L5, S1 3 Extensor digitorum brevis Deep peroneal L5, S1 1 Abductor hallucis Tibial (medial plantar) S1, S2 inferior to the medial malleolus by tapping with a Tests for Structural Integrity reflex hammer. Ligament and Tendon Integrity Tests for Upper Motor Neuron Involvement Thompson Test for Achilles Tendon Rupture Babinski’s response and Oppenheim’s test are used to This test is performed to confirm rupture of the diagnose upper motor neuron disease. Babinski’s re- Achilles tendon (Figure 13.92). The tendon often rup- sponse is obtained by scratching the foot on the plan- tures at a site 2–6 cm proximal to the calcaneus, which tar aspect from the heel to the upper lateral sole and coincides with a critical zone of circulation. The test across the metatarsal heads (Figure 13.90). A positive is performed with the patient prone and the feet dan- response is dorsiflexion of the great toe. Flexion of gling over the edge of the table. Squeeze the gastroc- the foot, knee, and hip can occur concomitantly. nemius muscle firmly with your hand and observe for evidence of plantar flexion. The absence of plantar Oppenheim’s test is performed by running a flexion is a positive test result. Also, observe the pa- knuckle or fingernail up the anterior tibial surface. tient for excessive passive dorsiflexion and a palpable A positive response is the same as for Babinski’s re- gap in the tendon. sponse (Figure 13.91).
418 The Ankle and Foot Chapter 13 Figure 13.82 Testing the ankle jerk. L5 L4 L4 L5 L5 Dermatome S1 LL Dermatome L5 4 4 L4 Key S2 S1 S1 sensory Dermatome L5 areas S1 Plantar S1 aspect S1 L5 Key sensory area S1 Key sensory area Figure 13.83 The dermatomes of the lower leg, foot, and ankle. Note the key sensory areas for L4, L5, and S1.
Chapter 13 The Ankle and Foot 419 Lateral Saphenous cutaneous nerve nerve (L3, L4) (L5, S1) Saphenous nerve (L3, L4) Superficial peroneal nerve (L4, L5, S1) Deep Sural Superficial peroneal nerve peroneal nerve (L5, S1, S2) nerve (L5, S2) (L4, L5, S1) Deep peroneal nerve (L5, S1) Figure 13.84 Anterior view of the peripheral nerves of the lower leg and foot and their distributions. Sural Sural communicating nerve (L5, S2, S2) nerve (L5, S1, S2) Sciatic nerve Lateral (L4, L5, cutaneous S1, S2, S3) nerve Saphenous (L5, S1) nerve (L2, L3, L4) Medial cutaneous nerve of thigh (L2, L3, L4) Sural nerve (L5, S1, S2) Saphenous nerve (L2, L3, L4) Medial Medial calcaneal calcaneal (S1, S2) (S1, S2) Figure 13.85 Posterior view of the peripheral nerves of the lower leg and foot with their distributions.
420 The Ankle and Foot Chapter 13 Medial calcaneal branches(S1, 2) Medial Lateral plantar plantar nerve (S1,2) nerve (L4,5) Sural nerve Saphenous (L5, S1, 2) nerve (L2, 3, 4) Figure 13.86 The nerves of the plantar surface of the foot. Anterior Drawer Sign Figure 13.87 Pain in the leg and foot may be due to pathology This test is used to determine whether there is struc- in the lumbar spine, sacrum, hip, or knee. tural integrity of the anterior talofibular ligament, an- terior joint capsule, and calcaneofibular band (Figure sition (Figure 13.94). Cup the patient’s heel in your 13.93). The test is performed with the patient sit- hand and attempt to invert the calcaneus and talus. ting with the knees flexed over the edge of the table. Excessive inversion movement of the talus within the Stabilize the lower leg with one hand and take the ankle mortise is a positive test result. calcaneus in the palm of the opposite hand. Place the ankle in 20 degrees of plantar flexion. This position Bone Integrity makes the anterior talofibular ligament perpendicular Test for Stress Fractures to the lower leg. Now attempt to bring the calcaneus Stress fractures are common in the bones of the lower and talus forward out of the ankle mortise. Excessive leg and foot. If a stress fracture is suspected, the area anterior movement of the foot, which is often accom- of localized tenderness over the bone can be exam- panied by a clunk, is a positive anterior drawer sign. ined with a tuning fork. Placing the tuning fork onto This test can also be performed with the patient in the the painful area will cause increased pain in a stress supine position with the hips and knees flexed. The reliability depends in part on the ability of the patient to relax and cooperate. Inversion Stress Test This test is performed if the anterior drawer test result is positive. This test uncovers damage to the calcane- ofibular ligament, which is responsible for preventing excessive inversion. The patient is positioned either seated at the edge of the table or in the supine po-
Chapter 13 The Ankle and Foot 421 Common Head of fracture. This test should not be relied on without the peroneal fibula benefit of x-rays or MRI testing. nerve Neural Integrity Site of compression Test for Morton’s Neuroma of common peroneal A Morton’s neuroma develops in the second or third web space where the interdigital nerves branch nerve (Figure 13.95). By holding the foot with your hand and squeezing the metatarsals together, a click Peroneus may be heard. This occurs in patients with ad- longus vanced Morton’s neuroma and is called a Moulder’s click. Extensor digitorum Vascular Integrity brevis Homan’s Sign Figure 13.88 The peroneal nerve is shown at its most common This maneuver is used to aid in the diagnosis of throm- site of compression, where it wraps around the fibular head. bophlebitis of the deep veins of the leg (Figure 13.96). The test is performed by passively dorsiflexing the pa- tient’s foot with the knee extended. Pain in the calf is considered a positive Homan’s sign. Swelling, tender- ness, and warmth of the lower leg are also indicative of deep vein thrombosis. Tarsal Posterior tibial tunnel nerve Medial plantar Flexor nerve retinaculum Abductor hallucis Calcaneal muscle branches Lateral plantar nerve Quadratus plantae muscle Figure 13.89 The anatomy of the tarsal tunnel. The posterior tibial nerve passes underneath the flexor retinaculum and is subject to compression at this site.
422 The Ankle and Foot Chapter 13 Fanning Dorsiflexion Buerger’s Test This test is used to determine if there is arterial in- sufficiency in the leg. The patient is laid as flat as possible in supine. Support and lift the lower leg to an angle of 30 degrees. Hold the leg in this position for 2 minutes. Observe the color of the leg and foot. If the leg or foot is pale, there is reduced arterial blood flow. Next, have the patient sit up and allow their foot and leg to dangle over the edge of the table. If the toes and then the foot turn bright red (termed dependent rubor), there is arterial insufficiency in the leg. Tests for Alignment Dorsiflexion Deviations from normal alignment of the forefoot and hindfoot are common. Abnormal weight-bearing Figure 13.90 Babinski’s response is found in patients with upper forces due to these deviations cause pain and disorders motor neuron disease. such as tendinitis, stress fractures, corns, and other pressure problems. Frequently, abnormal alignment patterns, which are initially flexible, become rigid. The most common abnormality is a hindfoot valgus with compensatory forefoot varus, which is known as pes planus or a flat foot. Test for Flexible versus Rigid Flat Foot A curved medial longitudinal arch should normally be observed when the patient is both sitting and standing. If a medial longitudinal arch is noted in the seated position and disappears when the patient stands, this is referred as a flexible flat foot (Figure 13.97). If the patient does not have a visible arch in the seated position, this is known as a rigid flat foot (Figure 13.98). Figure 13.91 Oppenheim’s sign is found in patients with upper Test for Medial Longitudinal Arch motor neuron disease. Feiss’ Line The patient is in the supine position. Palpate and then mark the medial malleolus and the first metatarsopha- langeal joint. Imagine a line between the two struc- tures. Then locate the navicular tubercle and note where it is situated in relation to the line. Have the pa- tient weight-bear and reassess the location of the nav- icular tubercle. Divide the space between the line and
Chapter 13 The Ankle and Foot 423 No foot movement when tendon is ruptured Figure 13.92 The Thompson test for continuity of the Achilles tendon. Absence of plantar flexion on squeezing the calf indicates a ruptured Achilles tendon (or a fused ankle joint). Anterior talofibular ligament Calcaneofibular ligament Figure 13.93 Testing anterior drawer of the ankle. Excessive anterior movement of the foot indicates a tear of the anterior talofibular ligament.
424 The Ankle and Foot Chapter 13 Calcaneofibular Tear of ligament Calcaneofibular ligament Figure 13.94 Inversion stress test of the ankle. Excessive foot inversion indicates a tear of the calcaneofibular ligament. Morton's neuroma Figure 13.95 Morton’s neuromas develop in the second or third Figure 13.96 Homan’s sign is used to test for deep vein web space where the interdigital nerves branch. They may be thrombophlebitis. This stretching maneuver places the deep painful to palpation and metatarsal compression. veins of the calf on stretch.
Chapter 13 The Ankle and Foot 425 Figure 13.98 Rigid flat feet remain flat in any position. Figure 13.97 Flexible flat feet are only visible in the standing foot crossed over the posterior aspect of the knee on position. The normal plantar arch is noted in the seated position. the test leg. A vertical line is drawn along the lower third of the leg in the midline (Figure 13.99). Another vertical line is drawn in the midline of the Achilles in- sertion into the calcaneus. While the subtalar joint is held in neutral position (described earlier in the chap- ter), the angle formed by the two lines is measured. An angle of approximately 0–10 degrees is normal. If the angle is less than 0 degree, the patient has a hindfoot varus. the floor into thirds. The navicular tubercle should Test for Forefoot–Heel Alignment normally lie close to the line. If it is lower, the degree of pes planus is determined by its relative location The patient is placed in the supine position with the and is graded as first-degree pes planus (1/3 of the way feet extending off the end of the table. While main- from the line), second degree if it is 2/3’s of the way, taining the subtalar joint in neutral, take the forefoot and third degree if the navicular tubercle is on the with the other hand and maximally pronate the fore- floor (see Figure 2.19). foot (Figure 13.100). Now imagine a plane that ex- tends through the heads of the second to the fourth Test for Leg–Heel Alignment metatarsals. This plane should be perpendicular to the vertical axis of the calcaneus. If the medial side of This test is used to determine whether a hindfoot val- the foot is elevated, the patient has a forefoot varus. gus or varus condition exists. The patient is placed If the lateral side of the foot is elevated, the patient prone with the test leg extended and the opposite has a forefoot valgus.
Plane 1 Plane 1 >10° Plane 2 Plane 2 <0° Varus Valgus Figure 13.99 Testing for hindfoot varus and valgus. Four lines are drawn on the posterior aspect of the leg, two lines in the distal third of the leg in the midline, and two lines at the attachment of the Achilles tendon to the heel. (a) Here, plane 1 and plane 2 form an angle that is more than 10 degrees and the patient has hindfoot varus. (b) The angle formed in between the two planes is less than 0 degree and hence the patient has hindfoot valgus. Plane A 90° Plane B Figure 13.100 Testing for forefoot varus and valgus. With the subtalar joint in neutral position, an imaginary plane (b) passing through the heads of the metatarsals should be perpendicular to the vertical (a) axis. If the medial side of the foot is elevated, there is a forefoot varus deformity. If the lateral side of the foot is elevated, the patient has forefoot valgus deformity.
Chapter 13 The Ankle and Foot 427 Test for Tibial Torsion By age 3, the tibia is externally rotated 15 degrees. At birth, the tibia is internally rotated approximately 30 degrees. Excessive toeing-in may be caused by internal tibial torsion (Figure 13.101). With the patient sitting on the edge of the table, the examiner imagines a plane that is perpendicular to the tibia and extends through the tibial tubercle. A plane extending through the an- kle mortise should be externally rotated 15 degrees (Figure 13.102). If this plane is externally rotated less than 13 degrees, the patient has internal tibial torsion (Figure 13.103). If the plane is rotated more than 18 degrees, the patient has external tibial torsion. Figure 13.101 Toeing-in may be caused by internal tibial torsion. Posterior Plane through ankle mortise 15˚ Medial Lateral Tibia Anterior Figure 13.102 A plane extending through the ankle mortise should be externally rotated 15 degrees.
Posterior Plane through ankle mortise 5˚ Medial Lateral Tibia Anterior Figure 13.103 An internal tibial torsion, the ankle mortise faces medially less than 13 degrees. Radiological Radiological views are presented in Figures 13.104 through 13.107. G = Hindfoot H = Midfoot I = Forefoot A = Ankle C = Calcaneus Cu = Cuboid T = Talus N = Navicular S = Spur MT = Metatarsal Hallux valgus Figure 13.104 Anteroposterior view of the foot.
Chapter 13 The Ankle and Foot 429 Figure 13.105 Lateral view of the ankle and foot. Figure 13.106 Oblique view of the foot.
430 The Ankle and Foot Chapter 13 Figure 13.107 View of the ankle mortise (*).
Chapter 13 The Ankle and Foot 431 Paradigm for an overuse syndrome of the foot and ankle A 22-year-old female jogger presents with a complaint of pain on weight-bearing at the medial aspect of the right heel. She has been “training” for a marathon for the past 2 months and has increased her running from an average of 5 miles/day to 10 miles/day, 6 days/week. There has been no evidence of swelling about the ankle and foot. She describes a pattern of stiffness on arising in the morning which lessens within 15 minutes of walking. The pain, however, returns and increases in proportion to her daily activities. She gives no history of similar symptoms with her prior training for distance runs. She recently began running in lightweight racing shoes. On physical exam, the patient has full range of motion in all joints of the lower extremities. She has a well-formed longitudinal arch which decreases in height on weight-bearing. There is a moderate amount of subtalar pronation on unilateral stance and tenderness to palpation along the distal medial aspect of the right calcaneus. Tenderness is also produced with passive dorsiflexion of the foot and toes. Tinel’s sign is negative on percussion over the tarsal tunnel. She has multiple subungual hematomas. X-rays are reported to show no abnormalities. This is a paradigm for chronic overuse syndrome of plantar fascia because: No history of acute trauma A significant increase in demand over a relatively short period Pain on initiation of activities which quickly abates Return of symptoms in proportion to activities SAMPLE EXAMINATION History: 20-year-old female Physical Examination Clues: (1) Female, training for a marathon for 1 month indicating possibility of greater presents with a 2-week history of right musculoskeletal soft tissue laxity, (2) leg pain, aggravated by running. There Excessive musculoskeletal flexibility, has been no history of prior trauma. She indicating potential for greater demand recently began using lighter weight to be placed on dynamic stabilizers “racing shoes.” (muscles), (3) Posteromedial tibial tenderness, indicating a specific Physical Examination: Well-developed anatomic region and structure at the site slender female, ambulating comfortably of injury. The subtalar joint is stabilized in her usual well-fitting running shoes. statically by the spring ligament and There is tenderness on palpation along dynamically by the posterior tibialis the anteromedial border of the right muscle and tendon. Increased tibia. Muscle testing was 5/5; however, musculoskeletal laxity results in reduced patient tended to invert with plantar contribution to joint stability by static flexion. Mobility testing of the calcaneus stabilizers (ligaments), placing greater was increased in eversion. Anterior and demand on the dynamic stabilizers posterior drawer tests were negative. (muscles). In this case, the relative The patient demonstrates generalized increased laxity in the calcaneonavicular hyperextensibility at the knee and elbow, (spring ligament) will expose the with flexible pronation of the subtalar posterior tibialis to greater demand and joint on weight-bearing. Feiss’ line potential overuse failure. reveals a grade 2 pes planus. Presumptive Diagnosis: Posterior tibial tendonitis (shin splints).
CHAPTER 14 Gait The Lower Extremity acted by a muscular effort. Otherwise, the body will fall to the unsupported side (Figure 11.1). This section is not intended as a definitive treatise on the lower extremity, but rather it is to serve as the At the base of each pillar is the foot and ankle com- introduction to the lower-extremity physical exami- plex. The ankle and foot are structures uniquely de- nation, based on the principles presented in the intro- signed to tolerate a lifetime of significant cyclic loads ductory chapters of this book. This section reviews of varying rates while traversing any terrain. The key the more salient aspects of lower-extremity structure, to the successful functioning of these structures lies in function, and physical examination. Its intended ob- the extraordinary stability of the ankle, and the im- jective is to present the entire lower extremity as a pact attenuation and surface accommodation proper- whole. With this perspective, it is hoped that the ex- ties of the foot. The stability of the ankle may well aminer will become sensitized to the anatomical rela- explain its ability to resist the inevitable mechanical tionships that place an individual at risk of injury. Its degeneration expected in such a small articulation ex- purpose is to provide the examiner (and patient) with posed to such repetitive stress. The ankle structure the means for identifying, addressing, and avoiding is that of a keystone recessed into a rigid mortise causes of injury. (Figure 14.1). It is because of this extraordinary sta- bility, unless lost secondary to injury, that the an- The linkage and interdependence of articulations kle does not demonstrate the normal osteoarthritic and structures of the lower extremity, back, and pelvis changes with aging found in all other synovial joints. must be considered when evaluating and diagnosing This is even more impressive in light of the signifi- complaints of the lower extremity. cant loads that are being supported by the relatively small articular surface of the ankle joint (approxi- The lower extremities are pillars on which the body mately 40% that of the hip or knee) during weight- is supported. They permit and facilitate movement of bearing activities such as running. However, this sta- the body in space. They accomplish this task through bility carries with it an inability to accommodate ro- a series of linkages: the pelvis, hip, knee, ankle, and tational and angular stresses that would otherwise foot. Each of these linkages has a unique shape and ultimately lead to compromise of the ankle joint if function. Together they permit the lower extremity they were not first buffered by the foot below. The to efficiently accommodate varying terrains and con- suppleness of the foot articulations, that is, subtalar tours. pronation, accommodates varying surface topogra- phies to reduce these torques. The arches attenuate the The body’s center of gravity is located in the mid- repetitive stress of the weight-bearing loads that occur line, 1 cm anterior to the first sacral vertebra. During during locomotion. This system of complementary bipedal stance, the body’s weight is supported equally functions forces recognition of the ankle and foot not over each lower limb, creating a downward compres- as isolated regions, but rather as a single ankle–foot sion load on the joints of the lower extremities. Dur- mechanism. ing the unilateral support phase of gait, however, the body’s center of gravity is medial to the supporting The talus holds the key to the intimate structural limb. Therefore, during unilateral support, the hip, and mechanical relationship that exists between the knee and ankle of the supporting limb will experi- ankle and foot. As the part of the ankle that is held ence not only a compression load, but also a varus within a rigid mortise, the talus is limited to flexion– (inward) rotational destabilizing force referred to as extension motion. As a part of the foot, the talus must a moment. This destabilizing force must be counter-
Chapter 14 Gait 433 Tibia Fibula Talus Tibial plafond Calcaneus Talus Figure 14.1 The talus is a rectangular bone keystoned within a rigid mortise formed by the medial malleolar process of the tibia, the tibial plafond, and the lateral malleolus. accommodate medial rotation. This medial rotation Figure 14.2 Pronation (plantar medial rotation) of the talus is termed pronation. Efficient locomotion requires the results in internal rotation of the leg and supination torque of simultaneous occurrence of both talar functions. The the middle of the foot. lower extremity must accommodate the internal rota- tional torque that subtalar pronation creates. It must unchecked, this situation will create excessive load- transmit this force proximally through the rigid an- ing at several points along the lower extremity: kle mortise during gait. This torque is most efficiently 1. valgus and medial rotation of the first accommodated by a complex combination of knee flexion and internal rotation of the entire lower ex- metatarsophalangeal joint (leading to hallux tremity through the ball-and-socket mechanism of the valgus and bunion formation); hip joint. Such a compensatory motion has the poten- 2. excessive stretching and strain of the tibialis tial to place excessive stresses at the structures proxi- posterior muscle and tendon (shin splints); mal to the ankle and foot, such as the patellofemoral 3. increased internal rotation of the knee, resulting articulation (Figure 14.2). in an apparent increased “Q angle,” lateral patellar subluxation stress, increased medial Closer inspection of the ankle and foot shows that retinacular tension, increased lateral compression the body of the talus is supported by the calcaneus, loading of the patellofemoral facet, and increased and these bones diverge at 30 degrees in both the tension in the popliteus muscle; and coronal and sagittal planes. The result is that the head 4. increased internal rotation of the hip, increased of the talus is supported by soft tissues (the talocal- tension/stretch loading of the external rotators of caneonavicular or “spring” ligament, and the poste- the hip (producing piriformis syndrome and rior tibialis tendon). As such, in the presence of soft- sciatic nerve irritation [sciatica]). tissue or generalized ligamentous laxity or muscular As discussed earlier, situations that create excessive weakness, the head of the talus can experience exces- repetitive loading may lead to breakdown of tissues sive plantar flexion. This excess movement will force and structure (the “vicious cycle of injury”). Each of the calcaneus laterally, with an eversion of the hind- the pathological conditions listed above is a poten- foot. During weight bearing, this displacement will tial consequence of insufficient subtalar support and force internal rotation of the entire lower extremity resultant excessive pronation, which has produced a about the ball-and-socket articulation of the hip. If biological system failure.
434 Gait Chapter 14 There are several clinical examples of biological creates and increases (apparent) valgus angulation of system failure secondary to excessive subtalar prona- the knee joint. This valgus in turn creates a greater lat- tion. The swelling of the medial capsule and resultant eral displacement vector on the patellofemoral mecha- accumulation of hard and soft tissues about the first nism with quadriceps contraction (Figure 14.4). This metatarsophalangeal joint of the foot, known as a occurs because the direction of the quadriceps pull bunion, is the direct consequence of excessive loading attempts to resolve the Q angle to a straight line stresses at the medial aspect of the first metatarsopha- of 180 degrees. This increased laterally directed vec- langeal joint (Figure 14.3). The unsuccessful attempt tor force on the patella has a direct consequence on of the tibialis posterior muscle–tendon to support the the longevity and attrition of patellar articular carti- subtalar arch results in excessive stretching and stress- lage. It also creates excessive tension within the me- ing of that muscle–tendon unit. This explains the ap- dial peripatellar soft tissues. Both situations can result pearance of pain in the posteromedial aspect of the in the painful conditions of patellar chondromalacia leg and ankle (shin splints) at the location of the mus- and plica syndrome. Attempts to resist or correct this cle’s origin, in an insufficiently conditioned runner. internal rotational torque by muscular effort can be The hip, as a ball-and-socket articulation, provides created at several points along the lower extremity. little resistance to inward rotational torques. As such, As already mentioned, one mechanism is contraction inward rotation of the entire lower extremity forces of the tibialis posterior muscle of the leg. This at- the axis of the knee to rotate medially. This inward tempts to counteract talar pronation by supporting rotation of the knee will accentuate the valgus align- the body of the talus against plantar flexion. A sec- ment of the knee as it flexes. This combination of ond mechanism is that of the popliteus muscle of medial or internal rotation and flexion of the knee the posterolateral aspect of the knee, attempting to Q angle Figure 14.3 Hindfoot pronation may result in valgus stressing of Figure 14.4 The angle formed between the line of the the first metatarsophalangeal joint. Chronic valgus stress can quadriceps musculature and the patellar tendon is termed the Q result in the formation of a swelling (bunion) and angulation of angle. Contraction of the quadriceps mechanism attempts to this joint (hallux valgus deformity). resolve the Q angle to 180 degrees. Therefore, the greater the Q angle, the larger the resultant lateral displacement vector force when quadriceps contraction occurs.
Chapter 14 Gait 435 internally rotate the leg. A third mechanism occurs What Is Normal Gait? at the buttocks, posterior to the hip joint. Here, the piriformis and external rotator muscles of the hip are Normal gait is the efficient forward movement of well positioned to exert an external rotation effort on the body. Efficient means that energy expenditure is the lower extremity. minimized. Any deviation from this minimum can be termed an abnormal gait pattern. There are varying However, if these muscles, one or all, are incapable degrees of abnormal. Normal gait therefore can be de- of meeting the demand being made, the result will fined as the forward locomotion of the body during be breakdown, inflammatory reaction, and pain, with which the body’s center of gravity describes a sinu- the consequences of initiating a vicious cycle of injury. soidal curve of minimum amplitude in both the Y and This inability to meet the demand required might be Z axes (Figure 14.5). An increase in the displacement due to a general lack of proper conditioning (relative of the body’s center of gravity from this path requires overload), or it may be due to a truly excessive load increased energy expenditure, hence creating an in- being applied (absolute overload). In either event, in- creased metabolic demand. The result is decreased jury will result. efficiency of locomotion and increased fatigue. This is why vaulting over a fused knee and leaning toward At the knee, a breakdown of the popliteus tendon one side due to abductor weakness are patterns of ab- can present as posterolateral knee pain. The symp- normal gait. They are each characterized by increased toms resulting from hip external rotator weakness displacement of the center of gravity. In vaulting, will present as buttock pain. At the hip, these injuries there is excessive vertical displacement of the center can also affect adjacent but otherwise uninvolved tis- of gravity, whereas in the lateral list of the Trendelen- sues such as the sciatic nerve. The sciatic nerve lies in burg gait, there is increased side-to-side translation of close proximity to and, in 15% of people, penetrates the body’s center of gravity. the external rotator muscles. Therefore, inflammation and stiffness of the external rotator muscles can cre- Gait is a cyclical activity that requires repetitive ate tethering of the sciatic nerve. This in turn can positioning of the lower extremities. The gait cycle masquerade as an injury to the sciatic nerve or as a is divided into two phases: stance and swing (Figure referral of symptoms of a more proximal injury (i.e., 14.6). The stance phase is further subdivided into five spinal trauma or intervertebral disk herniation). discrete periods: 1. Heel-strike It is hoped that this brief discourse on the interre- 2. Foot flat lationships that exist within the lower extremity will 3. Mid stance prevent the examiner from approaching the lower ex- 4. Heel-off tremity in a fragmentary fashion. It cannot be empha- 5. Toe-off sized enough that the body, and lower extremity in particular, is a complex system of interdependent and The stance phase occupies 60% of the time during interacting components. This concept is fundamental one cycle of normal gait. The remaining 40% of the to the process of accurate diagnosis. gait cycle comprises the swing phase, which is divided into three periods: What Is Gait? 1. Initial swing (acceleration) 2. Mid swing Gait is the forward movement of the erect body, us- 3. Terminal swing (deceleration) ing the lower extremities for propulsion. Movement of any mass requires the expenditure of energy. The The period when both feet are in contact with the amount of energy required is a function of the amount ground is called double support. The step length is the of mass to be moved and the amount of displacement distance between the left heel contact and the right of that mass’s center of gravity along the X (anterior– heel contact. The stride length is the distance between posterior), Y (horizontal), and Z (vertical) axes from one left heel-strike and the next left heel-strike. its point of origin. The body’s center of gravity is lo- cated in the midline, 1 cm anterior to S1 (first sacral There are six determinants of gait. These postural segment) when the patient is erect with the feet placed accommodations contribute to the efficiency of am- a few inches apart and the arms at the side. bulation by reducing energy expenditure. The first five reduce the vertical displacement of the body. The sixth reduces lateral displacement of the body: 1. Pelvic tilt – about 5 degrees on the swing side
436 Gait Chapter 14 Right Left Up Down Figure 14.5 During normal gait, the body’s center of gravity describes a curve of minimum amplitude in the vertical and horizontal axes. Stance Swing phase (60%) phase (40%) Heel Foot Mid Heel Toe Mid Heel contact flat stance off off swing contact Figure 14.6 The subdivisions of the stance and swing phases of gait.
Chapter 14 Gait 437 2. Pelvic rotation – about 8 degrees total on the a flexion moment. For example, at heel-strike, the swing side body’s center of gravity is behind the axis of the knee. The moment arm acting at the knee is posterior to 3. Knee flexion – to about 20 degrees in early stance the knee joint’s center of rotation. The resultant mo- phase ment of the body weight acting at the knee will close (reduce the angle) the knee joint, causing the knee 4. Plantar flexion – to about 15 degrees in early to flex spontaneously. Therefore, the moment acting stance phase at the knee at heel-strike until midstance is a flexion moment (Figure 14.8). 5. Plantar flexion – to about 20 degrees in late stance phase Similarly, at heel-strike, the body’s center of gravity is anterior to the hip joint’s center of rotation. There- 6. Narrow walking base – due to normal knee fore, the moment arm with which gravity acts at the valgus and foot placement. hip during heel-strike will cause spontaneous closing During each cycle of gait, gravity is a downward (flexion) of the thigh on the torso. Hence, gravity act- ing on the hip at heel-strike creates a flexion moment. force constantly acting at the body’s center of grav- ity. As such, it causes rotation to occur at each of When the moment acting on the joint creates an the joints of the lower extremity. This rotational de- opening (increase) in joint angle, it is termed an ex- formity is called a moment. A moment’s magnitude tension moment. An example of an extension moment is a function of the size of the force acting and the is the quadriceps contracting. The quadriceps pulling perpendicular distance between the center of gravity through the patellar tendon acts on a moment arm and the axis about which the force of gravity is acting that is anterior to the axis of knee motion. It therefore (the moment arm) (Figure 14.7). When the moment opens (increases) the angle of the knee joint. Hence, arm is the Z (vertical) axis, the resulting moments are termed varus, for rotation toward the midline, or val- gus, for rotation away from the midline. When the moment results in the closing of a joint, it is termed b Knee tends to flex G Quadriceps contract and resist knee flexion Body weight Left heel strike Figure 14.7 The moment of varus (inward) rotation at the hip is Figure 14.8 At heel-strike, the body’s center of gravity is the product of the force of gravity, G, acting at the body’s posterior to the axis of the knee joint. There will be a center of gravity, and the perpendicular distance, b, from the spontaneous tendency for the knee to flex. This is called a body’s center to the hip: moment of the hip = G × b. flexion moment. This flexion moment is resisted by the active contraction of the knee extensors (quadriceps).
438 Gait Chapter 14 the quadriceps extends the knee by virtue of the ex- Hip tension moment it creates at the knee when the muscle abductors contracts. Body weight The quadriceps extension moment serves to coun- teract the spontaneous flexion of the knee that occurs Figure 14.9 A cane held in the contralateral hand assists the hip from heel-strike to midstance due to the posterior po- abductor muscles in resisting the gravitational moment that sition of the body’s center of gravity relative to the pulls the body toward the unsupported side during swing phase. axis of the knee. the knee in extension is an effective means of pro- By understanding the concept of moment, an anal- tecting a polio victim with quadriceps paralysis from ysis can be made for each joint throughout the gait sudden spontaneous knee flexion and falling during cycle. With such an analysis of the relative positions of gait. the body’s center of gravity and the joint in question, it is theoretically possible to predict when a muscular The Examination of Abnormal Gait structure must be active and where it should be po- sitioned for optimal effect so as to maintain an equi- As stated above, the evaluation of abnormal gait re- librium state of balance (erect posture) during gait. In quires a working knowledge of normal biomechanics. other words, the muscles function to counteract the Abnormalities occur as a result of pain, weakness, affect of gravity on the joints. abnormal range of motion, and leg length discrep- ancy. These factors can occur separately or together. Conversely, an inability to maintain this equilib- They are closely interrelated. For example, weakness rium state can be analyzed so as to understand what of a muscle group can result in a painful joint, which structures are malfunctioning or malpositioned. Such would then lose normal range of motion. When iso- an analysis is fundamental and crucial to the accurate lated, however, pain, weakness, abnormal range of diagnosis and treatment of gait abnormalities. motion, and leg length discrepancy within a particu- lar anatomical region result in a characteristic gait ab- For example, limping due to hip disease can be an- normality. Some of these abnormalities were referred alyzed into the gravitational moment acting to rotate to in prior chapters. the torso inwardly during unilateral stance and the counterbalancing valgus moment created by the ab- Gait disorders due to central nervous system disease ductor muscles (in particular, the gluteus medius). An or injury, such as spastic, ataxic, or parkinsonian gait, example of a valgus moment is the action of the glu- teus medius acting on the hip at unilateral midstance phase of gait. At this point in the gait cycle, the ab- ductor muscle will contract. Its force vector will pull the pelvis in a valgus (outward) rotation. This will serve to counteract the varus (inward) moment cre- ated by the force of gravity. The abductor, however, has a shorter moment arm than does gravity with which to work. Therefore, the abductors must exert a proportionately greater force than that of gravity in order to balance the body across the hip joint. In fact, since the abductor moment arm (a) is about one-half that of the body’s (b), the abductor force (A) must be twice that of the weight of the body (B)—the action of gravity pulling at the body’s center of gravity. This can be expressed as an equilibrium state equation: A × a = B × b, knowing a = b, then A = 2B. With such an analysis of the hip, it is easy to predict the use- fulness of a cane held in the opposite hand as a means to assist weak abductor musculature. The cane will prevent the inward rotation of the torso toward the unsupported side caused by gravity and insufficiently resisted by weak abductor muscles (Figure 14.9). Sim- ilarly, analysis of the knee will explain how bracing
Chapter 14 Gait 439 are not described here, as they are beyond the scope of this text. The key to observing abnormal gait is the ability to recognize symmetry of movement. You should ob- serve the patient walking for some distance. Some- times it is necessary to watch the patient walk down a long hallway or outdoors. Subtle abnormalities will not be evident inside the examining room. A patient will walk differently when he or she is “performing” for you. If it is possible, try to observe the patient when he or she is not aware of being watched. The foot and ankle, knee, and hip should be ob- served separately for fluidity and degree of motion. The examples that follow are meant to illustrate how pain, weakness, abnormal range of motion, and leg length discrepancy affect the normal symmetry of mo- tion that occurs at the foot and ankle, knee, and hip (Table 14.1). Foot and Ankle Figure 14.10 An antalgic gait due to pain in the great toe or foot will result in a shortened stance phase. Antalgic Gait during swing-through will cause the toes to contact The patient with pain in the foot or ankle will make the ground. To avoid this from happening, the patient every effort to avoid weight bearing on the painful will flex the hip and knee in an exaggerated fashion as part. For example, if the first metatarsophalangeal if he or she was trying to climb a stair so that the foot joint is painful due to gout, the patient will not want will clear the ground during swing-through (Figure to extend that joint. This results in a flat-footed push- 14.11). This is called a steppage gait. off. The weight is maintained posteriorly on the foot. The patient will also spend less time in the stance Eccentric dorsiflexion of the foot also occurs as phase on the painful foot, causing an asymmetrical the body weight is transferred from the heel to the cadence (Figure 14.10). forefoot following heel-strike. Weakness of the foot dorsiflexors results in a slapping of the foot against Weakness the ground following heel-strike, known as foot slap (Figure 14.12). Weakness of the dorsiflexors of the foot due to per- oneal nerve injury, for example, will result in a drop foot or steppage gait. Inability to dorsiflex the foot Table 14.1 Factors affecting gait. Observable effect on gait Cause of abnormal gait Pain Decreased duration of stance phase. Avoidance of ground contact Weakness with the painful part. Abnormal range of motion and leg length Increased or decreased motion in the affected joint at the time of discrepancy the gait cycle when muscle normally contracts. Compensatory motion usually occurs in other joints to prevent falling (by adjusting the location of the center of gravity) and to allow for limb clearance. Compensatory movement in other joints to allow for weight bearing, limb clearance, or relocation of the center of gravity over the weight-bearing limb.
440 Gait Chapter 14 Tibialis Abnormal Range of Motion anterior If the ankle is unable to dorsiflex, as in an equinus deformity (Figure 14.13), the patient lands with each step on the metatarsal heads. This is known as pri- mary toe-strike (Figure 14.14). Due to the primary toe-strike, the line of force is far in front of the knee and this causes a hyperextension moment at the knee. Therefore, the patient may develop genu recurvatum as a result of an equinus deformity. As in the case of foot drop, the patient will again have difficulty pre- venting the toes from hitting the ground during swing phase. The patient will therefore have to elevate the foot in the air by either increasing knee and hip flex- ion as in a steppage gait, circumducting the leg at the hip (Figure 14.15), or hiking the extremity up from the hip (Figure 14.16). These maneuvers effectively shorten the leg and allow for toe clearance during swing-through. Figure 14.11 Weakness of dorsiflexion results in a steppage gait Knee with increased hip and knee flexion to allow for clearance of the toe during swing-through. Antalgic Gait The patient with a painful knee will walk with less weight on the painful side. Less time will also be spent on that side. The patient will attempt to maintain the Tibialis anterior Figure 14.12 After heel-strike, with weakness of foot Figure 14.13 A talipes equinus deformity of the foot. dorsiflexion, the patient’s forefoot slaps against the ground. This is called foot slap.
Chapter 14 Gait 441 Primary toe strike Figure 14.14 With a talipes equinus deformity of the foot, the Figure 14.16 The patient may also clear the ground with the patient contacts the ground with the ball of the foot instead of relatively lengthened extremity due to an equinus deformity by the heel. This is called primary toe-strike. hip hiking. Figure 14.15 An equinus deformity of the foot will result in knee in flexion if there is an effusion. If the knee is relative lengthening of the extremity and the patient must kept in extension, the patient will have to circumduct circumduct the hip in order to clear the ground. at the hip or hike the lower extremity upward from the hip in order to clear the ground during swing- through. Heel-strike is painful and will be avoided. Weakness Quadriceps weakness is common in patients with po- liomyelitis. The gait abnormality that results is hy- perextension of the knee following heel-strike. The patient has to try to maintain the weight in front of the knee to create an extension moment. This is ef- fected by throwing the trunk forward following heel- strike. The patient may also attempt to extend the knee by pushing the thigh backward following heel contact (Figure 14.17). Weakness of the quadriceps frequently results in overstretching of the posterior capsule of the knee joint and this causes genu recur- vatum. Abnormal Range of Motion Loss of full knee extension will result in a function- ally shorter extremity. The patient will have to ele- vate the body on the normal side as that leg tries to swing-through while he or she supports the weight
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