The articulation between the talus and the calcaneus

What is missing?

1. Case hx

2. Observations

3.The four T'S

4. Functional tests

5. Special tests

6. Muscle tests
7. Palpation

1. Case hx

2. Observations

3. The four T'S

4. RULE OUTS

5. Functional tests

6. Special tests

7. Muscle tests
8. Palpation

Rule out: lumbar spine

How

›Client → Active flexion, extension, side bending and rotation.

›Follow with overpressure on all the movements EXCEPT for extension

Rule out knee

Position: supine

Active ROM

›Flexion→pain free = apply overpressure

›Extension→pain free = apply overpressure

Position: hook lying position (knee flexed to 90^ο)  

›therapist passively glides sup. tibiofibular jt for mvmt

if pain free

›palpate sup. tibiofibular joint for mvmt

›actively or passively dorsiflex and plantarflex talocrural joint

›sup. tib/fib jt moves sup/post with dorsiflexion and ant/inf with plantarflexion (with passive relaxed)

Movements required

Toe Flexion and Extension

If pain free = therapist will apply overpressure

Therapist should ask client if any pain is felt after each mvmt while noting funcitonal ROM.

›if pain: ask location of pain, if they feel it in the muscle belly or joint.

›Normal ROM^ο: 20^ο

›Minimal ROM^ο for normal ambulation: 10^ο

Injury to prime mover: tibialis anterior and accessory dorsiflexors ie: extensor hallucis longus, extensor digitorum longus

Posterior structures being stretched:  achilles tendon, gastrocnemius, soleus, posterior joint capsule and ligaments

Intra/extracapsullar swelling

Normal ROM = 50^o

Injury to prime movers:  gastrocnemius, soleus

Injury to accessory movers:  tibialis posterior, peroneus longus/brevis

Anterior structures being stretched:  anterior capsule, anterior talofibular ligament, anterior fibers of the deltoid ligament, and dorsiflexors

Intra/extracapsular swelling

Normal ROM = 5^o

*look for symmetry BL*

Injury to prime movers: Tibialis anterior, tibialis posterior

Injury to accessory movers: Flexor hallucis longus, flexor digitorum longus, extensor hallucis longus

Lateral structures being stretched:  anterior talofibular ligament, calcaneofibular ligament, peroneal muscles

Swelling

Normal ROM = 5^o

*varies so look for symmetry BL*

Injury to prime movers:  peroneus longus/brevis

Injury to accessory movers:  Extensor digitorum longus

medial structures being stretched:  tib. ant/post

swelling

›Injury to posterior structures being stretched 

›tightness of posterior structures

›swelling

*posterior structures: soleus, gastrocnemius, achilles tendon*

Normal end feel

›Tissue stretch

›Bony end-feel (talus in contact with tibia-fibula mortis)

›Injury to anterior structures being stretched 

›Injury to anterior capsule

›Injury to prime movers of dorsiflexion or anterior talofibular ligament

Testing toes = separate great toe

*great toe has its own muscle supply*

Dorsiflexion

Prime mover:  tibialis anterior

Nerve root: L4

Plantar flexion

Prime mover: Triceps surae

Nerve root: S1 and S2

Inversion

Prime mover:  tibialis anterior/posterior

Nerve root: L4

Eversion

Prime mover:  Peroneus longus/brevis

Nerve root: S1

Three talar tilts

Ligaments tested

› anterior talofibular ligament

› calcaneofibular ligament

› deltoid ligament

Passive plantar flexion and inversion

›Positive sign = pain felt along ligament (palpable in sinus tarsi), at attachments or excessive ROM if ligament is ruptured

*always put the foot into neutral between each test*

Foot from neutral to passive  inversion

›Positive sign = pain felt along ligament, at attachments (calcaneus to fibula) or excessive ROM if ligament is ruptured

*rupture of the calcaneofibular lig only happens of the ATFL is already ruptured*

*always put the foot into neutral between each test*

Foot from neutral to eversion passively

*anterior fibers: plantar flexion + eversion*

*posterior fibers:  dorsiflexion + eversion*

›Positive sign = pain felt along ligament, at attachments (@ med. malleolus).

*excessive eversion can cause micro-tearing of ligament but usually medial malleolus is avulsed*

*always put the foot into neutral between each test*

anterior drawer tests the anterior talofibular ligament

*ATFL is also tested with the three talar tilt*

What do you to during the anterior drawer test?

›Grab calcaneus with one hand, client's sole resting on forearm, stabilize above ankle joint

›While grabbing calcaneus, tract ankle slightly (distract down)

›Then draw foot anteriorly (forward)

Wedge tests integrity of inferior tibiofibular ligament

›Positive sign = pain at the region of the inferior tibiofibular ligament

›Client foot in neutral

›Therapist pushes talus superiorly between tibia and fibula forcing them apart and stressing anterior inferior tibiofibular lig

›if no pain = tap once on the heel with the base of your hand

› Client prone

› Therapist squeezes calf muscle

Positive sign = no plantar flexion

Homan's sign tests for deep vein thrombosis

Case hx:

› pain felt deep in calf or popliteal fossa of the knee

› onset of pain after long period of immobilization

› constant aching worsened with activity (walking, climbing stairs)

› client report being able to walk long distance then pain in calf appears and grows until they rest and pain dissipates

› pain reoccuring with activity

*test could be inconclusive but can reinforce suspicions*

›client prone with knee flexed at 90^o

›dorsiflex foot and slowly extend knee

*this ↑ pressure in deep posterior compartment*

Positive sign = excruciating pain

If no positive sign
› palpate or squeeze the calf after knee extension

*some say palpating may cause thrombus to loosen and cause stroke*

*DVT is an ABSOLUTE CI for RMT*

Squeeze tests for presence of a neuroma between 3^rd and 4^th metatarsal heads (sometimes 2^nd and 3^rd)

*neuroma: tumour or new growth of nerve cells*

*Commonly called Morton's Neuroma*

›Encircle both hands around metatarsal heads and squeeze them together

Positive sign = sharp pain between the 3^rd and 4^th or 2^nd and 3^rd metatarsals

›Gastrocnemius and Soleus

›Client's knee is extended, in prone

How do you perform plantar flexors test? What do you note?

›Client prone, knee extended

›Instruct client to "raise your heel" (plantar flexion) and apply resistance

›View knees laterally

*weak soleus : dorsiflexion with knee flexion  (in standing position)*

→Soleus strength compensates for weak quads, hyperextending the knee

*weak gastrocnemius: tendency to hyperextend the knee*

→gastrocnemius crosses the knee and plays a role in knee flexion = prevents knee hyperextension

› Client in high or long sitting

› Therapist resists client's eversion of foot with plantar flexion of the ankle

Tibialis anterior

›client long or high sitting

›resist dorsiflexion of ankle and inversion of foot

* place foot in inversion and resist client's attempt at ankle dorsiflexion since primary action is dorsiflexion*

Tibialis posterior

› client long/high sitting

› resist plantar flexion of ankle and inversion of foot

*place foot in inversion and resist client's plantar flexion since primary action is plantar flexion*

› Extensor digitorum longus/brevis

› extensor hallucis longus/brevis

› flexor digitorum longus/brevis

› flexor hallucis longus/brevis

› Myotomes

› Dermatomes

› Deep tendon reflex (S1)

› Proprioception

How do you perform a neurological testing?

› client high seated, legs dangling

› put achilles tendon on slight stretch (passively dorsiflex ankle)

› tap achilles tendon with flat end of reflex hammer

› repeat 10 times

› Achilles tendonitis/rupture

› Ankle sprains

› Bursitis