Therapeutic Kinesiology:Musculoskeletal Systems, Palpation, and Body Mechanics

Therapeutic Kinesiology Instructor Manual: Ch11 p.1 TK INSTRUCTOR MANUAL: CHAPTER 11 The Ankle and Foot Chapter manuals include: Objectives Lecture Notes Suggested Classroom and Student Development Activities For other chapter-by-chapter resources, see: Key Term Quizzes Muscle Origin and Insertion Worksheets Muscle OIAs List by Chapter MyTest Test Bank For additional resources see “Teaching Tips and Tools”: 7 research-based learning principles for kinesiology courses in massage 5-step self-directed learning cycle for body mechanics courses Tools that build metacognitive skills: e.g., concept (mind) maps, grading rubrics, and self-assessments inventories OBJECTIVES Name the 28 bones in the ankle and foot and describe the shape and location of each one. Name three functional parts of the foot and the bones in each part. List and demonstrate the palpation of seven bony landmarks of the ankle and foot. List the major ligaments of the ankle and foot and describe their locations and functions. List the three arches of the feet, identify their functions, and describe each one. Name and describe five major ligaments that support the vault of the arches. List the eight major joints of the foot and describe the structure and function of each one. Identify the origins, insertions, and actions of extrinsic muscles of the ankle and foot. Identify trigger points and pain referral patterns of extrinsic muscles of the ankle and foot. Demonstrate the active movement and palpation of each extrinsic ankle and foot muscle. Identify the origins, insertions, and actions of intrinsic muscles of the ankle and foot. Identify trigger points and pain referral patterns of intrinsic muscles of the ankle and foot. Demonstrate the active movement and palpation of each intrinsic muscle of the foot. LECTURE NOTES BONES OF THE ANKLE AND FOOT Tibia Transfers 90% of load from knee to foot Most vertically oriented bone in body Tapers into medial malleolus Fibula Runs lateral to tibia Provides lateral splint for ankle joint Tapers into lateral malleolus Foot Similar to structure hand with one less bone Bones are sturdier and larger than hand Each foot has 26 bones Seven tarsals Five metatarsals Fourteen phalanges Three functional sections of foot Rearfoot Midfoot Forefoot Tarsals: Each foot has seven tarsal bones Calcaneus: Largest, most posterior tarsal, the heel Talus: Keystone of ankle, transfers forces three directions Navicular: Keystone of medial arch Three cuneiforms: Medial/intermediate/lateral across transverse arch Cuboid: Large cube-shaped bone in middle of lateral arch Metatarsals Five long bones Rays in forefoot, transfer weight from ankle to toes Phalanges Small long bones in toes Three in each toe: proximal, middle, distal Only two in hallux (first toe) Two sesamoid bones, under first metatarsal of first toe Three arches in each foot form architectural vault. Medial longitudinal arch: Between calcaneus and hallux Lateral longitudinal arch: Between fifth metatarsal and heel Transverse arch: Between lateral arch and medial arch Functions of arches Medial arch functions like tie-rod It flattens under weight It rebounds to produce energy Arches absorb shock from impact of heel strike Adapt foot to uneven terrain JOINT AND LIGAMENTS OF ANKLE AND FOOT Introduction Each foot has 25 joints, over 100 ligaments Foot is twisted osteoligamentous plate Hindfoot and heel are oriented sagitally Distal forefoot is oriented horizontally Four supporting ligaments on sole of foot Calcaneonavicular ligament Short, wide, three-part ligament Sustentaculum tali to navicular tuberosity Calcaneus to navicular Calcaneus to talus Also called spring ligament Supports and stabilizes center of medial arch Short plantar ligament: calcaneus to cuboid Long plantar ligament: calcaneus to cuboid/metatarsals 35 Plantar aponeurosis: calcaneal tuberosity to base of phalanges Thick fascia from calcaneal tuberosity to phalanges Stabilizes longitudinal arches Cushions and protects sole of foot When inflammed, plantar aponeurosis develops plantarfaciitis It becomes stiff and inflexible It becomes painful to stretch and walk Plantar plate: Thick fibrocartilaginous pad across ball of foot Binds, supports, and cushions metatarsal heads Encapsulates two sesamoid bones under first metatarsal base Covered by deep transverse metatarsal ligament Keeps foot from splaying sideways Tibiofibular joints Tibia and fibula bound length by interosseous membrane Both tibiofibular joints are mechanically linked Proximal tibiofibular joint: synovial plane joint Distal tibiofibular joint: fibrous joint During ankle motion, fibula slides/rotates against tibia Talocrural joint: Hinge joint Between tibia, fibula, and talus Neutral position of talocrural joint is 90 degrees Range of motion Dorsiflexion: 20 degrees Plantarflexion: 45 degrees Comparable to mortise joint with malleor grips Motion similar to wrench turning around bolt Ligaments of talocrural joint Medial collateral ligament (MCL): four close-packed ligaments Also called deltoid ligament due to fan shape Dense fibers make it stronger than LCL Stabilizes medial side of ankle Limits excessive eversion Lateral collateral ligament (LCL): three individual ligaments Limits excessive eversion Includes anterior talofibular ligament Most commonly injured ligament Injured during eversion sprains Subtalar joint: Ellipsoid joint Between talus and calcaneus Range of motion Inversion: 45 degrees Eversion: 20 degrees Called "lower ankle joint" because it moves with ankle Moves with ankle during supination and pronation Supination and pronation of foot Combined movements in talocrural and subtalar joints. Supination: Inversion + Plantarflexion + Adduction (SIP-ADD) Pronation = Eversion + Dorsiflexion + Abduction (PED-ABD) Transverse tarsal joint: Gliding joint Gliding joint forming midtarsal articulation Made of talonavicular and calcaneocuboid joints Divides rearfoot from midfoot Absorb shock with slight give during weight loading Spring ligament cradles talonavicular joint like hammock Neutral position of ankle Talus aligns over calcaneus Between position of inversion and eversion Misalignments of ankle Pes planus Hyperpronation or "flatfoot" Causes calcaneal valgus, heel turns away from midline Pes cavus Hypersupination Causes calcaneal varus, heel turns toward midline Intertarsal and tarsometatarsal joints: Gliding joints Joints between cuneiforms, navicular, and cuboid Extremely stable group of joints In continuous synovial membrane and joint capsule Contribute more to stability of midfoot mobility Tarsometatarsal joints: Gliding joints Joints between tarsals and metatarsals Extremely stable group of joints Stabilized by wedging orientation of cuneiforms Transfers weight from ankle to toes Intertarsal and tarsometatarsal joints allow forefoot to twist against midfoot Metatarsophalangeal (MTP) joints: Ellipsoid joints Between metatarsals and phalanges Range of motion Flexion: 35 degrees Hyperextension: 45 degrees Adduction and abduction (spreads toes) Spreading toes critical for loading/unloading medial arch Interphalangeal (IP) joints Fourteen hinge joints between proximal and distal phalanges Two in each toe (PIPs, DIPs) Only one in hallux (first toe) Range of motion: flexion and extension IPs have excessive accessory (twisting) motion MUSCLES OF ANKLE AND FOOT Overview: Extrinsic muscles Have origins in leg, insertions in toes Four groups in four fascial compartments Anterior: tibialis anterior, extensor digitorum, and hallicus longus Posterior: gastrocnemius, soleus, and plantaris Deep posterior: tibialis posterior, flexor digitorum, and hallicus longus Lateral: peroneus longus and peroneus brevis Overview: Intrinsic muscles Have origins and insertions in feet Give arches mobility Flexibility to absorb shock Ability to intrinsically adjust to uneven terrain Stabilize joints in arch during propulsion Overview Dorsal layer: ext hallucis brevis and ext dig brevis Superficial plantar layer: abd hallucis, flex dig brevis, abd digiti minimi Second plantar layer: quadratus plantae and lumbricals Third plantar layer: flex hallucis brevis, add hallucis, flex digiti minimi brevis Deep layer: plantar interossei and dorsal interossei Anterior compartment Superficial location is easy to palpate Tendons visible on top of foot Tibialis anterior O: Lateral tibial condyle, proximal two-thirds of anterior lateral tibia, interosseous membrane I: First cuneiform, base of first metatarsal head A: Dorsiflexes ankle and inverts foot Prominent muscle along lateral side of shin Forms anatomical stirrup with peroneus longus Extensor digitorum longus O: Lateral tibial condyle, proximal two-thirds of anterior fibula, interosseous membrane I: Base of middle and distal phalanx of lateral four toes A: Extends lateral four toes, assists dorsiflexion and eversion Extensor hallicus longus O: Middle half of anterior fibula, interosseous membrane I: Base of distal phalanx of first toe A: Extends first toe, assists dorsiflexion and inversion Posterior compartment Tapers into triceps surae at Achilles tendon Superficial location is easy to palpate Gastrocnemius: Generates impetus for strong push and takeoff O: Posterior medial and lateral condyles of femur I: Posterior calcaneus via Achilles tendon A: Plantarflexes ankle Soleus: Under gastrocnemius, postural function, "second heart" O: Proximal posterior tibia and fibula, soleal line of posterior tibia I: Posterior calcaneus via medial aspect of Achilles tendon A: Plantarflexes ankle Plantaris: Small, weak muscle behind knee O: Lateral posterior femoral epicondyle, oblique popliteal ligament I: Posterior surface of calcaneus A: Assists plantarflexion and knee flexion Deep posterior compartment Compartment situated in core of leg Deep location makes it difficult to directly palpate Tibialis posterior O: Proximal posterior tibia and fibula, interosseous membrane I: Navicular, cuboid, cuneiforms, base of the second to fourth metatarsals A: Plantarflexes ankle, inverts foot, stabilizes medial arch Tendon lifts and stabilizes medial arch Tendon passes through tarsal tunnel Flexor digitorum longus O: Medial posterior tibia I: Base of distal phalanges of lateral four toes A: Flexes toes, assists plantarflexion of ankle and inversion of foot Flexor hallicus longus O: Lower two-thirds of posterior fibula, interosseous membrane I: Base of distal phalanx of first toe A: Flexes first toe, assists plantarflexion of ankle and inversion of foot Lateral compartment Compartment situated on lateral side of leg Superficial and easy to palpate Peroneus longus (fibularis longus) O: Upper two-thirds of fibula I: Base of first metatarsal, medial cuneiform A: Everts ankle, assists plantarflexion of ankle Shares insertion with tibialis anterior From lateral half of anatomical stirrup Supports/lifts transverse arch, steers foot Peroneus brevis (fibularis brevis) O: Lower two-thirds of fibula I: Base of fifth metatarsal A: Everts the ankle, assists plantarflexion of ankle Dorsal layer of plantar muscles Only two muscles with origins on dorsal foot Have no counterpart in hands Extensor digitorum brevis: Small fleshy muscle, easily mistaken for bruise O: Anterior lateral calcaneus, extensor retinaculum I: Extensor digitorum longus tendons from second to fourth toes A: Extends second to fourth toes Extensor hallucis brevis: Directly medial to extensor digitorum brevis O: Anterior lateral calcaneus, extensor retinaculum I: Proximal phalanx of first toe A: Extends first toe Superficial layer of plantar muscles Abductor hallucis O: Medial aspect of calcaneal tuberosity, flexor retinaculum, plantar aponeurosis I: Medial side of base of proximal phalanx of first toe A: Flexes and abducts first toe Flexor digitorum brevis: In middle of sole of foot O: Medial posterior tibia I: Base of distal phalanges of lateral four toes A: Flexes toes, assists plantarflexion of ankle and inversion of foot Abductor digiti minimi: Between heel and fifth toe O: Lateral aspect of calcaneal tuberosity, plantar aponeurosis I: Lateral side of proximal phalanx of fifth toe A: Abducts fifth toe and assists flexion Second layer of plantar muscles (have unique tendons) Quadratus plantae: Tendon gives rise to flexor digitorum brevis O: Plantar surface of calcaneus I: Distal tendon of flexor digitorum longus A: Assists flexion of lateral four toes by directing pull of flexor digitorum longus along line of pure flexion Lumbricals: Tendons loop over toes O: Medial side of distal tendons of flexor digitorum longus I: Dorsal medial surface of proximal phalanges of second to fifth toes A: Flexes MTP joints on second to fifth toes while extending IP joints Third layer of plantar muscles Flexor hallucis brevis: Tendon encapsulates sesamoids of first toe O: Plantar surface of cuboid and lateral cuneiform I: Medial and lateral side of base of proximal phalanx of first toe A: Flexes the MTP joint of first toe Adductor hallucis: Double-bellied, shaped like the number 7 O: Oblique head: base of second, third, and fourth metatarsals, sheath of peroneus longus tendon Transverse head: transverse tarsal ligaments of third, fourth, and fifth toes I: Lateral side of proximal phalanx of first toe A: Adducts first toe Flexor digiti minimi brevis O: Base of fifth metatarsal, sheath of peroneus longus tendon I: Proximal end of proximal phalanx of fifth toe A: Flexes PIP joint of fifth toe Deepest intrinsic layer Plantar interossei: Between metatarsals on plantar side O: Medial proximal side of third to fifth metatarsals I: Medial proximal aspect of the proximal phalanges of same toes A: Adduct and flex three lateral phalanges Dorsal interossei: Between metatarsals on dorsal side O: Shafts of metatarsals I: Base of phalanges 24, extensor digitorum longus tendons of same toes A: Extend and abduct second through fourth toes SUGGESTED CLASSROOM STUDENT DEVELOPMENT ACTIVITIES PROVIDE AN OVERVIEW OF THE CLASS Before class, write a short schematic overview of the class on the board, then go over it at the beginning of class. For example: Today's class covers: Bones of ankle and foot Joints and ligaments Muscles of ankle and foot Activities: Review, lecture and assessments, palpation exercises, recap STRUCTURAL OBSERVATION EXERCISE: The ankle and foot Have three students volunteers stand next to each other so that the other students can observe their feet and ankles. Have the volunteers remove their shoes and socks and roll their pants up to their knees. Ask the students the following questions: Front view Do feet face straight ahead? Are they turned out or in? Is weight on one leg more than another? On heels more than toes? Is shin vertical or rotated? Is crease across front of ankle straight? Are toes flexed (curled) or extended (flat)? Is foot chronically supinated or pronated? Where is weight on foot (heel, toes, outside, inside)? How does this affect rest of lower limb, of body? What is shape of the medial and transfer arch? Lifted, dropped, twisted? Side view Is weight on heels or toes? How does this affect the spinal alignment? Back view Is the Achilles tendon vertical? Is more weight on one foot or the other? GAIT OBSERVATION EXERCISE: The ankle and foot Have the student observe the feet of one of the volunteers as he or she walks back and forth. As students observe ankle and foot motion, ask them these questions: Does this person roll through whole foot? Is there a toe-off? Walk heavy on heels? What happens to the gait without the toe-off? Walking heavy on heels? Walking toed-out? What muscles might be short, overstretched? What muscles would you test for adaptive shortening? EXPLORING TECHNIQUE EXERCISES Restoring arches in stiff, flat feet (p. 280 Passive range of motion for the ankle (p. 286) PALPATION EXERCISES Tibia and fibula (p.271) Tarsals (p. 275) Metatarsals and phalanges (p. 277) Subtalar and transverse tarsal joints (p. 289) Intertarsal and tarsometatarsal joints (p. 291) Metatarsophalangeal and interphalangeal joints (p. 293) Tibialis anterior, extensor digitorum longus, and extensor hallucis longus (p. 298) Gastrocnemius and soleus (p. 303) Tibialis posterior, flexor digitorum longus, and flexor hallucis longus (p. 307) Peroneus longus and peroneus brevis (p. 312) Extensor digitorum brevis and extensor hallucis brevis (p. 316) Abductor hallucis, flexor digitorum brevis, and abductor digiti minimi (p. 319) Quadratus plantae and lumbricals (p. 322) Flexor hallucis brevis, adductor hallucis, and flexor digiti minimi brevis (p. 325) SELF-CARE EXERCISES Stretching the gastrocnemius and soleus (p. 303) Strengthening the intrinsic muscles of the feet (p. 321) © 2013 by Education, Inc. Foster, Instructor Resources for Therapeutic Kinesiology