foot and ankle update: lower quarter biomechanics … materials web site.pdf · walking on uneven...

Foot and Ankle Update: Lower Quarter Biomechanics and Clinical Rehabilitation

Ed Mulligan, PT, DPT, OCS, SCS, ATC – www.continuing‐ed.cc ‐ 2010

Foot and Ankle Ability Measure (FAAM)

Please answer every question with one response that most closely describes to your condition within the past week. If the activity in question is limited by something other than your foot or ankle mark not applicable (N/A).

Nodifficulty

Slightdifficulty

Moderatedifficulty

Extreme difficulty

Unable to do

N/A

Standing Walking on even ground Walking on even ground without shoes Walking up hills Walking down hills Going up stairs Going down stairs Walking on uneven ground Stepping up and down curbs Squatting Coming up on your toes Walking 5 minutes or less Walking approximately 10 minutes Walking 15 minutes or greater

Because of your foot and ankle how much difficulty do you have with:

Nodifficulty

Slightdifficulty

Moderatedifficulty

Extreme difficulty

Unable to do

N/A

Home Responsibilities Activities of daily living Personal care Light to moderate work (standing, walking) Heavy work (push/pulling,climbing, carrying) Recreational activities How would you rate your current level of function during your usual activities of daily living from 0 to 100 with 100 being your level of function prior to your foot or ankle problem and 0 being the inability to perform any of your usual daily activities?

.0 %

FAAM Sports Scale (optional if applicable) Because of your foot and ankle how much difficulty do you have with:

Nodifficulty

Slightdifficulty

Moderatedifficulty

Extreme difficulty

Unable to do

N/A

Running Jumping Landing Starting and stopping quickly Cutting/lateral movements Low impact activities Ability to perform activity with your normal technique

Ability to participate in your desired sport as long as you would like

How would you rate your current level of function during your sports related activities from 0 to 100 with 100 being your level of function prior to your foot or ankle problem and 0 being the inability to perform any of your usual daily activities?

.0 %

Overall, how would you rate your current level of function? � Normal �Nearly normal � Abnormal � Severely abnormal



The FAAM was developed as a regional specific instrument to comprehensively assess physical performance among individuals with a range of leg, foot, and ankle musculoskeletal disorders. Higher scores represent higher levels of function. This outcome tool has been shown to reliable with an ICC of 0.87 with a standard error of measurement (SEM) of 2.1 points for the ADL portion of the scale and an ICC of 0.89 with a SEM of 4.5 points for the optional sports scale. The instrument has also been shown to have content and construct validity in a variety of lower extremity pathologies. The responsiveness of the tool is outlined below. Scoring instructions for the FAAM

The ADL and Sports subscales are scored separately. The response to each item on the ADL subscale is scored from 4 to 0, with 4 being “no difficulty” and 0 being “unable to do”. N/A responses are not counted. The score on each of the items are added together to get the item score total. The total number of items with a response is multiplied by 4 to get the highest potential score. If the subject answers all 21 items, the highest potential score is 84. If one item is not answered the highest score is 80, if two are not answered the total highest score is 76, etc. The item score total is divided by the highest potential score. This value is then multiplied by 100 to get a percentage. A higher score represents a higher level of physical function.

The Sports subscale is scored the same as above, 4 being “no difficulty at all” to 0 being “unable to do”. The score on each item are added together to get the item score total. The number of items with a response is multiplied by 4 to get the highest potential score. If the subject answers all 8 items the highest potential score is 32. If one item is not answered the highest potential score is 28, if two are not answered the highest potential score is 24, etc. The item score total is divided by the highest potential score. This value is multiplied by 100 to get a percentage. A higher score represents a higher level of physical function. Psychometric Information

Relates to scores out of 100 percentage points

ADL subscale Sports subscale

Error associated with a one time measurement 95% confidence

7 points 10 points

Minimal detectable difference over a four week period 95% confidence

6 points 12 points

*Minimal Clinically Important Difference

8 points 9 points

* The Minimal Clinically Important Difference is the score distinguished patients who felt they improved with physical therapy from those who felt they did not improve over a four week period.

Plantar Fascitis Taping Technique Modified Low-Dye for the Hypermobile Pronating Foot

1. Prep plantar surface of foot with tape adherent. Anchor strip at met head level (not encircled)

2. Place the subtalar and talocrural joint in neutral with the 1

st ray

mildly plantarflexed

3. 1 or 1.5" white tape, run the 1st strap from the 1st metatarsal head coursing along the medioplantar border of the foot, wrapping around the heel, and then back up the lateroplantar surface of the foot to the 5th metatarsal head. Maintain tension on the tape to achieve a bowstring effect on the medial longitudinal arch. Figure 1

4. The 2nd-3rd-4th straps originate from the same location as the

1st strap but insert more medially on each successive strap until reaching back to the 1st metatarsal head. Fig 2

5. Closing straps begin on the lateral portion of the foot and move

transversely to the medial portion of the foot eliminating the bowstring in the medial arch. (not so much tension in the closing straps so as to cause wrinkles in the plantar aspect of the foot)

6. Finish taping procedure with strips over the dorsum of the foot to

lock & secure the tape job.

7. At the completion of the taping - the 1st ray should be plantarflexed and the the arch heightened. An arch cookie secured in the medial longitudinal arch may augment the effectiveness. Figure 3

** Ator, et al. JOSPT 14:1, 1991 showed that Low Dye taping effectiveness as judged by navicular height change was significant between pre and post-tape conditions; but was not significant between pre-tape and post ten minutes of physical activity suggesting that the taping will not hold up against the stress of exercise.

Alternative Techniques for the Rigid Pes Cavus Foot: 1. Shock attenuating/absorbing heel pad with plantar fascia cut out or

depression 2. Arch cookie that fills the medial longitudinal arch extending from the base of

the calcaneus to the base of the 1st metatarsal head.

Figure 1

Figure 3

Figure 2

Brian Mulligan Technique

This technique seems to work best for the hypermobile pronating footing secondary to a compensatory rearfoot varus. With the lower leg externally rotated, the tape is applied from the lateral side of the heel, up and over the medial side of the foot, end on the dorsal lateral side of the ankle

SUBTALAR SLING TAPING TECHNIQUE for INVERSION ANKLE SPRAINS

BRIAN MULLIGAN FIBULAR HEAD TAPING TECHNIQUE

Application of stirrup strips and horseshoe Completed application of

subtalar strips

Origin of the subtalar sling over the 2

nd

metatarsal head

Application of dorsal forefoot strips to pull

the subtalar sling against the surface of

the foot

Tape repositioning of the distal tibiofibular joint. Fibular head is secured in a dorsosuperior positon

PERONEAL TENDON SUBLUXATION TAPING TECHNIQUE 1. After preparing for typical ankle taping, place "J" pad made of felt

posterior to the lateral malleolus following its course towards the cuboid pulley.

2. Secure this pad with "Y" strap moving proximally from under the foot

at the 1st met head or moving distally with the tape spliting just posterior to the lateral malleolus. This "Y" strap attempts to recreate the retinacular structures that secure the peroneal tendon in its tunnel posterior to the lateral malleolus.

3. Finish the taping techniqe with horseshoe and figure 8 traps that

prevent the ankle from reach the extremes of plantarflexion/inversion. These straps will limit the range over which powerful eccentric df/eversion contractions can cause peroneal subluxation.

METATARSALGIA PADDING and CUSHIONING DESIGNS and TECHNIQUES

added cushioning adjacent support excavation met pad toe crest 1

st Ray cut out Dancers Pad

ANTI-PRONATION TAPING TECHNIQUE

Throughout the following procedures, do not place the ankle in an inverted position when the tape is applied. Keep the foot in a 90º dorsiflexion and the STJ in neutral or the reverse 8-stirrup technique will not be as effective. 1. Anchor strip at the musculotendinous junction. 2. Apply a stirrup. Start on the top lateral aspect of the

anchor strip and run it under the foot parallel to the achilles tendon, bisecting both the lateral and medial malleoli. Attach it to the anchor strip on the medial side. Figure 1

3. The first reverse 8-stirrup begins with a horizontal

strip. Start directly above the lateral malleolus, pull the tape around the back of the ankle above the medial malleolus, continue under the foot, come up on the medial side of the ankle, and overlap the stirrup strap. Notice the tape forms a partial figure 8, then continues into a medial stirrup. Figure 2 and 3

Note: Do not force the foot into inversion, but maintain a neutral position throughout the taping procedure

4. Overlapping at least ½ , apply a second reverse 8-

stirrup following the previous procedure. Two to four reverse 8-stirrups may be used dependent upon the patient’s size. The last strip should be applied directly over the navicular. Figure 3

5. Close all open areas with anchor strips moving from

bottom to top. 6. The heel lock completes the taping procedure. Apply

a lateral heel lock by starting high on the instep. Bring the tape along the ankle at a slight angle, hooking the heel, leading under the arch, coming up on the opposite side, and finishing at the starting point. Finish the procedure with a medial heel lock. Figure 4

Figure 1

Figure 3

Figure 2

Figure 4

ACHILLES TAPING: Anchor at the base of the foot below and the musculotendinous junction above. Fan shaped strips run from the base of the foot proximally to place the foot in a plantarflexed position. Taping may be augmented by pacing a heel lift in the shoes to further reduce tensile strain. Figure 1.

ALTERNATE ACHILLES TAPING MEHTOD: Brian Mulligan Technique (most effective for hyperpronaters) Tape is used to minimize the bowstring effect on the achilles during pronation from a hyperpronated position in midstance. Tape is run from lateral to medial to cause the achilles to be more concave medially. Figure 2

TURF TOE TAPING TECHNIQUE: 1. Prep plantar surface of foot and toe with tape adherent. Anchor

strip encircle the 1st phalanx and mid foot. Do not extend the anchor strip to the IP joint as this will cause the MTP joint to extend during the taping technique.

2. Using pre-cut moleskin or 1" white tape, run checkrein strap on

the plantar-medial surface of the foot to limit dorsiflexion and adduction of the 1st MTP joint. Close the check reins with elastic tape. Figure 3.

3. Modify athletic shoe wear. Assure proper length fit to decrease

the lever arm effect on the joint. Place in the shoe a spring steel, polyethylene, or orthoplast insert to increase the rigidity of the distal forefoot.

Figure 1

Figure 2

Figure 3

SUBTALAR JOINT NEUTRAL CASTING TECHNIQUE PURPOSE: 1. Capture the relationship of the forefoot to the rearfoot 2. Reproduce the ideal position of the foot in midstance just prior to heel off. POSITIONING The patient is placed in a prone position with the feet to be casted extended over the back of a padded plinth. If the extremities are in a lot of external rotation, the calcaneus can be brought back more into the frontal plane by flexing, abducting, and externally rotating the opposite hip. SUPPLIES:

1. For each foot to be casted: Two - fast drying plaster of paris splints (green label), 5 x 30 inches, folded in half. One of the plaster splints is folded approximately a 1/4 inch on the proximal border to facilitate cast removal.

2. Large plaster bucket with warm water and non sterile vinyl examination gloves

PROCEDURE: 1. The first U shaped splint (with the 1/4" folded lip) is placed over the calcaneus and the medial and

lateral aspects of the foot. The splint is pleated at the heel, folded medially, and then smoothed over the plantar contour of the foot.

2. The second U shaped splint is placed around the toes and then brought proximally towards the

medial and lateral aspects of the foot. Again, the plaster is smoothed to the plantar surface of the foot. Care must be taken not to compress the toes while the plaster is being applied.

3. Once both the two plaster splints are molded in place,

the caster must place the subtalar joint in its neutral position. This is accomplished by using the outside hands thumb and index finger to load the forefoot into maximal pronation at the 4th and 5th metatarsal heads. Once soft tissue resistance is met, the calcaneus should be inverted and everted until the inside hand can symmetrically palpate the medial and lateral heads of the talus.

4. Once the subtalar joint position is found, the inside hand can smooth the plaster to accurately capture the shape of the calcaneus, the calcaneal inclination, medial and lateral longitudinal arches, and any bony abnormalities or exostoses.

5. The cast can be removed when it has hardened enough that tapping with your fingernail on the

plaster is audible. Break the seal of the cast by gently opening the cast on the medial and lateral sides of the foot. Slide the cast over the calcaneus posteriorly, and then gently twist the cast off as you slide the cast distally down the foot. "Removing a slipper."

Common Problems 1. Anterior tib contraction giving the appearance of a forefoot varus 2. Not identifying or holding subtalar joint neutral. Use rule of 1/3rds to recognize appropriate casts.

Flat - gentle slope - steep slope. Does the cast represent the shape of the patient's foot? 3. Incomplete or no "loading" of the 4th and 5th metatarsal heads. Must dorsiflex the plantar surface

of the foot until mild tissue resistance is felt. The caster may notice a mild thumb indent from where this loading occurred during casting. It can be punched out after the cast is removed. Excessive loading can be avoided by placing traction at the 4th and 5th met heads once the initial tissue resistance is met.

4. Proper loading of the forefoot means ensuring that both the 4th and 5th met heads are loaded and

the loading is not proximally on the metatarsal shaft or distally on the phalanges. 5. Placing the cast to high on the heel and making it difficult to remove after drying. The cast only

need to extend halfway up the posterior surface of the calcaneus

ORTHOTIC LABS and SERVICES Foot Management 7201 Friendship Road Pittsville MD 21850 1-800-HOT-FOOT www.footmanagment.com Orthotic Types:

Rigid thermoplastic, dense/soft porous polyethylene in sport and street models. Cost:

Sport Orthotics $58-84 Street Orthotics $51-78 Accommodations available Fitting:

Foam impression trays or STJ neutral slipper casts Shipping:

• Return shipped UPS at no charge • Rush orders (2 days in lab) -

$15 • Normal orders are in lab 5-7

days Other Services/Products:

Full line of pre-cut foot pads including met pads, heel lifts, morton's toe pads, dancer pads, blister pads, heel wedges, plantar fascia straps, etc.

Variety of Pre-fab orthotics ADRESSES: Alimed 297 High St Dedhamn, MA 02026-2839 1-800-225-2610 FAX: 617-329-8392

Berkemann Foot & Ankle Orthopedics 4 Columbus Ave Mt Kisco NY 10459 1-800-431-7801

Gill Podiatry Lab 7803 Freeway Circle Middlebury Hts OH 44130 1-800-321-1348

Langer Biomechanics Group Illinois Office: 1120 Larkin Dr Wheeling, IL 60090 1-800-367-2057 www.langerbiomechanics.com Orthotic Types:

Rohadur Slimthotics Sporthotics - golf, ski, running, football, tennis, basketball, aerobics, tennis, etc. Geriatrics Accommodative Cost: (1998)

Rohadur $61-83 Sporthotics $70-100 Active Semi-Rigid $65-90 Dress Orthotics $65-85 Accommodative $60-70

6-month guarantee against orthotic breakage or post avulsion Fitting:

• Subtalar joint neutral slipper cast • Specialized order form for each type

of orthotic Shipping:

• Prepaid postage on free shipping • cartons • Shipped UPS • 5-7 working days in lab turnaround Other Services:

Newsletter, CE courses, gait analysis systems, podiatry consultant Langer Biomechanics Group Professional Protective Technology 11 East Industry Court Deer Park, NY 11729 1-800-233-2687 PPT Insoles System

PPT Insoles in varying thickness and with or without nylon top covers. Com- ponents include heel lifts/spur pads, met pads, arch pads, and heel wedges. Cost: Insoles $14-20 PPT Tempthotic Kit $15 Components $2-4

PAL (Podiatry Arts Lab) 1805 Riverway Dr; Pekin IL 61554 1-800-447-0151; FAX: 309-347-3618 www.palhealthsystems.com Orthotic Types:

Sport - Running, Golf, Lateral Movement Sports Street - Leisure Dress and high heel Accomodative Pediatric Costs:

Sport $80-94 Street $73-89

Lifetime guarantee against shell breakage; 6 month guarantee on forefoot and rearfoot posts. All adjustments within 6 months are free of charge. Fitting:

• Subtalar neutral slipper casts • Specialized order form. Posting can

be done according to measurements, cast, or lab standards.

Shipping:

Two-way shipping cartons with pre-paid postage and shipping address. Returned orthotic has statement of posting performed. Other Services:

• Full line of orthotic accommodations • Flex codes provided on all orthotics • Colorful brochure with indications and

uses • Helpful lab techs for troubleshooting • Podiatry consults available Accomodative Insert Orthotic System

PAL HEALTH TECHNOLOGIES Healthtech Division 293 Herman St.; Pekin, IL 61554 1-800-447-0151 Underdog System:

Insoles, Heel Lifts, Heel Spur Pads, Forefoot and Rearfoot Varus/Valgus Posts, and Metatarsal Pads. Cost:

Insoles $10-13 Accommodations $4-8

ACCOMMODATIVE ORTHOTIC MATERIALS: PPT: Description: non-thermoplastic, polyurethane open-cell foam. Very durable Durometer: soft Thickness: 1/16 to 1/2 inch Availability: nylon or felt covered; uncovered SPENCO: Description: non-thermoplastic, closed-cell polyurethane foam. Compressible and resilient. Durometer: soft Thickness: 1/8" Availability: nylon covered PLASTAZOTE: Description: thermoplastic, closed-cell polyethylene foam. Not durable. Durometer: soft, medium, firm Thickness: 1/16 - 1 inch Heating: heat at 240 degrees until malleable; auto-thermoadhesive; low memory; protect with teflon during heat and protect patient with stockinette during molding SORBATHANE: Description: viscoelastic polymer that has no structure. non-cellular solid that flows Durometer: soft Thickness: standard SEMI-RIGID THERMOPLASTIC MATERIALS ALIPLAST: Description: thermoplastic, closed-cell polyethylene foam. Compressed white matte opaque foam with smooth glossy surface. Good foot-orthotic interface surface. Durometer: soft, medium, firm, and extra-firm Thickness: 3/16 - 1/2 inch Heating: high specific heat. Auto-thermoadhesive. Memory. Heat at 275 degrees. Protect with teflon during heating PELITE: Description: thermoplastic, closed-cell polyethylene foam. Soft white, non-allergenic. Memory. Durometer: soft, medium, firm, and extra-firm Thickness: 1/8-3/4 inch Heating: high specific heat, non-autoadhesive. Heat at 265 degrees for < one minute. NICKELPLAST: Description: thermoplastic white foam. High compression and stable resistance to pressure. Durometer: high density support Thickness: 1/8, 3/16, and 1/4 inch THERMCORK: Description: cork-like material that is heat moldable and easily ground. Natural cork in plastic matrix; Closed-cell. Durometer: firm, does not bottom-out Thickness: 1/8 and 1/4 inch Heating: Heat at 300 degrees. Can be vacuum pressed over positive mold.

SEMI-RIGID ORTHOTIC FABRICATION Positive Mold: Preparation: Line negative slipper cast with plaster parting agent such as powder/liquid soap, petroleum jelly, or pam. Mixing: 2:1 ratio of pottery plaster to water; mix thoroughly to remove lumps. Pour immediately and allow to dry minimum of 20-30 minutes. Do not vacuum press for 24 hours or cast will fracture. 6-8 cups of plaster and 3-4 cups of water to create enough plaster for pair of orthotics After dry, peel slipper cast gauze away from positive mold and gently sand rough edges and skin lines. Orthotic Fabrication: Supplies Needed: Aliplast XPE 3/16" - reduce friction Convection Oven Pelite EF 3/16 or ThermCork as posting Barge Cement PPT 1/4 arch cookie Bench Grinder - Mask Leather or nylon top cover Heavy Duty Scissors Vacuum Press (ace bandage or bike inner tube) Fabrication: 1. Cut out tracing of materials to be used. Leave a 1/4 to 1/2 inch border 2. Heat thermoplastics in convection oven for 1-3 minutes. Remove most malleable material and apply layer of barge cement. Then place on other materials and re- heat. 3. Use vacuum press to form thermoplastics to positive mold. 4. Glue 1/4 inch PPT crescent shaped arch cookie 5. Wait 24 hours for grinding Grinding: 1. Bisect calcaneus on cast 2. Shape to model: length: posting proximal to met heads width: no wider than mold

3. Grind medial and lateral sides to calcaneal bisection. Bevel from lateral to medial to allow orthotic to sit on the shoe last and not bind in the shoe.

4. Grind bottom of orthotic device flat 5. Wedge distal end of orthotic paper thin

6. Grind rearfoot until calcaneal bisection is appropriate and until top layer spot is visible 7. Grind appropriate forefoot post

ORTHOTIC ACCOMMODATIONS/MODIFICATIONS DEFINITIONS Heel Spur Pad - horseshoe shaped pad to decrease weight bearing stress at the site of the plantar

fascia attachment

Heel Lift - neoprene, viscolas, or cork lift added to the rearfoot of the orthotic to correct. 3/8" max intrinsic.

Morton's Extension - the orthotic is extended along the first ray so that it will accept more pressure during toe off and reduce the pressure the 2nd ray has to accept

Met Pad or Rise - oval shaped pad placed behind the 2-3-4 met heads to lift their shafts and help support the transverse arch. Thickness typically 1/8-1/4 inch.

Met Bar - similar to a met pad but it picks up the shafts of all 5 rays

Met Cut-Out - depression in the orthotic to relieve pressure on specific metatarsal heads

Clips - small rise on the edge of the orthotic to help hold the foot in the orthotic. Helpful with more rigid orthotics and often used with severe pes planus pronators who may roll off the orthotic medially.

Wedges - extrinsic beveled posts on semi-rigid and soft orthotics

Dancer's Pad - a met pad rise under the 2-3-4 met heads and pockets the 1st and 5th met heads. Often used for athletes who are on the balls of their feet and twist.

Sesamoid Cut-Out - similar to a met cut out; specifically under the 1st met head.

8/15/2010

1

Therapeutic Exercise for the Foot-Ankle

Ed Mulligan, PT, DPT, OCS, SCS, ATCAssistant Professor

h di id i

continuing EDcontinuing ED

Orthopedic Residency Program Director

Department of Physical TherapyUT Southwestern Medical CenterDallas, TX

If exercise therapy could be packed into a


ppill it would be the single most widely prescribed and beneficial medicine the world has ever known

Exercise Application

Exercise should be as precisely prescribed as medicine for it to

li it i t d d d i l b fit


realize its intended and maximal benefit

Why is this Important?Most common intervention provided

– 12 patients/day doing 5 exercises = 300 exercises/week = 15,00 exercise prescriptions/year

Exercise Prescription Considerations

Exercise Intervention Goal– Target tissue type and tolerance

– Influence of healing stage


Influence of healing stage

– Protect (inflammatory) ‐ Stimulate (proliferative) ‐ Challenge (remodeling)

Stage of Rehabilitation Focus– Mobility‐Stability‐Controlled Mobility‐Skill

Amount, Plane, and Speed of MotionPosture and Position Determinants

Biomechanical Correctness

Strength Training– Type of contraction

Intensity – Frequency – Duration



– Intensity – Frequency – Duration– Repetition science – Dosage determination

Exercise Mastery and Progression– Easy to Hard– Simple to Complex– Safe to Provocative– Known to Unknown


Who is the Patient?– SAID based on genetics, age, size, sex, and

attitude and activity



attitude, and activity

• “Y?”– Individualized prescription

Can you tell what the patient’s occupation or avocation is?

– Fun (not silly or pointless)– Who is responsible for the patient’s improvement?

8/15/2010

2

science of specificity

Specific motion of a specific joint through a specificrange at a specific speed in a specific direction through

ifi i t f ifi ti li t bt i ifi


specific input of specific stimuli to obtain a specificmuscle response or specific facilitation of a specifictissue dependent upon the specific tissue involved in a specific injury to achieve specific physical performance requirements and goals with specific fiber muscle recruitment fueled by a specific muscle energy system

Biomechanical Ankle Platform SystemCLINICAL APPLICATIONS


BAPS Board Axes of Motion

Anatomical Description of Axis Location

Talocrural Joint 15° from frontal plane


Subtalar Joint 16° from sagittal plane

MTJ Oblique 55° from sagittal plane

MTJ Longitudinal 10° from sagittal plane

BAPS Board

Motion Vectors• Plantar/dorsiflexion perpendicular to TCJ axis• Calcaneal inver/eversion (pronation‐supination)


• Calcaneal inver/eversion (pronation supination) perpendicular to the STJ axis

Tendon to Axis Locations• Anterior Compartment Muscles• Lateral Compartment Muscles• Posterior Superficial Compartment Muscles• Posterior Deep Compartment Muscles


BAPS Board Weight-Bearing Function

Concentric acceleration

d


and

Eccentric deceleration

Muscles control and reverse motion

8/15/2010

3

BAPS Board Overload Positions

P = Gastroc/Soleus

PL = Peroneals


PL Peroneals

AL = EDL

AM = Anterior Tib/EHL

PM = TDH

P Concentric pf‐Eccentric dfConcentric supination‐Eccentric pronation

PL Concentric pf and calcaneal eversion(pronation)

BAPS Board Overload Positions


PL Concentric pf and calcaneal eversion(pronation)Eccentric df and calcaneal inversion (supination)

AL Concentric df and calcaneal eversion (pronation)Eccentric pf and calcaneal inversion (supination)

AM Concentric df and calcaneal inversion (supination)Eccentric pf and calcaneal eversion (pronation)

PM Concentric pf and calcaneal inversion (supination)Eccentric df and calcaneal eversion (pronation)

BAPS BoardDeterminants of Flexibility


BAPS Board

Tight Gastroc ‐ SoleusUnable to make P contact (dorsiflex)


(dorsiflex)

• board slides forward

• knee extends

• foot slides forward

• met heads lift off the board

BAPS Board

Tight TDH (posterior superficial compartment)

Unable to make PM contact


Unable to make PM contact (dorsiflex/evert)

• board slides laterally

• hip IRs and/or thigh adducts

• knee extends

• foot slides laterally or lifts off laterally

BAPS Board

Tight Ant Tib ‐ EHLUnable to make AM contact (plantarflex/evert)


(plantarflex/evert)

• board slides laterally

• hip IRs and or thigh adducts

• knee flexes

• toes out

8/15/2010

4

BAPS Board

Tight EDLUnable to make AL contact (plantarflex/invert)


(plantarflex/invert)

• board slides medially

• hip ERs and/or thigh abducts

• knee flexes

• toes in

BAPS Board

Tight PeronealsUnable to make PL contact (dorsiflex/invert)


(dorsiflex/invert)

• board slides medially

• hip ERs and/or thigh abducts

• knee extends

• inner border of foot leaves BAPS surface

BAPS Board Treatment Variables

• Training SurfaceTile or hardwood vs. carpet

• Mobility Level (1‐5)


Mobility Level (1 5)• Sets – Reps – Time• Direction , Pattern, & Speed of Training• WB status• Visual Cues• Neuromuscular Distraction• Footwear – Orthotics ‐ Braces


Gastrocnemius

continuing EDcontinuing ED continuing EDcontinuing ED

8/15/2010

5

Gastrocnemius

• BAPS – posterior overload

• Shuttle – Total Gym Heel Raises


• Tubing – single knee flexion initiation

• Single Leg Stance Forward leans• Stairmaster• Swimming with Flippers• Forward Walkaways

BAPS Board with Posterior Overload


Gravity Eliminated Heel Raises


Single Leg Knee Flexion Initiation


Sagittal Plane Leans


Retro Resisted Step Ups


8/15/2010

6

Stairmaster Reciprocal Heel Raises


Toe Walks


Resisted Take Offs


Jump Rope


Soleus


Soleus

BAPS – posterior overload

Soleus Pumps


Tubing – terminal knee extension

Tubing Step Downs

Tonic training emphasis

8/15/2010

7

Seated Heel Raises (Soleus Pumps)


Don Tigney Terminal Knee Extension


Anterior Tibialis


• BAPS – anteromedial overload

• Shuttle or Total Gym Toe Raises

Anterior Tibialis


• Heel or Downhill Walk

• Retro Walkaways

• Lunge Steps

• Supro Dance

BAPS with Anteromedial Overload


Gravity Eliminated Toe Raises


8/15/2010

8

Anterior Lunges


Resisted Step Ups - Return


Heel Walking


Posterior Tibialis


Posterior Tibialis

• BAPS – posteromedial overload

• Shuttle or Total Gym Heel Raises


Heel Raises• Uphill Walk• Contra‐Kicks

– unstable or cambered surface

• Towel Slides• Supro Dance• Trunk Rotations

– tubing, body blade, doorway

BAPS with posteromedial overload


8/15/2010

9

Medial Towel Slides


Arch Raise from everted position


Contra Kicks on inverted inclination


Frontal plane Contra Kicks on unstable surface


SuPro Dance


Weight Bearing Resisted Exercise

Concentric STJ Inversion


Eccentric STJ Eversion

8/15/2010

10

Inverted Heel Raises


Peroneals


Peroneals

BAPS – posterolateral overload

Slide Board


Contra‐Kicks– unstable or cambered surface

Lateral Towel Slides

Lateral Lunge

BAPS with posterolateral overload


Lateral Towel Sweeps


Hip Abduction Contra Kicks


8/15/2010

11

Resisted Lateral Step Ups - Return


Slide Board


Pronation-Supination Training

Bilateral Unilateral Trunk Rotation

Bilateral Unilateral Body Blade Rotation


Bilateral Unilateral Tubing Resisted Rotation

Bilateral Unilateral Squat Position RotationUnilateral Doorway Rotations for Speed

Unstable Surface Training

Frontal Plane Contra Kicks

Unilateral Trunk Twists


Bi-Unilateral Body Blade Twists


Lawnmower


Rotational Step Up

8/15/2010

12

Doorway Trunk Twists for Speed


Dyna Disc Catch


Resisted Rotation


Intrinsic Foot Musculature

Intrinsic foot muscles act a stabilizers to the MLA much like the multifidus/TA in the spine or the RC in the shoulder

Lack of IFM activity will increase the navicular drop


Lack of IFM activity will increase the navicular drop

Lack of IFM activity will put greater demand on passive structures like the plantar fascia

Intrinsic Foot Musculature Training

First learn to supinate (heighten arch) without the use of extrinsic muscles in non‐weight bearing

Monitor extrinsics and do not let toes flex (patient should


– Monitor extrinsics and do not let toes flex (patient should always be able to extend toes

Incorrect Correct

Progress to Weight Bearing– Short foot exercise – maintain navicular height; take

away balance assist or put on more labile surfaces as

Intrinsic Foot Musculature Training


away balance assist or put on more labile surfaces as improvement occurs

– Work on long tonic holds

Short Foot Exercise

8/15/2010

13

Balance – Perturbation Variables

• Double to Single Limb• Weight Shifts and Transitional Movements• Head Position


• Vision – Eyes Open Closed• Vestibular – Cervical Motion• Surface Stability• Extremity Motion

– UE/LE– Direction or Plane of Motion– Speed– Resistance

“Make rehab fun”





Daniel L Riddle, Bruce E Hillner, Philip S Wells, Robert E Johnson, Heather J Hoffman and Wilhelm A Zuelzer. Diagnosis of Lower‐Extremity Deep Vein Thrombosis in Outpatients With Musculoskeletal Disorders: A National Survey Study of Physical Therapists. Phys Ther 2004; 84(8):717‐ 728 Background and Purpose. Prompt identification of outpatients who may have proximal lower extremity deep vein thrombosis (PDVT) is important, in part, because of the risk of pulmonary embolism. The purposes of our study were to determine the degree of accuracy of physical therapists' estimates of the probability of PDVT in hypothetical patient vignettes and to determine whether physical therapists would contact the referring physician about the hypothetical patients' condition as recommended in published evidence. Subjects and Methods. A survey instrument consisting of 6 vignettes was sent to a nationally representative random sample of 1,500 physical therapists. The clinical decision rule developed by Wells and colleagues served as the gold standard for PDVT probability. Results. A total of 969 (65% response rate) physical therapists completed the survey. We found no evidence of nonresponse bias. For the 2 high‐probability vignettes, 87% and 64% of the physical therapists underestimated the probability of PDVT. For the 2 high‐probability cases, 32% and 27% of the physical therapists reported that they would not have contacted the referring physician. For the 2 moderate‐probability cases, 15% and 30% of the physical therapists would not have contacted the referring physician. Therapist experience, certification status, place of practice, and region of the country did not explain the findings. Discussion and Conclusion. The care of outpatients who are at risk for PDVT could potentially be improved by use of the clinical decision rule developed by Wells and colleagues, although more study is warranted.

Clinical Decision Rule Developed by Wells and Colleagues

a Score interpretation: 0=probability of proximal lower‐extremity deep vein thrombosis (PDVT) of 3% (95% confidence interval [CI]=1.7%–5.9%), 1 or 2=probability of PDVT of 17% (95% CI=12%–23%), 3=probability of PDVT of 75% (95% CI=63%–84%).

b Tenderness along the deep venous system is assessed by firm palpation in the center of the posterior calf, the popliteal space, and along the area of the femoral vein in the anterior thigh and groin.

c Measured 10 cm below tibial tuberosity. d Most common alternative diagnoses are cellulitis, calf strain, and postoperative swelling

foot and ankle update: lower quarter biomechanics … materials web site.pdf · walking on uneven...

Documents