1. Foot and Ankle Exam with Gait Analysis Review
ANDY Davis Mspt, Lat
Sport and Spine Clinic of Weston
January 26th, 2018

2. Disclosures
No conflict of interest or company affiliation for this presentation

3. Plan of Attack Taking a good Running History Orthopedic Evaluation
Inspection/Palpation
Range of Motion
Strength Testing
Special Tests
Neurovascular
Dynamic movement testing
Gait Analysis

4. Running History
How long have the signs and symptoms been there – gradual or acute?
Any changes in frequency, terrain, speed, distance, diet?
New shoes?
Are they training for a race, if so how far away is it?
Running history (new to running or a seasoned runner)
What is their reason for being at the evaluation?
(each runner is a sample size of 1) Injured or for performance?
Any other medical history?

5. Ortho Evaluation Inspection- Posture Standing:
Lumbopelvic Region- (scoliosis, excessive lordosis of lack there of )
Hips: (anterior/posterior rotation, iliac crest height)
Knees (genu valgus or varus)
Subtalar Joint (pes planus or cavus)
Feet and Ankle (FF adduction, FF abduction/ER)

6. Ortho Evaluation Palpation
Ankle and Foot Posterior (Gastoc, Soleus, Posterior Tibialis, Poplitieus, Plantaris, Achilles)
Lateral: (ATF, CF, PTF ligaments, Peroneals, lateral malleolus)
Anterior: (Distal Tib/Fib, syndesmosis, Talus)
Medial: (Medial malleolus, Deltoid ligament, tarsal tunnel, navicular)

7. ROM & MMT
Range of Dorsi flexion, Plantar flexion, Inversion and eversion. Also check Soleus.
MMT: in OKC but also need to check in CKC for the foot and ankle.
For both ROM and MMT, need also to check proximally to help provide info for the big picture.
Especially - Hip extension
Do they have enough range to run?

8. Special Tests Ankle Sprain
Lateral ligaments (Anterior Drawer, varus test)
Syndesmosis (ER test, Squeeze test)
Achilles Rupture (Thompson, Heel Raise)
Tarsal Tunnel (Tinel’s tap)
At the foot – Morton’s squeeze test

9. Neurovascular Pulses (dorsalis pedis, posterior tibialis)
Ankle sensory innervention: (medial – saphenous and lateral - sural nerve)
Foot: Dorsal (lateral is sural nerve, mid and medial superficial peroneal nerve, lateral first digit and medial second is deep peroneal). Plantar (Heel – medial calcaneal nerve, arch – saphenous nerve, Middle – medial plantar nerve, and lateral – lateral plantar nerve.

10. Dynamic Movement Bilateral Squat (quad or glut dominate)
Single leg balance
Single leg squat
Single leg hop
Toe Yoga
Posterior Tibialis Insufficiency with heel raises
STJ positioning
Lumbar ROM

11. Mobility and Strength Screen
Look at hip extension
Hip quadrant – screen also for SI joint involvement
Psoas and Hip Flexor tightness
Ober’s of IT Band tightness
Gluteus Medius Strength
Gluteus Maximus Strength
Ankle DF, 1st MTP DF /PF mobility
Forefoot varus/valgus
Runners need stability and they need power/strength

12. Dynamic Movement

13. Squat Tests
Bilateral squat test helps to tell you if the runner is more quad or glut dominant
Single leg squat does show the amount of proximal to distal control as well as balance
Single leg squat test can be scored on a scale to 6 with one point taken away: if hands come off the hips, trunk shifts, pelvic drop, knee goes medial to 2nd toe, inside of the foot elevates, and loss of balance.

14. Toe Yoga Shows the FHB muscle strength, control
“Shoes don’t stabalize the foot- muscles do”–Jay Dicharry

15. Dynamic Movement Heel raise ability
STJN position – can they maintain in STJN with full contact of the first ray
Postural stability and balance
Thomas test – Hip flexor tightness
Craig’s test – femoral retroversion, antiversion, neutral
Hip quadrant scoring and ROM
Core strength

16. Dynamic Assessment SI clearing tests Psoas tightness
Lumbar and thoracic spine mobility with PA mobs
Ober’s test for IT band
Glut max and medius strength
-MMT with IR/ext to exclude TFL for Glut Medius
-Glut max should some strength correlation to bilateral squat form
Patellar position
Ankle and foot mobility at 1st ray

17. Dynamic Assessment
Ankle joint mobility – anterior vs posterior tightness
1st toe mobility into DF

18. Shoes

19. Shoes

21. Shoes Classification of foot position???
- Wet test, static and dynamic navicular drop
Traditional running shoes are built with a 2:1 ratio, where rearfoot is twice as high as forefoot
Midsole impairs feedback
- Midsole stiffness has a marked effect on proprioception illustrating that peripheral sensory information is a variable in performance (Kurz et al, Gait Posture 2003)
- Too much cushioning causes the runner to land with increased limb stiffness, and can lead to instability secondary to less proprioceptive feedback for stability (Barnes et al, J Sports Sci 1994 and Bishop et al, J Athl Train 2006)

22. Shoes Things to consider:
- Try on shoes later in the day and there should be a about a half inch from the longest toe to the shoe.
- Is width ok
- If orthotics, will they fit in the shoe and also the style of the shoe – is it too much correction when added together?
- Is free flex point across the MET heads
- Durability: miles, and the midsole looses 40-55% cushion after miles
Foot pronation not associated with increased injury risk in novice runners wearing neutral shoe.
(Nielsen RO, et al 2014 Br J Sports Med)

23. Gait Evaluation

24. Running “Head to toe” Posterior view Lateral view
Anterior view (if able)
Camera placement – need room to capture the runner
Marking of landmarks?

25. Imbalances

26. Gait

27. Gait What is “good form” Stride length
Use posterior chain muscles of glut max and hamstrings

28. Gait Evaluation

29. Gait
Stride width

30. Running

31. Spring

32. Running

33. Gait
Gait with forward lean

34. Cadence
Ideal is steps per minute

35. Conclusion