2. RHS 221 Manual Muscle Testing Theory – 1 hour practical – 2 hours Dr. Ali Aldali, MS, PT Department of Physical Therapy King Saud University

3.  Brief Review of Anatomy  Evaluation of the Ankle and foot Joints  Muscle Testing and rang of motion measurement of the ankle and foot Joints.

4. Tibia Fibula Distal Tib-fib joint Talus Ankle Mortise Calcaneus Subtalar Joint

5. Talus Calcaneus Navicular Cuboid Cuneiforms 1, 2, 3 Metatarsals Proximal Phalanges Middle Phalanges Distal Phalanges

6. Rearfoot Forefoot Talonavicular Joint Calcaneocuboid Joint

7. Tibonavicular (Deltoid) Tibocalcaneal (Deltoid) Posterior (Deltoid) Long Plantar Plantar calcaneonavicular (Spring Ligament)

8. Ant Tibiofibular Ant Talofibular CalcaneofibularCalcaneofibular Long Plantar

9. Tibialis Anterior Extensor Digitorum Extensor Hallicus Longus

10. Gastrocnemius: Medial and Lateral heads Achilles Tendon PlantarisPlantaris SoleusSoleus

11. Flexor Digitorum Tibialis Posterior Flexor Digitorum Tendon Tibialis Posterior Tendon Flexor Hallicus Longus

13.  Requires 75 0 of 1st MTP extension - occurs as result of:  heel lift  STJ supination  1st MT shorter than 2nd  normal sesamoid function Normal gait:

15. 1. Ankle Planter Flexion. 2. Foot Dorsiflexion and Inversion. 3. Foot Inversion. 4. Foot Eversion with Plantar Flexion

16. 1. Prim mover /agonist: Origin Insertion Gastrocnemius Medial head Femur (medial condyle) Tendo Calcaneus-calcaneus (posterior) Lateral head Femur (lateral condyle) Tendo Calcaneus ….. Soleus Fibula (posterior) Tendo Calcaneus-calcaneus (posterior) 2. Synergist / Accessory Muscles: Tibialis posterior, plantaris, peroneus longus & brevis, Flexor digitorum & hallucis longus. 3. Nerve supply: Gastrocnemius & Soleus: Tibia n. 4. Range of motion: from 0 to 45 ْ

19. 5. Fixation: By Weight of thigh. 6. Effect of weakness and contracture: effect of weak : result in an hyperextension of the knee as well as in a non-weight bearing position as in standing. During walking the inability to rise on toes. effect of contracture: - result in an equinus position of the foot and flexion of the knee. - also a restriction of the ankle dorsiflexion when the knee is extended and a restriction of the knee extension when the ankle is dorsiflexed. 7. Factor Limiting of motion: a. Tension of anterior talofibular ligament and anterior fibers of deltoid ligaments. b. Tension of dorsiflexor muscles. c. Contact of posterior portion of talus with tibia. 8. Substitution: by 1. Flexor hallucis longus and flexor digitorum longus 2. Peroneus longus and brevis. 3. Tibialis posterior.

20. 9. Procedures: WB test and Non WB test a- patient position (pt): b- Therapist Position: inner hand: Outer hand: Direction of Resistance : Instruction to patient: c- grading system: Normal(5), Good(4), Fair(3), Poor(2), Trace(1), Zero(0) make sure patient tolerates maximal resistance plus hold 3 sec. e. Palpation site:

21.  The Achilles tendon, the largest tendon in the body, spans two joints and connects the calcaneus to the gastrocnemius and soleus muscles, comprising the largest and strongest muscle complex in the calf (Figure 1). The tendon is vulnerable to injury because of its limited blood supply, especially when subjected to strong forces.Figure 1  Injury onset can be gradual or sudden, and the course of healing is often lengthy. A thorough history and specific physical examination are essential to make the appropriate diagnosis and facilitate a specific treatment plan. The mainstay of treatment for tendonitis, peritendonitis, tendinosis, and retrocalcaneobursitis is ice, rest, and non-steroidal anti-inflammatory drugs, but physical therapy, orthotics, and surgery may be necessary in recalcitrant cases.  In patients with tendon rupture, casting or surgery is required. Appropriate treatment often leads to full recovery.

22.  Gastrocnemius-soleus-Achilles complex  Spans 3 joints  Flex knee  Plantar flex tibiotalar joint  Supinate subtalar joint  Up to 10 times body weight through tendon when running

23.  Physical  Partial  Localized tenderness  Complete  Defect  Cannot heel raise  Positive Thompson test

24. 1. Prime mover/agonist: Tibialis Anterior origin insertion Tibialis Anterior tibia (lat. Condyle) 1 st cuneiform (on medial surf.) 1 st metatarsal (base). 2. Synergist/ Accessory muscles: Peroneus tertius, extensor digitorum and hallucis longus. 3. Nerve supply: Deep peroneal n. (L4-S1) 4. Range of motion: 0 ْ to 20 ْ

25. 5. Fixation: a. By weight of leg. 6. Effect of weakness/contracture/shortening: effect of weakness: decrease the ability to dorsiflex the ankle joint, result to (droop of foot). effect of contracture: in ability to plantarflex the ankle. 7. Factor limited range of motion: a. Tension of latero-tarsal ligament. b. Tension of peroneus longus and peroneus brevis muscles. c. Contact of tarsal bone medially 8. Substitution: By the extensor digitorum and hallucis longus muscles results in toes extension

26. 9. Procedures: a- patient position (pt): b- Therapist Position: inner hand: Outer hand: Direction of Resistance : Instruction to patient: c- grading system: Normal(5), Good(4), Fair(3), Poor(2), Trace(1), Zero(0) make sure patient tolerates maximal resistance pluse hold 3 sec. e. Palpation site:

27. 1. Prime mover/agonist: Tibialis posterior origin insertion Tibialis posterior tibia post. (lat. Condyle) Navicular bone (tuberosity) Fibula (proximal posterior medial). 1 st cuneiform 2. Synergist/ Accessory muscles: Peroneus tertius (with Dorsiflexion), extensor digitorum and hallucis longus. 3. Nerve supply: Tibial (medial popliteal) n. (L4-L5) 4. Range of motion: 0 ْ to 35 ْ

28. 5. Fixation: a. By weight of leg. 6. Effect of weakness/contracture/shortening: effect of weakness: may dropping in medial arch of the foot. ( flat foot). effect of contracture: in ability to plantarflex & evert the ankle. 7. Factor limited range of motion: a. Tension of latero-tarsal ligaments. b. Tension of peroneal muscles group. c. Contact of lateral bones medially. 8. Substitution: By the flexors digitorum and hallucis longus muscles results in toes flexion

29. 9. Procedures: a- patient position (pt): b- Therapist Position: inner hand: Outer hand: Direction of Resistance : Instruction to patient: c- grading system: Normal(5), Good(4), Fair(3), Poor(2), Trace(1), Zero(0) make sure patient tolerates maximal resistance pluse hold 3 sec. e. Palpation site:

30. 1. Prime mover/agonist: origin insertion Peroneus longus Fibula (head & lat. Aspect) 1 st Metatarsal (base & lat aspect) Peroneus brevis Fibula (middle & lat. Aspect) 5 th Metatarsal (tuberosity, at base, & lat. Aspect) 2. Synergist/ Accessory muscles: Gastrocnemius. 3. Nerve supply: Superficial peroneal n. (L5-S1) 4. Range of motion: 0 ْ to 25 ْ

31. 5. Fixation: a. By weight of leg. 6. Effect of weakness/contracture/shortening: effect of weakness: may results in:  Decrease the strength of eversion of the foot & planter flexion of the ankle jt.  Decrease lateral stability of the foot. effect of contracture: results in an everted or valgus position of the foot. 7. Factor limited range of motion: a. Tension of medial tarsal ligaments. b. Tension of tibialis anterior and tibialis posterior muscles. c. Contact of tarsal bones laterally 8. Substitution: No substitution.

32. 9. Procedures: a- patient position (pt): b- Therapist Position: inner hand: Outer hand: Direction of Resistance : Instruction to patient: c- grading system: Normal(5), Good(4), Fair(3), Poor(2), Trace(1), Zero(0) make sure patient tolerates maximal resistance plus hold 3 sec. e. Palpation site: