1. Ankle & Foot (3)

2. Flexion: Metatarsophalangeal Joint

3. Range of motion Range of motion Great Toe : 0° – 45 ° Lateral Four Toes : 0° – 40 ° Testing position Testing position Supine or sitting, ankle & foot in 0° of dorsiflexion, plantar flexion, inversion, eversion. MTP in 0° abduction & adduction. IP 0° of flexion & extension Stabilization Stabilization Stabilize metatarsal to prevent plantar flexion of ankle & inversion or eversion of foot. Do not hold MTP of other toes in extension, because tension in transverse metatarsal ligament will restrict the motion

4. Goniometer Alignment Goniometer AlignmentFulcrum Dorsal aspect of MTP joint Proximal Arm Dorsal midline of metatarsal Distal Arm Dorsal midline of proximal phalanx

5. Alternative Goniometer Alignment For First Metatarsophalangeal Joint Alternative Goniometer Alignment For First Metatarsophalangeal JointFulcrum Medial aspect of the first MTP joint Proximal Arm Medial midline of the first metatarsal Distal Arm Medial midline of the proximal phalanx the first toe

6. Patient Instruction Patient Instruction Ask the patient to Bend their toe.

7. Normal End Feel Normal End Feel Firm, because of tension in: Dorsal Joint capsule Dorsal Joint capsule Collateral ligaments Collateral ligaments Extensor digitorum brevis Extensor digitorum brevis

8. Hallux & Toe Metatarsophalangeal Flexion Muscles Lumbricales Flexor Hallucis Brevis

9. Lumbricales Origin: Tendons of Flexor digitorum longus + 1 st lumbricale + 2 nd -4 th lumbricales 2 nd -4 th lumbricales Insertion: Toes 2-5 (proximal phalanges & dorsal expansions of tendons of Extensor digitorum longus) Innervation: Medial Planter Nerve (L5-S1)  1 st lumbricale Lateral Planter Nerve (S2-S3)  2 nd 3 rd 4 th lumbricales

10. Flexor Hallucis Brevis Origin: Lateral head: cuboid bone + lateral cuneiform bone Medial head: medial intermascular septum + tendon of Tibialis posterior Insertion: Lateral & Medial heads : Hallux ( proximal phalanx on both sides of base) + blend with abductor hallucis Intervention: Medial Planter Nerve (S1-S2)

11. 1- Hallux MP Flexion (Flexor Hallucis Brevis) Test For Grades 5, 4, 3, 2, 1 and 0 Patient Position Patient Position The patient is short sitting with legs hanging over the edge of the table. The ankle is in a neutral position Therapist and Patient Instructions Therapist and Patient Instructions The therapist is seated on a stool in front of the patient. The test foot rests on the examiner's lap. The therapist stabilizes the dorsum of the foot just below the ankle with one hand, and uses the index finger of the other hand to resist beneath the proximal phalanx of the great toe. Ask the patient to, “Bend your big toe over my finger. Hold it. Don’t let me straighten it.”

12. Test For Grades 5, 4, 3, 2, 1 and 0 Grade 5 (Normal): completes full range of motion and holds against maximal resistance. Grade 4 (Good): completes available range of motion and holds against strong to moderate resistance. Grade 3 (Fair): patient completes available range of MP flexion of great toe but unable to hold against any resistance Grade 2 (Poor): completes only partial range of motion. Grade 1 (Trace): therapist my note contractile activity but no toe motion Grade 0 (Zero): no contractile activity

13. 2- Toe MP Flexion (Lumbricales) Test For Grades 5, 4, 3, 2, 1 and 0 Patient Position Patient Position The patient is short sitting with legs hanging over the edge of the table. The ankle is in a neutral position Therapist and Patient Instructions Therapist and Patient Instructions The therapist is seated on a stool in front of the patient. The test foot rests on the examiner's lap. The therapist stabilizes the dorsum of the foot just below the ankle with one hand, and uses the index finger of the other hand to resist beneath the MP joints of the four lesser toes. Then patient actively flexes the toes at the MP joints, keeping the IP joints neutral. Ask the patient to, “Bend your toes over my finger.”

14. Test For Grades 5, 4, 3, 2, 1 and 0 Grade 5 (Normal): completes full range of motion and holds against maximal resistance. Grade 4 (Good): completes available range of motion and holds against strong to moderate resistance. Grade 3 (Fair): patient completes available range of MP flexion of toes but unable to hold against any resistance Grade 2 (Poor): completes only partial range of motion. Grade 1 (Trace): therapist my note contractile activity but no toe motion Grade 0 (Zero): no contractile activity

15. Extension: Metatarsophalangeal Joint

16. Range of motion Range of motion 0° to 50°-70 ° Testing position Testing position Supine or sitting, ankle & foot in 0° of dorsiflexion, plantar flexion, inversion, eversion. MTP in 0° abduction & adduction. IP 0° of flexion & extension Stabilization Stabilization Stabilize metatarsal to prevent dorsiflexion of ankle & inversion or eversion of foot. Do not hold MTP of other toes in flexion, because tension in transverse metatarsal ligament will restrict the motion

17. Goniometer Alignment Goniometer AlignmentFulcrum Dorsal aspect of MTP joint Proximal Arm Dorsal midline of metatarsal Distal Arm Dorsal midline of proximal phalanx

18. Alternative Goniometer Alignment For First Metatarsophalangeal Joint Alternative Goniometer Alignment For First Metatarsophalangeal JointFulcrum Medial aspect of the first MTP joint Proximal Arm Medial midline of the first metatarsal Distal Arm Medial midline of the proximal phalanx the first toe

19. Patient Instruction Patient Instruction Instruct the patient to extend their toe.

20. Normal End Feel Normal End Feel Firm, because of tension in: Planter Joint capsule Planter Joint capsule Planter pad Planter pad Flexor hallucis brevis Flexor hallucis brevis Flexor digitorum brevis Flexor digitorum brevis Flexor digiti minimi Flexor digiti minimi

21. Hallux & Toe MP & IP Extension Muscles Extensor Digitorum Longus Extensor Digitorum Brevis Extensor Hallucis Longus

22. Extensor Digitorum Longus Origin: Lateral condyle of tibia + shaft of fibula + fascia cruris + interosseous membrabe + intermascular septum Insertion: Toes 2-5 (to each middle & each distal phalanx, dorsal surface) Innervation: Deep Peroneal Nerve (L5-S1)

23. Extensor Digitorum Brevis Origin: Calcaneus + lateral talocalcaneal ligament + extensor retinaculum Insertion: Ends in four tendons: Hallux ( proximal phalanx, dorsal surface) + toes 2-4: join tendons of extensor digitorum longus Innervation: Deep Peroneal Nerve (L5-S1)

24. Extensor Hallucis Longus Origin: Shaft of fibula + interosseous membrane Insertion: Hallux (distal phalanx, dorsal aspect of base) + expansion to proximal phalanx Innervation: Deep Peroneal Nerve (L5)

25. 1- Hallux Test For Grades 5, 4, 3, 2, 1 and 0 Patient Position Patient Position The patient is short sitting or supine. Ankle is neutral Therapist and Patient Instructions Therapist and Patient Instructions The therapist stabilizes the metatarsal area by contouring hand around the plantar surface of the foot with the thumb curving around the base of the great toe. The other hand stabilizes the foot at heel. For resistance, place the thumb over the MP or IP joint. Ask the patient to, “straighten you big toe, hold it.”

26. 2- Toes Test For Grades 5, 4, 3, 2, 1 and 0 Patient Position Patient Position The patient is short sitting or supine. Ankle is neutral Therapist and Patient Instructions Therapist and Patient Instructions The therapist uses both hands to stabilize the metatarsals with the fingers on the plantar surface and the thumbs on the dorsum of the foot. The other hand is used to give resistance with the thumb placed over the dorsal surface of the proximal phalanges of the toes. Ask the patient, “straighten you toes, hold it.”

27. Test For Grades 5, 4, 3, 2, 1 and 0 Grade 5 (Normal) & Grade 4 (Good): : patient can extend the toes fully against variable resistance (which may be small) Grade 3 (Fair) & Grade 2 (Poor): patient can complete range of motion with no resistance (Grade 3), or can complete partial range of motion (Grade 2). Grade 1 (Trace): tendons of the Extensor digitorum longus can be palpated or observed over dorsum of metatarsals. Tendon of the Extensor digitorum brevis often can be palpated on the lateral side of the dorsum of the foot just in front of the malleolus Grade 0 (Zero): no contractile activity

28. Abduction: Metatarsophalangeal Joint

29. Testing position Testing position Supine or sitting, foot in 0° of inversion & eversion. MTP & IP 0° of flexion & extension Stabilization Stabilization Stabilize metatarsal to prevent inversion or eversion of foot.

30. Goniometer Alignment Goniometer AlignmentFulcrum Dorsal aspect of MTP joint Proximal Arm Dorsal midline of metatarsal Distal Arm Dorsal midline of proximal phalanx

31. Normal End Feel Normal End Feel Firm, because of tension in: Joint capsule Joint capsule Collateral ligaments Collateral ligaments Fascia of the web space between toes Fascia of the web space between toes Addactor hallucis Addactor hallucis Planter interosseus muscles Planter interosseus muscles

32. Adduction: Metatarsophalangeal Joint

33. Adduction is the return from abduction to the 0 starting position, it is not usually measured

34. Flexion: IP Joint of First Toe & PIP Joints of Four Lesser Toes

35. Range of motion Range of motion Great Toe : 0° to 30 ° – 90 ° Lateral Four Toes : 0° to 35 ° – 65 ° Testing position Testing position Supine or sitting, ankle & foot in neutral Stabilization Stabilization Stabilize metatarsal & proximal to prevent dorsiflexion or planterflexion of ankle & inversion & eversion of foot. Avoid flexion & extension of the MTP joint

36. Goniometer Alignment Goniometer AlignmentFulcrum Dorsal aspect of IP joint being tested Proximal Arm Dorsal midline of proximal phalanx Distal Arm Dorsal midline of the phalanx distal to the joint being tested

37. Normal End Feel Normal End Feel May be soft: because of compression of soft tissues between the planter surfaces of the phalanges because of compression of soft tissues between the planter surfaces of the phalanges Sometimes it might be firm, because of tension in: Dorsal Joint capsule Dorsal Joint capsule Collateral ligaments Collateral ligaments

38. Flexion: DIP Joints of The Four Lesser Toes

39. Range of motion Range of motion 0° to 30 ° 0° to 30 ° Testing position Testing position Supine or sitting, ankle & foot in neutral Stabilization Stabilization Stabilize metatarsal,proximal and middle phalanx to prevent dorsiflexion or planterflexion of ankle & inversion & eversion of foot. Avoid flexion & extension of the MTP & PIP joints of the toe being tested

40. Goniometer Alignment Goniometer AlignmentFulcrum Dorsal aspect of DIP joint being tested Proximal Arm Dorsal midline of middle phalanx Distal Arm Dorsal midline of the distal phlanx

41. Normal End Feel Normal End Feel Firm, because of tension in: Dorsal Joint capsule Dorsal Joint capsule Collateral ligaments Collateral ligaments Oblique retinacular ligament Oblique retinacular ligament

42. Hallux & Toe DIP & PIP Flexion Muscles Flexor Digitorum Longus Flexor Digitorum Brevis Flexor Hallucis Longus

43. Flexor Digitorum Longus Origin: Shaft of tibia + fascia over tibialis posterior Insertion: Toes 2-5 (distal phalanges, planter surfaces & bases) Innervation: Tibial Nerve (L5-S2)

44. Flexor Digitorum Brevis Origin: Calcaneus + plantar aponeurosis + intermascular septum Insertion: Toes 2-5 (by four tendons to middle phalanges, both sides) Innervation: Medial Plantar Nerve (S1-S2)

45. Flexor Hallucis Longus Origin: Shaft of fibula + interosseous membrane + intermascular septum + fascia over tibialis posterior Insertion: Slip of tendon to Flexor digitorum longus + hallux Innervation: Tibial Nerve (L5-S2)

46. Test For Grades 5, 4, 3, 2, 1 and 0 Patient Position Patient Position The patient is short sitting with foot on examiner's lap, or supine. Therapist and Patient Instructions Therapist and Patient Instructions The therapist is seated on a stool in front of the patient. One hand grasps the anterior foot with fingers placed across the dorsum of the foot & the thumb under the (PIP) or (DIP) or under the IP of the hallux for stabilizaion. The other hand applies resistance using the examiner’s four fingers or thumb under the middle phalanges (for the IP test); under the distal phalanges (for the DIP test); & with the index finger under the distal phalanx of the hallux Ask the patient, “Curl your toes. Hold it. Curl your big toe. Hold it.”

47. Test For Grades 5, 4, 3, 2, 1 and 0 Grade 5 (Normal) & Grade 4 (Good): : patient complets range of motion of toes & then hallux; resistance in bothe tests may be minimal Grade 3 (Fair) & Grade 2 (Poor): patient can complete range of motion with no resistance (Grade 3), or can complete partial range of motion (Grade 2). Grade 1 (Trace) & Grade 0 (Zero): minimal to no palpable contractile activity occurs. Tendon of the Flexor hallucis longus may be palpated on the planter surface of the proximal phalanx of the great toe

48. Good Luck To You All Good Luck To You All