CONSISTENCIA Y UTILIDAD DEL DERECHO REAL DE HERENCIA

Clinical Note: Have the client begin the following isometric testing using only a portion of their strength and then, over a count of 5, build up until maximum exertion is reached. If the therapist is concerned that a client may overpower them, then they should tell the client to resist their pressure with only equal counter-pressure, and then have the client match the increasing pressure being applied by the therapist, over a count of 5. The client is supposed to immediately tell the therapist if pain is felt, and stop the isometric testing to prevent further injury to involved tissues. The client needs to reach full exertion, if that is possible, to see if: a) there is full strength and then pain, indicating a mild strain to the tissues; or b) if weakness is encountered without any pain, which is a neurological red flag. This will require a referral back to their primary physician. If the client is told to use only part of their strength then both a) and b) could be missed.

If the client can perform strength testing while weight-bearing, do as follows (see Quick Testing):

Have the client perform each of these actions while they walk back and forth. If it is necessary to help the client keep their balance, place your hand on their shoulder and follow along with them as they walk. Even if you let the client walk back and forth on their own, stay close and be ready to assist them to stay upright. Note: these are not isometric tests, but since the musculature of the legs is very strong, isometric testing may be impractical as the client often overpowers the therapist.

Plantar Flexion Dorsiflexion Supination Pronation

Stand on toes, Stand on heels, Roll onto lateral edge of Roll onto inside edges of then walk. then walk. feet; knees coming further feet; knees coming together

apart (varus), then walk. (valgus), then walk.

13

Comprehensive Assessment for Massage Therapists

CHAPTER I ANKLE & FOOT

If the client cannot walk back and forth, perform the test by supporting as follows:

Hold out your hands palms up and tell the client to place their hands on top of yours. While the client performs these actions (as shown previously) standing in one spot, you can notice weakness or fatigue by the client putting pressure into your hand. It will be felt in one hand on the weak side, or onto both hands if bilaterally fatigued or weak. Difficulty with balance will cause the client’s pressure to alternate in amount. They may move side-to-side and/or forward and back. Have the client report any pain or sense of weakness. Perform the tests as described below:

Plantar Flexion Dorsiflexion Supination Pronation

1 2 3 4

First, have client go up onto toes while standing on both feet. Hold for 5 seconds, repeat 10 times. If there is no discomfort or fatigue, then repeat test one foot at a time. Remember to test unaffected side first. Plantar flexion is tested differently than other three motions because strength of plantar flexors usually requires time to fatigue before unilateral weakness will even begin to show. To test other three motions, have client perform and hold each motion (pictures 2, 3 and 4) for 20 to 30 seconds. To prevent any further injury, always do these three AR tests bilaterally.

ANKLE & FOOT ^{CHAPTER I}

If the client appears either acutely injured, or is unable to do the AR testing weight-bearing, then do the following:

• With the client supine (or high-sitting), tell the client to hold a position while they resist you moving their foot. Remember to increase the amount of pressure slowly. Move toward maximum yet pain-free exertion;

• Test dorsiflexion, plantar flexion, pronation and supination in this manner.

Resisted Plantar Flexion Resisted Dorsiflexion

Have client’s ankle in neutral position. To test all Stabilize above ankle with one hand, and apply plantar flexor muscles as a group, have client’s pressure or resistance with other hand across legs extended. Stabilize thigh with one hand, metatarsals. Have ankle in neutral position.

and with other, cup heel and have your forearm under client’s foot. Tell client to hold this position as you try to dorsiflex foot.

Resisted Pronation Resisted Supination

With ankle in neutral position, stabilize lower leg above ankle, then have your other hand cupped around calcaneus and lateral border of client’s foot against inside of your forearm.

Have them try to hold this position while you try to invert hindfoot and adduct forefoot (i.e., bring foot into supination).

With ankle in neutral position, stabilize lower leg above ankle, then have your other hand cupped around calcaneus and medial border of client’s foot against inside of your forearm.

Have them try to hold this position while you try to evert hindfoot and abduct forefoot (i.e., bring foot into pronation).

15

Comprehensive Assessment for Massage Therapists

CHAPTER I ANKLE & FOOT

Special Tests

Differential Muscle Testing

The therapist uses differential muscle testing on those muscles that have been possibly implicated as impaired, during AF- or AR-ROM testing, or by the client’s description of pain and/or dysfunction.

Differentiating Between Soleus & Gastrocnemius

Though these two muscles share the same tendon, the gastrocnemius crosses the knee while the soleus does not. Because of this, one is often more hypertonic and/or more painful than the other. Which muscle is affected depends on many factors such as daily activities, knee and ankle issues, etc.

1. Testing Both Muscles 2. Stressing Soleus

Stand at side of table and reach back to cup Keep position of resisting hand as in first picture, client’s calcaneus with hand while forearm is under but now knee is bent, making gastrocnemius less foot. Have client’s foot close to neutral and either efficient so soleus becomes prime mover.

resist client’s attempt to plantar flex or have them Compare results of two tests.

hold this position and try to dorsiflex foot.

Differentiating In Standing

1. First, have client stand on toes for a minute or more, (or they can go up on toes repeatedly if more fatiguing is required).

2. To make gastrocnemius insufficient and stress soleus more, have client flex knees slightly.

• Compare results of these two testing positions.

ANKLE & FOOT ^{CHAPTER I}

We can also stress the tibialis posterior specifically. It can be highly involved in plantar flexion when clients exert themselves while walking long distances or running, and especially climbing stairs. The tibialis anterior can also be stressed specifically.

Testing Tibialis Posterior Testing Tibialis Anterior

Plantar flex and invert foot for client and then try Dorsiflex and invert foot. Ask client to hold position.

to dorsiflex and evert foot as client resists. As they resist, try to plantar flex and evert foot.

Testing Fibularis (Peroneus) Longus & Brevis

These muscles both evert and plantar flex the foot. The fibularis muscles are commonly injured (eccentric muscle strain) when the client sprains the lateral ligaments of the ankle. Often tender on palpation when clients suffer chronic ankle and foot ailments.

Testing Fibularis Longus & Brevis

Passively evert and plantar flex foot. Next, have client resist dorsiflexion and inversion. Note: You cannot differentiate between longus and brevis, as they are too close together and fibres run in same direction.

17

Comprehensive Assessment for Massage Therapists

CHAPTER I ANKLE & FOOT

The fibularis (peroneus) tertius helps to evert and dorsiflex the foot. Therefore, we can resist the client performing these motions simultaneously; or we can place the foot in inversion and dorsiflexion and have the client resist our attempt to move it out of that position. The latter is preferred.

Testing Fibularis Tertius

Evert and dorsiflex foot for client. Then have client resist you trying to invert foot.

The long flexors and extensors of the toes also need investigation here, as they can contribute to talocrural joint motions, as well as their principal task of moving the phalanges.

Testing Flexor Hallux Longus Testing Flexor Digitorum Longus

Flex client’s big toe for them, then try to Flex toes for client and then have them resist extend toe by pressing up on distal phalange. you trying to extend them. Your pressure It should be strong enough to resist. should be exerted at distal phalanges.

Testing Extensor Hallux Longus Testing Extensor Digitorum Longus & Brevis

Lift big toe into extension. Have client hold Extend client’s toes for them. Ask client to try extension while you try to flex toe. Client to extend toes further as you resist. To stress should be able to resist. Weakness without brevis more, dorsiflex foot to make longus pain suggests problem with L5 motor nerve. insufficient and then have client extend.

ANKLE & FOOT ^{CHAPTER I}