R EQUERIMIENTOS

The plantar interossei and lumbricals are deep intrinsic muscles that lie on the plantar surface of the meta-tarsals rather than between them, as seen with the dorsal interossei. They have been grouped here because the PRT treatment of these muscles affects the release of both. Deep palpation over these structures elicits their tenderness, and their fasciculation will be felt during treatment.

Origin: Plantar interossei: Plantar surface of the third through fifth metatarsals Lumbricals: Flexor digitorum longus tendon

Insertion: Plantar interossei: Medial side of the proximal phalange of the same toe, dorsal digital expansion

Lumbricals: Proximal second through fifth phalanges, dorsal expansion of the extensor digitorum longus tendons

Action: Plantar interossei: Third through fifth toe adduction, MP flexion; assists interphalangeal (IP) extension Lumbricals: Second through fifth metacarpal phalangeal (MP) flexion;

assists proximal interphalangeal (PIP) and distal interphalangeal (DIP) extension

Innervation: Plantar interossei: S2-S3 (lateral plantar nerve)

First lumbrical: L5-S1 (medial plantar nerve)

Second through fourth lumbricals:

S2-S3 (deep branch of the lateral plantar nerve)

Plantar interossei

E6296/Speicher/Fig. 04.10a/532034/JG/R2

4thlumbrical 3rd lumbrical

2nd lumbrical 1st lumbrical

Second plantar layer

E6296/Speicher/Fig. 4.10b/531993/JG/R1

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Palpation Procedure

• Place the foot in a relaxed plantar-flexed posi-tion off the end of the treatment table or on your thigh.

• Palpate the density or firmness of the muscle contraction for these tissues over the plantar surfaces of the metatarsals while the patient flexes the toes against resistance.

• Note the location of any tender points or fas-ciculatory response of the muscles and over the metatarsal shafts.

• Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) or the thumbs at the location throughout the PRT treatment procedure until reassessment has occurred.

PRT Clinician Procedure

• The patient is prone with the knee flexed to

~60° with the ankle on your thigh.

• Cup the forefoot with your far hand while resting the dorsum of the foot on your thigh in maximal plantar flexion while your near hand monitors the lesion.

• Compress the metatarsal shafts together with your far hand while applying toe flexion.

• Apply rotation for fine-tuning with the far hand.

• Corollary tissues treated: Flexor digitorum brevis and longus, flexor hallucis longus and brevis

See video 4.5 for the plantar interossei and lumbricals PRT procedure.

Patient Self-Treatment Procedure

• Use the self-treatment procedure for the plan-tar fascia, but do not translate the heel toward the toes.

• The focus of the positioning should be on compressing the metatarsal shafts toward one another while applying toe flexion and rotation.

Plantar interossei and lumbricals palpation procedure.

Plantar Interossei and Lumbricals > continued

Plantar interossei and lumbricals PRT clinician procedure.

Plantar interossei and lumbricals patient self-treatment procedure.

Metatarsalgia

Metatarsalgia, or forefoot pain, is considered a symptom of another condition in the foot, such as Morton’s neuroma (Bauer et al. 2014). The condition can be acute as a result of high-impact activities, but it typically results from an overload of the plantar foot structures over time from kinetic chain compensation. The clinician must first determine and address the causative factors for this condition to ensure that the releases are sustained. If the foot continues to be irritated, the tissue lesions will likely return.

Common Signs and Symptoms

• Pain at and between the metatarsal heads

• Point tenderness over and between the metatarsal heads

• Decreased ability to bear weight on the affected structures

Common Differential Diagnoses

• Morton’s neuroma

• Sesamoid fracture

• Metatarsal stress fracture

• Hallucis rigidis

Clinician Therapeutic Interventions

• Determine the root of the patient’s condition (e.g., faulty biomechanics, particularly at the first and second metatarsals, plantar warts, leg length discrepancy, training alteration, surface change, shoe alteration).

• Consider requesting a radiograph or MRI to rule out fracture and nerve impingement at the forefoot and midfoot areas.

• Scan and treat the structures in the order presented in the Treatment Points and Sequencing box. However, base your treat-ment sequencing off the most dominant (tender) points first.

• Follow PRT with thermal ultrasound or laser, joint and/or neural mobilization, and myo-fascial massage.

• Implement open- and closed-chain strength-ening for the intrinsic foot, pretibial, hip, and core muscles.

• Implement PNF stretching of the triceps surae complex and plantar foot tissues.

• Consider using a metatarsal pad to spread and elevate the metatarsals, but base its use on patient response.

• Address any other insulting factors or con-ditions.

• Slowly progress the patient to dynamic physical activity.

Patient Self-Treatment Interventions

• Perform self-release on a daily basis or when irritated.

• PNF stretch the plantar foot structures and triceps surae complex after exercise on a daily basis. Do not stretch if it produces pain because doing so may result in additional tissue lesions.

• Perform self-massage for five to eight min-utes daily after stretching.

• Ice-massage the affected area when irritated.

If greater relief occurs with heat, apply heat (e.g., warm whirlpool or Jacuzzi). (Note: Con-sult with the clinician about where you are in the healing process, which will determine whether to apply heat or ice.)

Treatment Points and Sequencing 1. Plantar interossei and lumbricals 2. Flexor hallucis brevis

3. Plantar aponeurosis 4. Abductor hallucis 5. Abductor digiti minimi 6. Dorsal interossei 7. Posterior tibialis 8. Medial gastrocnemius 9. Soleus

10. Popliteus