Recommendations for Professional Physical Therapy Curricula for the Foot and Ankle

Clinical Sciences Matrix

Terminal Behavioral Objectives Example Instructional Example Instructional Primary Content After the completion of the Objectives for the classroom Objectives for the Clinic content, the student will be able to… Screening General Constitutional signs Select appropriate screening Recall and identify the clinical Apply results of written and Fatigue examination for the signs and patient response to verbal responses to a review of Fever integumentary, cardiopulmonary, written and verbal questions systems with subjective and Malaise neurological and musculoskeletal which indicate health objective clinical exam Weight change body systems to screen for conditions beyond the scope of findings to make the conditions beyond the scope of PT practice. determination that the patient Musculoskeletal PT practice that require a referral is: Fractures to another health care provider. 1. appropriate for PT Ottawa ankle Simulated case examples to 2. is appropriate for PT Rules recognize selected with referral Avulsion components. 3. not appropriate for PT Severe pain with and requires referral weight bearing elsewhere. Non-mechanical pain Systemic arthritides (i.e. gout) Rheumatic Diseases

Neurological • Dermatomal versus non-dermatomal (i.e. stocking glove) o Sensation testing 5.07 monofilament testing o Vibration - 128 Hz Myotomal patterns of weakness versus peripheral nerve injuries (i.e. common fibular nerve lesion)

Cardiopulmonary DVT - screening WELLS Criteria. Riddle et Peripheral vascular disease

Integumentary Infection open wounds post operative wounds abnormal skin and nail inspection

Psychosocial depression alcohol use

Examination Patient/Client history and Determine the Severity, The student will describe the By the final clinical review of medical record Irritability, Nature and Stage of components of the subjective experience, the student will utilizing the domains of the the complaint of the patient and examination and how the perform a subjective patient ICF model understand their relevance in the subjective examination examination rated at entry- domains of the ICF model. questions relate to the domains level by the clinical instructor System reviews based on of the ICF model. on the CPI patient/client needs recognize the components of the subjective examination that may The student will generate The student will compare and Use of Standard Tests and be part of the medical diagnosis (synthesis) a complete contrast the findings of the measures from Guide to PT and PT diagnosis to distinguish subjective examination to subjective examination to help Comment [S3]: Subjective exam alone will not be sufficient to make the tx Practice the b ----- s______f______determine the local, remote, determine if the patient is: vs refer determination. (BSF) impairments that require referred, or systemic origins of 4. appropriate for PT Specific to the Foot and Ankle assessment. the patient’s complaint. 5. is appropriate for PT Region: with referral 6. not appropriate for PT Red flags (specific to F&A) and requires referral 1. night sweats Select appropriate systems The student will recall the elsewhere. Comment [S2]: I believe in PT Guide terminology a systems review is 2. sleep disturbance examination techniques for the components of the screening decidedly different than the regional MS 3. change in neurologic integumentary, cardiopulmonary, examination and correctly The student determines the screen function neurological, and performs a screening appropriate tests and measures 4. change in musculoskeletal systems to assist examination to determine the for the screening specific to neurological status - in the progression to the specific local, remote, referred, or the foot and ankle. progressive weakness PT examination procedures, systemic origins of the and/or sensatory diagnosis, prognosis, and patient’s complaint. changes treatment plan

Yellow flags Diabetes - Charcot foot Progressive neurologic change - progressive weakness and/or sensation Comment [S1]: These are also noted changes under red flags. Should it be under just one heading?

DVT - screening WELLS Criteria. Riddle et al

Inspection/Observation Perform an inspection of the feet The student will: Interpret and integrate and ankles that includes noting Identify clinical signs of inspection and observation Swelling - Figure 8 test, and assessing when appropriate: inflammation in the foot and results into assessment and circumference measures, 1. swelling ankle. plan of care of patients with Comment [S4]: Patient first language Pitting edema - yes or no 2. integument foot and ankle dysfunction is generally accepted but not required. a. color texture Identify signs of a reduced Integument - b. toe nails autonomic response in the foot Color and texture:. Noting c. temperature and ankle. (insert picture) discoloration, shiny and or d. trophic changes ecchymosis. e. calluses Identify signs of vascular compromise (insert picture) Toe nails noting whether they Correlate inspection findings are dystrophic and thickened. with other exam findings when Identify signs of infection and determining assessment and plan other integumentary problems Temperature - hot or cold, of care sweat response Determine when to refer simulated patients to another Trophic changes - hair growth - healthcare provider for vascular problems integumentary problems of the foot and ankle Calluses: formation or lack of calluses, exostosis and boney overgrowth Foot Posture explain, conduct, and interpret The student will: The student will correctly Assessments/deformity measures of foot posture perform and apply the Foot perform, interpret, and including: Posture Index to assess foot integrate foot posture and Foot Posture Foot Posture Index posture deformity clinical findings Foot Posture Index Visual assessment of foot posture with the assessment and plan Weight bearing and non- (weight bearing and non-weight identify foot pronation and of care of patients with foot weight bearing visual bearing) supination postures in weight and ankle dysfunction assessment of hindfoot bearing and non-weight varus and valgus identify and explain the following bearing foot and ankle deformities: Forefoot • Hallux valgus identify and describe various Too many toes sign • Hammer toe foot deformities Medial longitudinal arch height • Claw toe (visual or navicular height) • Mallet toe • Overlapping/crossover Toe deformities: toes Hallux valgus • Morton's foot structure Hammer toe (2nd toe longer than the Claw toe 1st) Mallet toe • Metatarsus adductus Overlapping/crossover

Morton's foot structure (2nd toe Correlate foot posture assessment longer than the 1st) findings with other exam findings Metatarsus adducts when determining assessment

and plan of care

Movement Analysis The student will: The student will: Describe key components of a Perform gait assessment with a Gait assessment Perform a gait assessment gait assessment patient • Spatiotemporal measures Determine demonstrated gait Identify and describe gait Identify and document gait • Specific Visual deviations deviations performed by a deviations demonstrated by a Analysis Rancho Los simulated patient or patient patient Amigos method video • Common gait Select appropriate gait deviations related to the Perform gait assessment assessment procedures specific ankle and foot (see efficiently with a classmate to the patient condition and appendix Gait) setting • Gait speed Explain the rationale for • Stairs selection of various gait integrate gait assessment assessment procedures based findings with other tests and on setting, severity, intensity, measures and patient nature and stage functional status Correctly identify normal vs. abnormal motions of the ankle Describe key components of Discriminate patients Double Leg squats and foot during the double leg movement in the double and appropriate for double and • DF ROM squat test single leg squat tests single leg squat testing

• Visual analysis Perform double and/or single hindfoot, midfoot and Perform double and single leg leg squat test forefoot movement squat tests with a classmate

Correctly identify normal vs. Identify and document Single leg squats abnormal motions of the entire Identify deviations performed LE during the single leg squat movement patterns • LE alignment - note by a simulated patient or test demonstrated by a patient on femoral patient video during the double and/or single leg squat adduction/internal double and single leg squat Correlate movement analysis test rotation vs. femoral tests findings with other exam findings abduction/external when determining assessment rotation and plan of care

Running

Range of Movement The student will: The student will: Perform ROM examination Ankle Dorsiflexion Select the most appropriate Identify various tests and measures on a patient Weight bearing ROM measurement for measures to thoroughly assess Knee to wall- Distance of examination. patient impairments Perform ROM tests and toe to wall or inclinometer measures efficiently Knee straight - inclinometer, Correctly perform selected tests Describe the procedural (consider block for forefoot) and measures components for measuring Provide rational for ROM tests range of motion and measures selected Non-weight bearing Correctly interprets objective Knee straight - Supine measurement findings Relate the anatomic structures Conducts self assessments of Goniometry (Di Giovanni, being assessed by specific psycho-motor skills and Norkin & White 2003) Identifies the need for potential ROM measures modifies performance based on Ankle Plantar flexion test and measure modification feedback Non Weight bearing based on setting, severity, Identify common procedural Supine goniometry with the intensity, nature and stage errors when performing ROM distal arm aligned with the measurement inferior aspect of calcaneus Discriminates valid and reliable (old article Steve said) ROM tests and measures Perform an examination of a Comment [S5]: Need reference student in the classroom Subtalar Inversion/Eversion Correctly identifies joint end simulating ROM restrictions Non-weight bearing prone - feel / motion barriers with inversion/eversion observe passive motion assessment Provide a rational for choice of qualitatively and/or ROM measures selected goniometry. Correlates findings of ROM Foot Inversion/eversion measures to identified Non-weight bearing supine - abnormal motion patterns supine distal arm aligned with the 2nd metatarsal (citation Conducts self assessments of from Martin) (Norkin & psycho-motor skills and White) modifies performance based on feedback. Hallux dorsiflexion- Non-weight bearing or Analyze and discuss a patient- Weight bearing client video to identify (DNawoczenski, 200?) modifications to ROM testing Comment [S6]: Reference based on patient condition and Medial longitudinal arch - setting Weight bearing - Navicular drop test

Midfoot motion (Calcaneocuboid and talonavicular joints) Non-weight bearing - assess forefoot movement when the rear foot is everted and inverted. A normal test is when the foot is inverted and stability increases (i.e. less forefoot movement is noted).

Accessory Joint Movement Discriminate mobility findings Describe the relationship of Perform accessory joint as hypomobile, hypermobile or rear foot to forefoot mobility assessment measures Talocrural - posterior glide within normal limits. biomechanical axes and it on a patient test,anterior/posterior glides influence on joint mobility and /distraction Synthesize information from stability Perform accessory motion Subtalar- medial/lateral/anterior ROM assessment and accessory safely and efficiently glides/distraction movement testing to identify Perform mobility testing for the Talonavicular joint - bony versus soft tissue joints listed for hypomobility Provide rational for accessory dorsal/plantar gliding restrictions /normal/hypermobility to motion assessment. Calcaneocuboid - determine the potential for dorsal/plantar gliding Correlate ROM and mobility manual therapy interventions Conducts self assessments of First Ray mobility - dorsal assessment findings with other psycho-motor skills and /plantar movement exam findings when Correctly interpret findings of a modifies performance based on Distal tibiofibular - determining assessment and joint mobility assessment on a feedback. anterior/posterior gliding plan of care classmate Interphalangeal and Metatarsal phalangeal joints - Conducts self assessments of distraction/dorsal/plantar psycho-motor skills and gliding modifies performance based on feedback.

Strength Assessment to demonstrate competence in The student will: The student will: performing MMT of the foot interpret MMT and correlate analyze MMT tests of the foot Manual Muscle testing(MMT) and ankle findings with simulated foot and ankle in patients with foot Ankle plantar and ankle conditions and ankle dysfunction flexion/dorsiflexion/inversion/e demonstrate the ability to version/toe flexion/extension conduct and interpret heel raise interpret heel raise test results in discriminate modifications to tests (single leg and double leg). video clips of patients with foot assessment of muscle strength Hip/knee/trunk as indicated and ankle dysfunction based on a patient’s pathology, by movement analysis describe and administer sports irritability, and/or severity. specific tests for return to play discuss when to apply various Heel Rise Test - assessed for MMT of the foot and ankle generate hypotheses to address height, number of reps, rear describe and administer depending patients pathology, the probability a detected foot inversion or eversion functional tests for return to irritability, and/or severity weakness is directly caused by position, medial versus lateral work the pathology or is the result of forefoot pressure, arch height, discuss the reliability and a secondary effect (i.e. disuse). and comparison to normative to describe and perform validity issues associated with data functional tests associated with MMT of the foot and ankle. the foot and ankle including: Functional strength/return to 1) squats discuss the cause of muscle activity 2) step ups weakness in conditions 3) hopping associated with the foot and ankle (secondary result of Correlate strength assessment disuse or direct result of injury). findings with other exam findings when determining assessment and plan of care

Special Tests select, perform, and interpret The student will: The student will: Ankle - appropriate clinical special tests describe the procedural perform clinical special tests • Talocrural sprain to assist with assessment of foot components foot and ankle on a patient o anterior drawer and ankle conditions clinical special tests o talar tilt interpret special test results for • Syndesmotic sprain - Correlate special test findings accurately perform foot and integration into the assessment o dorsiflexion/ext with other exam findings when ankle clinical special tests and plan of care ernal rotation determining assessment and o squeeze plan of care discriminate validity and conduct self assessments of reliability of selected clinical psycho-motor skills and Tinel sign special tests modifies performance based on feedback. Windlass test identify common procedural errors when performing selected Ottawa(recent version) Foot special tests and Ankle Rules discriminate the appropriate use Thompson Test of foot and ankle special tests for simulated patients Clinical Prediction Rule for ankle instability

Palpation of Relevant The student will: Structures Identify key surface anatomical Discuss normal and potentially Perform an efficient structures relevant to abnormal clinical findings examination of a patient/client NOTE: Connect to relevant patient/client presenting chief identified from a palpation with foot/ankle pathology or diagnoses complaint(s). examination given selected complaint. pathological scenarios. Lateral Structures : Prioritize and demonstrate the Conduct a physical Fibula head/neck/shaft ability to apply the basic Perform an examination of a examination using palpation Fibularis longus/brevis mm concepts of gross anatomy to student in the classroom that techniques that contribute to Lateral malleolus the analysis of patient/client includes correct identification the formulation of the Anterior inferior tibiofibular problems related to and palpation of relevant differential diagnosis. joint musculoskeletal system of the osseous, musculotendinous, Anterior inferior tibiofibular leg, ankle, and foot. and/or neurovascular structures. Provides written and verbal ligament communication utilizing Calcaneus Differentiate normal vs. correct terminology and Peroneal tubercle abnormal findings obtained description for accurate Calcaneofibular ligament from surface anatomy recording of physical Fibular tendons palpation. examination findings. (Longus/Brevis) Cuboid Correlate palpation findings Conducts self-assessments of Styloid process 5 th metatarsal with other exam findings when psycho-motor skills and 5th metatarsal base/shaft/head determining assessment and modifies performance based on Sinus Tarsi plan of care feedback. Extensor digitorum brevis Anterior talofibular ligament

Dorsal Structures: Anterior compartment mm. Anterior inferior tibiofibular joint Anterior inferior tibiofibular ligament. Anterior tibialis tendon Extensor hallucis longus tendon Dorsalis pedis artery/pulse Extensor digitorum longus tendon Extensor digitorum brevis m. Talar neck Navicular 1st , 2 nd , 3 rd cuneiforms Metatarsals I-V base/shaft/head 1st metatarsal joint

Medial Structures: Medial malleolus Posterior tibialis tendon Flexor digitorum longus tendon Posterior tibial artery/pulse Deltoid ligament Talus Sustentaculum tali Calcaneonavicular “Spring" ligament Navicular tuberosity 1st cuneiform 1st metatarsal base/shaft/head Abductor hallucis m. 1st MTP joint

Posterior Structures: Calcaneus Achilles tendon Retrocalcaneal bursa Soleus m Gastrocnemius m

Plantar Structures: Calcaneus Calcaneal fat pad Calcaneal tubercle (medial) Plantar fascia/aponeurosis Metatarsal heads I-V Sesamoids

Vascular: -Popliteal Artery -Posterior Tibial Artery -Dorsalis Pedis Artery -Capillary Refill

Link between palpation and diagnosis. (Categorized above)

Confirmatory - should be done at the end Neurologic Examination Understand the proper selection The student will: The student will: Reflexes of the tests and measures is Discuss normal and potentially Perform neurologic Myotome dependent on: abnormal clinical findings examination measures on a Tinel's 1. Chief identified from each of the tests patient Tarsal Tunnel Test- complaint/subjective used in this area of examination dorsiflexion with eversion examination using clinical scenarios. Perform test and measures inversion and plantar flexion 2. Demographics efficiently and correctly (space occupying lesion) 3. SINS Perform these examination interpret results. 4. Functional level of tests correctly and safely SLUMP/SLR to test for patient proximal contribution to the interpret whether neurologic Conducts self assessments foot and ankle chief complaint finding(s) is/are specific to the psycho-motor skills and foot and ankle condition or modifies performance based on related to another condition of feedback. the LE or body systems . Interpret and integrate the results with the assessment and plan of care. Balance - Understand the proper selection The student will: The student will: --Romberg – Sharpened of the tests and measures is Discuss normal and potentially Perform balance measures on a Romberg dependent on: abnormal clinical findings patient --Single leg stance 1. Chief identified from each of the tests -----Eyes closed eyes open complaint/subjective used in this area of examination Perform test and measures -----head neck rotation examination using clinical scenarios. efficiently and correctly -----Surfaces - foam no foam 2. Demographics interpret results. -----assess for ankle, knee and 3. SINS Perform these examination hip strategy 4. Functional level of tests correctly and safely patient Modified Star Excursion Conducts self assessments of psycho-motor skills and Hop to Stabilization modifies performance based on Determines the need for a more feedback. in- depth fall risk assessment in selected patients Interpret and integrate the Assessment of falls risk - results with the assessment and BERG, TUG, Tinnetti, plan of care. Rickli and Jones

Lower Quarter Screen (LQS) Recognize the potential for The student will: The student will: Comment [S7]: Should this follow systems review earlier in the examination referred pain into the foot and correctly performthe perform a lower quarter screen matrix? ankle for means of specific components of a lower quarter on a patient to rule in /out examination of other body screen with a classmate referred pain and the need for regions, diagnosis, or potential specific examination of other referral to another healthcare recognize a referred pain body regions provider. pattern based on LQS examination results

Evaluation

Diagnosis PTTD Describes the continuum of dysfunction Describes the location and The student must have function of the TP and performs experience practicing clinical Discriminates between this diagnosis and MMT, and palpation of same. management of a tendinous pertinent differential diagnoses (rules out structure. the following): Describes the associated SPECIFICS? structural and movement The student describes having impairments including heel rise had exposure to an actual Describes signs and symptoms,relevant test and gait deviations. patient, a case study, history and examination including: simulation of a foot tendon • tenderness along the tendon problem, or related hooked- course on- evidence case. • reduced calcaneal inversion during heel rise • weak inversion/ PF • Abnormal alignment and The student supports movement associated with choosing examination items pronation consistent with severity and nature of the problem

Describes the continuum of dysfunction Describes location and function The student describes having Plantar Fasciitis of the plantar fascia including the had exposure to an actual Discriminates between this diagnosis and Windlass mechanism. Performs patient, a case study, pertinent differential diagnoses (rules out palpation of the plantar fascia simulation of a heel pain the following): patient, or related hooked- • Calcaneal stress fracture Describes associated structural on- evidence case. • Bone bruise and movement impairments • Fat pad atrophy including those seen during gait The student supports • Tarsal tunnel syndrome Performs an Examination of choosing examination items • Soft-tissue, primary, or metastatic potential sources of limited ankle consistent with severity and bone tumors dorsiflexion nature of the problem • Paget disease of bone

• Sever’s disease

• Referred pain as a result of an S1 radiculopathy

Describes signs and symptoms, relevant history and examination including: • Pain upon palpation of the proximal plantar fascia attachment • First step pain 1 st Toe extension reproduces pain at the proximal or distal attachment of ? ? PF?

Describes the continuum of tendinopathy Describes location and function The student describes having Achilles and progression of symptoms. of the Achilles tendon. Performs had experience in clinical Tendinopathy palpation and functional testing management of a tendinous Discriminates between this diagnosis and (heel rise and manual muscle structure pertinent differential diagnoses (rules out testing ). the following): The student supports • Acute achilles tendon rupture Performs palpation to determine choosing examination items • Partial tear of the Achilles tendon the anatomical location of the consistent with severity and • Retrocalcaneal bursitis tendinopathy nature of the problem • Posterior ankle impingement for an actual or simulated • Irritation or neuroma of the sural Describes the associated patient/ case study. nerve structural and movement (attached. hooked- on- • Os trigonum syndrome impairments including deviations evidence case) • Achilles tendon ossification in: Gait, unilateral heel rise, • Systemic inflammatory disease single limb hop, or ability to The student discriminates • Insertional Achilles tendinopathy descend stairs between a tendinous lesion • Boney enlargement on back of the and pertinent differential calcaneus (Haglunds deformity) diagnoses (rules in/out tendinous lesion)

Describes signs and symptoms, relevant history and examination including: • Localized pain and stiffness following periods of prolonged inactivity • Intermittent pain experienced during activity and exercise • Perceived tenderness and pain upon palpation to the Achilles tendon • Positive Achilles Tendon Palpation Test • Decreased plantar flexor strength with associated either increased or decreased dorsiflexion A? P? range of motion • limited ability to perform repetitive unilateral heel raises when compared to the contralateral side Lateral ankle Describes continuum of dysfunction of Describes the function of the The student describes having sprain and lateral ankle sprains and high anterior talo-fibular and calcaneo- had exposure to an actual syndesmotic/high ankle/syndesmotic sprain fibular ligaments. patient, a case study, ankle sprain simulation of a patient with Performs palpation of the ankle sprain or Describes signs and symptoms, relevant calcaneal-fibular and the anterior syndesmotic/high ankle history and examination including: tib-fib ligaments. sprain, or related hooked- on- - Pain with palpation of the evidence case. involved ligaments (ATFL, CFL, Performs a measurement of Ant tib-fib lig) swelling of the ankle using the - Mechanism of injury – figure of eight – in 20 degrees of inversion/plantarflexion (lateral plantar flexion ankle sprain) versus dorsiflexion and eversion (high ankle Performs a combination of tests sprain/syndesmotic) to assess ligament stability - Reproduction of ankle instability including: talar tilt, anterior or pain with special tests drawer for lateral ankle sprain and external rotation and squeeze test for high ankle sprain/syndesmotic sprain Discriminates between this diagnosis and pertinent differential diagnoses (rules out Describes the Ottawa Ankle the following): Rules and when to refer a patient • Peroneal tear for radiograph • Medial collateral ligament ankle sprain Supports choosing examination • Lisfranc items consistent with severity and Fracture/Dislocation nature of the problem • Subtalar sprain • Achilles tendon rupture • Lateral talar process injury • Anterior process of the calcaneus injury

Hallux Abducto- Describes the continuum of dysfunction Describes the location function The student describes having Valgus that can be addressed by a PT and of the 1st MTP and 1 st ray. had exposure to an actual patient, a case study, Discriminates between this diagnosis and Describes the associated simulation of hallux valgus, pertinent differential diagnoses (rules out structural and movement or related hooked- on- the following): impairments including: evidence case. • sesamoid stress fracture, • Palpation • avascular necrosis, • Gait The student supports • osteochondral fractures, and • Static foot alignment choosing examination items chondromalacia, • 1st MTP ROM consistent with severity and • metatarsalgia, nerve impingement, nature of the problem. • infection, • bursitis, The student performs an • sesamoiditis, assessment of the stability of an MTP joint. • bipartite sesamoids

(Hockenberry99, Dedmond 06).

Describes signs and symptoms, relevant history and examination including: • Palpation and observation including medial eminence tenderness, • severity of HAV deformity, • contribution of shoeware • static foot type based on standing alignment • Gait pattern and weight acceptance under 1 st MTP

Hallux Limitus Describes the continuum and etiology of Describes the location function The student describes having this dysfunction and of the 1st MTP, sesamoids, had exposure to an actual and 1 st ray. patient, a case study, a Describes signs and symptoms, relevant simulation of hallux limitus, history and examination including: Describes the associated or related hooked- on- • Limited accessory motion of the structural and movement evidence case. 1st MTP and/or ray. impairments including results of • Associated proximal alignments performing: The student supports and compensations due to reduced • palpation choosing examination items heel rise in gait and function. • gait examination consistent with severity and • Atypical function and position of • Static foot alignment nature of the problem. the sesamoid apparatus examination . • 1st MTP PROM The student performs an examination examination of the motion of • Flexor halluces longus the 1st MTP joint. manual muscle testing

Metatarsalgia Describes the continuum of dysfunction Describes the location and The student describes having function of the distal plantar had exposure to either an and discriminates between this diagnosis fascia, FDL, MTP joint capsule, actual patient, a case study, and pertinent differential diagnoses (rules interdigital nerve and fat pad. simulation of forefoot pain, or out the following): related hooked- on- evidence • Interdigital neuroma, Describes the associated case. • plantar keratosis, structural and movement • Frieberg’s disease, impairments including results of The patient supports choosing • Metatarsal stress fracture, performing: examination items consistent inflammatory arthropathy(such as • Palpation with severity and nature of rheumatoid arthritis, seronegative • Gait examination the problem. spondyloarthropathy, or • Manual Muscle testing of crystalline-induced arthritis), intrinsic foot muscle • tarsal coalition, strength • vertical talus, • Mulders test • or accessory navicular (Omey. • Tinel test Glasoe 05)

Describes signs and symptoms, relevant history and examination including: • Pain upon palpation of the distal 2-3rd metatarsal heads, plantar MTP, and FDL. • Special tests including digital Lachman, Drawer, or Mulders test • Pertinent gait abnormality Shin Splints/Medial Describes signs and symptoms, relevant • Performs palpation of Tibial Stress history and examination including: anterior compartment Syndrome • Pain in the front of the shin. muscles. • A patient who has high use (high • Performs palpation of the BMI or activity level) and poor anterior tibia where there foot alignment. is no muscle coverage. • Anterolateral lower leg pain is • Describes and performs often associated with the anterior demonstration ofthe compartment muscles. actions of the three • Anteromedial lower leg pain is muscles in the anterior indicative of stress fracture. compartment. Discriminates between this diagnosis and • Performs correct stretch pertinent differential diagnoses (rules out of each muscle in the the following): anterior compartment • Compartment Syndrome including elongation over all the joints each crosses. • Describes when to refer the patient to orthopaedics for diagnosis and management of a potential stress fracture.

Ankle Describes signs and symptoms, relevant Describes the associated The students describes having Osteoarthritis history and examination including for structural and movement had experience in the clinical (OA)- Non-surgical Non-surgical ankle OA: impairments including: management of OA. • Pain during and after activity Post-op • Continuum of joint deformity and description that surgical loss of motion management of OA can include • Prior history of ankle instability or Osteochondral procedures, ankle trauma replacement, or ankle fusion Describes signs and symptoms, relevant (while the current standard of history and examination including for care is ankle fusion for end stage Post-op OA: OA) • Obtains relevant information about surgical or medical Post-op –Describes and examines management to identify the tissues involved in the injury indications/contraindications for and/or surgery including the examination and intervention influence of time on return to function Neuropathic • Describes signs and symptoms, Performs the following The student performs a screen (Diabetic) Foot relevant history and examination examination items in the foot: for diabetes during the history including: Loss of protective • Visual exam of skin and The student describes and as sensation on at least on aspect of nails appropriate performs the plantar surface of the foot • Sensory examination of precautions for insensate feet (generally stocking/glove) the foot during examination and • Signs autonomic system • Palpation of pulses treatment. dysfunction (e.g. hair loss, loss of • Passive and active range sweating) of motion The student describes having • Diagnosis that can result in loss of had exposure to an actual peripheral sensation (diabetes, Performs a footwear examination patient, a case study, heavy metal, alcohol, idiopathic) discriminating between simulation, or in class patient Associated complications: appropriate and inappropriate lab of an individual with a • Ulcer formation footwear and orthosis neuropathic foot. • Neuropathic Charcot Arthropathy components • Joint deformity • Impaired balance Describes deformity and potential • Peripheral vascular consequences of each deformity disease/ischemia in people with this diagnosis (e.g. • Loss of joint mobility hammer/claw toe, medial and • Loss of foot bone mineral density lateral midfoot and hindfoot • Delayed bone and tissue healing deformity)

Perform examination of need for assistive device

Calcaneal Describes the continuum and etiology of • Describes that this Student describes having had Apophysitis this dysfunction problem warrants exposure to an actual patient (Sever’s from apophysitis through intervention and that if it or a case study of Sever’s Disease)/calcaneal epiphyseal fracture is a fracture it may require disease that includes its PT epiphyseal fracture • Explains that this type of immobilization for eight management. fracture cannot be diagnosed weeks followed by rehab through x ray, but rather is (stretching, strengthening, made through signs and balance work etc ) symptoms and responses to • Describes that the management. mechanism of injury is • Describes signs and symptoms, that the heel cord is tight relevant history and examination and pulls the calcaneal including: Pain at the heel; epiphysis apart. usually right at the posterior most • Performs appropriate tip secondary tests to address • Patient is a child of an age when force distribution and their calcaneus has not fully fused aberrant motion including (5-10 years) fabrication/adaptation of • History of high activity level temporary foot orthoses and/or growth spirt and heel lifts to support • Patient stands with heels in medial arch and/or eversion relative to subtalar hindfoot. neutral and associated dysfunctions functional leg length discrepancy shin splints proximal compensations and associated pains and dysfunctions Fracture (5 th Describes signs and symptoms, relevant Describes signs and symptoms, The student describes having metatarsal, history and screening examination relevant history and examination had experience with the PT navicular, midfoot) including: of fracture when performing clinical management of a • Pain with palpation Palpation of boney fracture. • Inability weight bear for 4 steps structures of the foot and • High incidence of non-union ankle

Describes signs and symptoms, relevant Student will describe a timeline history and examination related to to guide progression of care medical management including: : following the medical or surgical • Obtain relevant information about management of a fracture. surgical or medical management to identify indications/ contraindications for PT examination, intervention

Chronic Ankle Describes signs and symptoms, relevant Performs balance and The student describes having instability/ history and examination related to chronic proprioception testing. had exposure to either an functional and (functional and mechanical) ankle Performs a group of tests to actual patient with ankle mechanical instability including including: assess stability of ankle instability, a case study, or • patients with feelings of ligaments. simulation of a patient with instability, chronic ankle instability. • impaired balance and proprioception, The student supports • decreased passive or active range choosing examination items of motion. consistent with severity and nature of the problem. Discriminates between this diagnosis and pertinent differential diagnoses (rules out the following): • Peronal tendon pathology • Accessory ossicles • Tarsal coalition • Sinus tarsi syndrome • Subtalar sprains with or without instability • Spring or bifurcate ligament damage • Peronal tendon pathology • Accessory ossicles • Tarsal coalition • Sinus tarsi syndrome • Subtalar sprains with or without instability • Spring or bifurcate ligament damage • Ankle impingement Tarsal Tunnel Discriminates between this diagnosis and Performs palpation of posterior The student describes having pertinent differential diagnoses (rules out tibial nerve had exposure to either an the following): actual patient, a case study, or Performs the Tinel’s and simulation of a foot and ankle • Plantar fasciitis Provocative Tinel’s tests case in which they must choose to rule out • Describes signs and symptoms, involvement of the posterior relevant history and examination tibial nerve as a source of related to medical management symptoms. including: Distal production of symptoms with tapping (Tinel’s) of the posterior tibial nerve pathway. • Symptoms reproduced with sustained dorsiflexion- eversion of the foot

• Provocative Tinel’s: symptoms reproduced during tapping of the nerve pathway with the foot in dorsiflexion, maximal calcaneal eversion, and toes extended. (Kinoshita M, Okuda R, Morikawa J et al. The Dorsiflexion-Eversion Test for Diagnosis of Tarsal Tunnel Syndrome. J Bone Joint Surg Am. 2001; 83(12):1835-1839.) Do we need this first and last bullet? Equinus related to Describes signs and symptoms, relevant Discriminates between those The student any or all of the histor y and examination related to medical that do, and do not, attain heel describes having following: management including: strike during gait. had exposure to an • Passive • PROM DF less than 10 with the actual patient or a tightness of knee extended avoiding pronation Describes all the plantar flexor case study PF • Lack of heel strike during gait muscles that could be tight, involving clinical • Dynamic • Early heel off during gait (mild) active at the wrong time, or management tightness of • Stands with heels on ground and overly shortened. of an equinus foot PFors pronation or supination, walks on problem including (spasticity) toes (moderate) Performs PROM measurements discriminating • Poorly timed • Stands and walks on toes. (severe) of dorsiflexion with and without between origins of dorsiflexion pronation, with and without the equinus. This activity knee flexion involves • Weak or performing, absent Describes the likely presence of or describing, an dorsiflexors initial resistance (R1), verses examination that ultimate PROM (R2) in patients discriminates with spasticity. between tight plantar flexor muscle(s), joint limitation (s), poorly timed plantar or dorsiflexion, or excessive plantar flexion activity.

The student will discriminate between specific situations when referral is warranted being specific as to the type of referral (PT with neurological expertise, to physiatry or other MD skilled in medical management of spasticity including botulinum toxin injections, orthopaedic surgeon, neurosurgeon, or orthotist).

Hence, the student will describe that which discriminates a patient with plantar flexor spasticity from other patients.

Foot Supination • Describes signs and symptoms, Descriminates supination during The student supports Syndrome relevant history and examination the stated movements from other choosing examination items including: Related source motions consistent with severity and diagnosis including tibial stress nature of the problem. fracture, plantar fasciitis, Performs appropriate secondary metatarsal (MT) stress tests to address force distribution fracture/Metatarsalgia 1and 5, and aberrant motion The student discriminates sesamoiditis, fibularis (verbal/tactile cueing, taping, and excessive or poorly timed tendinopathy/tear, achilles orthosis fabrication and/or use). foot supination from other tendinopathy, Hallux abducto- motions during gait in a valgus, bunionette, Hallux limitus patient. • Hindfoot inversion, talo-navicular elevated, forefoot adduction, The student must describe plantarflexion first ray, reduced having had exposure to lateral arch height, during gait, actual, simulated and/or a hopping, running, and stepping relevant case study of foot • Callus formation at 1 st and 5 th supination syndrome. metatarsal heads • Footwear worn on lateral border • Force distribution and/or addressing aberrant motion identified reduces signs and symptoms • Associated proximal alignments and compensations (functional leg length discrepancies, lateral femoral rotation)

Foot Pronation • Describes signs and symptoms, Discriminates pronation during The student supports Syndrome relevant history and examination the stated movements from other choosing examination items including: Related source motions. consistent with severity and diagnosis including Medial tibial nature of the problem. stress syndrome , plantar fasciitis, Performs appropriate secondary metatarsal stress tests to reduce aberrant motion fracture/Metatarsalgia 2/3, (verbal/tactile cueing, taping, and The student discriminates Neuroma, PTTD, Achilles orthosis fabrication and/or use). excessive or poorly timed tendinopathy, Hallux Abducto- foot pronation from other valgus, Hallux Limitus, Fibularis motions during gait in a • Hindfoot eversion, talo-navicular patient descent, and forefoot abduction during gait, hopping, running, and The student describes having stepping had exposure to actual, • Callus formation at metatarsal simulated and/or a relevant heads 2 nd and 3 rd , and medial side case study of foot pronation of hallux syndrome. • Footwear worn on medial border of the shoe and under 2 nd and 3 rd metatarsal. • Correction of abberant motion identified reduces signs and symptoms • Associated proximal alignments and compensations (functional leg length discrepancies, medial tibial and femoral rotation, ?ipselateral pelvic drop)

Prognosis

Plan of Care

Intervention Therapeutic Exercises • Select and perform • Discuss rationale for • Design, implement, and • Balance appropriate therapeutic selecting specific progress an appropriate • Strengthening exercises therapeutic exercises, treatment program • Stretching • Demonstrate strategies including dosage, • Monitor patient • Endurance for the interventions • Demonstrate the ability response to • Apply principles of safe to instruct or perform interventions and practice to patient/client selected interventions modify as appropriate care • Discuss the principles of • • Deliver interventions exercise progression based on the best • Recognize and be able evidence available and to instruct patient on practice guidelines special interventions for the foot/ankle, including (but not limited to): o Plantar fascia stretching o Gastroc stretching, protecting the mid- foot o Foot intrinsic strengthening exercises o Proximal muscle strengthening including core, pelvis and LE

Padding • Understand the • Discuss the options to • Monitor patient (e.g. MT cookies, heel lifts, principles of the use of alter pressure response to padding donuts) padding for clinical distribution on the and make modifications conditions of the foot plantar aspect of the foot as necessary and ankle • Predict how different • Recognize when • Discuss the best types of padding may referral to other available evidence affect motion or plantar healthcare provider is regarding indications, pressure distribution appropriate contraindications, and • Demonstrate appropriate • precautions to utilizing placement of padding to padding techniques achieve the desired effect Footwear • Identify and discuss the • Evaluate the shoe fit of • Make recommendations structural features of a an individual for footwear and/or shoe o Length footwear modifications • Discuss the criteria for o Toe box width to address a particular proper shoe fitting o Toe box depth clinical condition • Describe the indications o Curvature of the o Running for footwear last population modifications,
Stability specialized footwear, • Make recommendations
Motion casting, or proper for footwear options control referral based on patient
Cushioni • presentation ng o Diabetic
population o Diabetic o Pronation population syndrome
Cushioni o Supination ng syndrome
Pressure o Neurologic distributi population on o Arthritic
Adequat population e toe box o width/ • Discuss the rationale for depth various features of a
shoe • Refer to appropriate • Identify the specific healthcare provider as components of a shoe necessary o Toe box o Heel counter o Vamp o Mid-sole o Sock liner Abnormal Motion • Discuss the rationale Excessive Motion o • Excessive Motion and best available • Describe the indications o Bracing evidence for each of the and recommendations • As available, observe or o Strapping interventions utilized to for bracing of the foot participate in the o Foot Orthoses control motion and ankle prescription, • Limited Motion • Discuss indications and o AFO fabrication, o Mobilization contraindications for o KAFO modification, or o Manipulation motion control, o Boot dispensing of bracing: including bracing and o Stirrup o AFO strapping o Lace-up o KAFO • Recognize the o Boot implications of • Describe the indications o Stirrup interventions on the and recommendations o Lace-up various components of for strapping of the foot the kinetic chain and ankle • Select and perform o Ankle Instability appropriate joint
Stirrup mobilization techniques
Basketwe related to limited motion ave • Discuss the rationale,
Heel lock indications, and o Medial Arch contraindications for
Low-Dye manipulation
Cross X
Reverse Six o Edema: Compression wrap with pressure gradient o Musculotendino us o support (Achilles) • As available, observe or • Recognize a patient participate in the (case) where foot prescription, orthotic management fabrication, would be appropriate modification, or • Understands the dispensing of a foot mechanism by which a orthosis foot orthosis restrains or o Custom encourages motion o Prefabricated • Observe the fabrication, o Accomodative modification, or fitting of a foot orthotic

Limited Motion • Demonstrates correct hand placement and technique when • Demonstrate proper providing grade I-IV technique when joint mobilizations to all performing at least one articulations of the joint mobilization of foot/ankle, 1 st MTP, and the foot/ankle complex inferior and superior tibiofibular joints • Discuss the rationale for parameters chosen for selected mobilization techniques • Identify indications for and safely perform manipulations: o Talocrural distraction o Subtalar joint o Cuboid whip Modalities • Discuss indications, • Monitor patient contraindications, and response to modalities precautions for utilizing and make modifications therapeutic modalities as necessary • Select and perform appropriate therapeutic modalities • Patient Education • Discuss specific clinical • Discuss footwear conditions with the considerations for patient and/or family, patients: including etiology, o Diabetes intervention options, and o Peripheral prognosis neuropathy • Educate patient o Peripheral regarding appropriate edema self-management o UMN Lesions strategies
Spasticit • Identify and discuss risk y factors and strategies for
Flaccidit injury prevention y o Trauma o Arthritic Conditions
OA
RA o Athletes Functional Training • •

APPENDICES

Appendix A

Table 18. Average values from various studies for a single heel rise test Author Sample Average Technique Repetitions Madeley, Young athletes 39 ± 11.7 Strings were used to document heel height and trunk 2006 199 (n = 30) position. The test was terminated if the participant (mean age 24 ± leaned forward touching the string at the level of their 5.7 years old) pectorals three times, the ipsilateral knee flexed, the dorsal aspect of the foot did not contact the string for three consecutive repetitions or the participant could no longer continue. At this point, the number of heel-rise repetitions that were performed was documented. One trial was used for this test. Lunsford, Adults (n = 27.9 ± 11.1 Each subject was allowed to touch the examiner with a 1995 199 203) single finger for balance. The test was terminated if (mean age men the subject leaned or pushed down on the examiner, the = 34.7 ± 8.5, subject's knee flexed, the plantar-flexion range of women = 29.3 ± motion decreased by more than 50% of the starting 5.0 years old) range of motion (measured quantitatively), or the subject quit or asked to stop. Jan, Adults (n = Male One examiner provided the finger-touch 2005 143 180) 21- 40 = 22.1 ± 9.8 support and counted the total number heel rises (21- 80 years 41- 60 = 12.1 ± 6.6 accomplished. Another examiner observed the old) 61- 80 = 4.1 ± 1.9 participant laterally for any extraneous trunk lean or knee flexion. The third examiner read the Female electrogoniometer output on the monitor and 21- 40 = 16.1 ± 6.7 terminated the test if the plantar flexion angle became 41- 60 = 9.3 ± 3.6 less than 50% of the maximum angle. 61- 80 = 2.7 ± 1.5 Appendix B Gait Velocity: NOTES Stride length: NOTES Cadence: NOTES Normal or Equal? Yes----NO Normal or Abnormal If no, what is Abnormal Cause: cause? Cause:

Task of Gait Weight Single Limb Single Limb Limb Limb Acceptance Support Support Advancement Advancement Phase of Gait Initial Contact Mid Stance Terminal Stance Pre Swing Initial, Mid, Reference Limb Loading Response Terminal Swing Contralateral Pre Swing Initial to Mid Mid to Terminal Initial Contact Mid and Terminal Limb Swing Swing Loading Response Stance ROCKER Heel rocker Ankle Rocker Forefoot rocker Forefoot rocker Ankle: Normal Strikes in relative From PF into DF of DF of ankle reaches DF to 25 degrees of Ankle remains in PF DF moves into PF ankle peak of 5-10 PF to assist knee to during initial swing, via foot to ground degrees flex to shorten limb need knee flexion to faster than tibia clear the limb moves forward Ankle Abnormal 1. Uncontrolled PF 1. Excessive DF 1. No heel rise prior Lack of PF Toe drag Int. Swing Common 2. Low Foot (knee flexion in to C/L contact KEY: Decreased Failure to achieve Findings Contact mid stance) 2. Contact area knee flexion neutral ankle for IC 3. Forefoot Contact 2. Early Heel Rise more lateral Loss of FF rocker 3. No forward tibial progression Foot: Normal Foot pronation best Early mid stance Rise of heel off the MTP joints continue Foot comes off the seen with calcaneal pronation may ground should see to extend, weight ground in the eversion and unlock continue, should supination to allow should progress over position it of midtarsal joints see pronation cease the foot to be rigid the 1 st MTP joint, maintained in pre late mid stance and with decrease WB supination is swing. Good place supination begin contact maintained to look for excessive Windlass pronation Mechanism Foot: Abnormal 1. Excessive 1. Midtarsal joints 1. Midtarsal joints 1. Lack MTP joint 1. Foot comes off calcaneal eversion remain unlocked remain unlocked extension ground in excessive 2. Limited calcaneal 2. Midtarsal joints 2. 1 st Ray does not 2. Excessive MTP pronation eversion remain locked PF extension 2. Foot comes off 3. Excessive MTJ 3. Excessive 3. Midtarsal joints 3. Roll off the side the ground in unlock inversion of remain locked of 1 st MTP jt. excessive supination 4. Limited MTJ hindfoot continues 4. 1 st ray in too 4. Roll off lateral unlock 4. Excessive much PF forefoot eversion of hindfoot continues

Gait Velocity: NOTES Stride length: NOTES Cadence: NOTES Normal or Equal? Yes----NO Normal or Abnormal If no, what is Abnormal Cause: cause? Cause: Task of Gait Weight Single Limb Single Limb Limb Limb Acceptance Support Support Advancement Advancement Phase of Gait Initial Contact Mid Stance Terminal Stance Pre Swing Initial, Mid, Reference Limb Loading Response Terminal Swing Contralateral Pre Swing Initial to Mid Mid to Terminal Initial Contact Mid and Terminal Limb Swing Swing Loading Response Stance

ROCKER Heel rocker Ankle Rocker Forefoot rocker Forefoot rocker Normal Yes---NO Yes---NO Yes---NO Yes---NO Yes---NO

ANKLE JOINT Normal Yes---NO Yes---NO Yes---NO Yes---NO Yes---NO If NO what is deviation?

What are possible causes for the deviation from normal?

FOOT Normal Yes---NO Yes---NO Yes---NO Yes---NO Yes---NO If NO what is deviation?

What are possible causes for the deviation from normal?

Appendix C Table 16. Normative values for the Single Limb Balance Test Age Gender Eyes Open Eyes Closed Mean of 3 Trials Mean of 3 Trials Mean Mean

Single Limb 18-39 Male 43.5±3.8 8.5±9.1 Balance Female 43.2±6.0 10.2±9.6 (in seconds) 317 40-49 Male 40.4±10.1 7.4±6.7 Female 40.1±11.5 7.3±7.4 50-59 Male 36.0±12.8 5.0±5.6 Female 38.1±12.4 4.5±3.8 60-69 Male 25.1±16.5 2.5 Female 28.7±16.7 3.1 70-79 Male 11.3±11.2 2.2 Female 18.3±15.3 1.9 80-89 Male 7.4±10.7 1.4 Female 5.6±8.4 1.3