Foot and Ankle Curricular Guidelines for Physical Therapist Professional Degree Programs

Home , Ankle fusion, Gait abnormality, Ottawa ankle rules

FOOT AND ANKLE CURRICULAR GUIDELINES FOR PHYSICAL THERAPIST PROFESSIONAL DEGREE PROGRAMS

Sponsored by the: Foot and Ankle Special Interest Group, Orthopaedic Section, APTA, Inc.

2015

INTRODUCTION 3 Foot and Ankle Curricular Guideline Task Force 3 Purpose 4 Method of Document Development 4 Task Force Guiding Principles 5 RECOMMENDATIONS FOR PROFESSIONAL PHYSICAL THERAPY CURRICULA FOR THE FOOT AND ANKLE 5 Organization of the Curricular Guideline 5 Foot and Ankle Clinical Sciences Matrix 6 Examination 6 History 6 Systems review 7 Tests and measures 8 Evaluation 18 Diagnosis 18 Plan of Care 30 Intervention 30 Appendix 1A 35 Appendix 1B 36 Appendix 2 37 Appendix 3 38 REFERENCES 38

2 Foot and Ankle Curricular Guidelines 2015

INTRODUCTION

Foot and Ankle Curricular Guideline Task Force This manuscript is based on the input and draft writing of the full Task Force who are listed alphabetically. It was formatted, completed and edited by the first three authors. All authors had the opportunity for final review prior to dissemination.

Task Force Members: Christopher Neville, PT, PhD (Task Force Chair), Associate Professor, Upstate Medical University, Syracuse, NY ([email protected]) Lisa Selby‐Silverstein, PT, PhD, NCS (Primary Editor), Professor, Neumann University, Aston, PA ([email protected]) Clarke Brown, PT, DPT, OCS, ATC (FASIG President), Owner, BrownStone Physical Therapy, Macedon, NY ([email protected]) Stephanie Albin, DPT, Intermountain Healthcare, Salt Lake City, UT Joseph A. Brosky, Jr., PT, DHS, SCS, Professor, Bellarmine University, Louisville, KY Mark Cornwall, PT, PhD, FAPTA, Professor, Department of Physical Therapy and Athletic Training, Northern Arizona University, Flagstaff, AZ Mary Hastings, DPT, ATC, Program in Physical Therapy, Washington University School of Medicine, St. Louis, MO Judy Hess, PT, MS, OCS, Midwestern University, Downers Grove, IL Jeff Houck, PT, PhD, Professor of Physical Therapy, George Fox University, Portland, OR Steven Paulseth, PT, DPT, SCS, ATC, Los Angeles, CA Steven Pettineo, DPT, OCS, CSCS, Assistant Professor, Temple University School of Podiatric Medicine, Philadelphia, PA Margaret Suzy Powers, PT, Bainbridge Island, WA Stephen Reischl, DPT, OCS, Adjunct Associate Professor of Clinical Physical Therapy, Division of Biokinesiology and Physical Therapy, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA Byron Russell, PT, PhD, Associate Dean of Health Sciences, College of Science, Health and Engineering, Department Physical Therapy, Eastern Washington University, Spokane, WA Nancy Shipe, PT, DPT, OCS, Assistant Professor, Slippery Rock University, Slippery Rock, PA 3 Foot and Ankle Curricular Guidelines 2015 Purpose The purpose of this consensus document is to provide guidance on foot and ankle curricular objectives and content for physical therapy professional degree programs. The intent of the document is to lay the groundwork for educators to produce entry‐level clinicians with a common foundation related to the foot and ankle. This is a particularly challenging task with the regional diversity by which foot and ankle care is approached by clinicians across the country. Additionally, there are relatively limited numbers of individuals with specialized practice and knowledge in this area. For these, and other reasons, the need for curricular guidance for the 200+ academic programs training future physical therapists is paramount. These guidelines are not intended to represent content that needs to be in one particular course. In fact, it is would be highly appropriate for the content to be included in different courses. Programs may adopt different models for integrating this material in their curricula.

The science guiding the practice of the foot and ankle in physical therapy (PT) is in some ways abundant (eg, there are 3 complete Orthopaedic Section of American Physical Therapy Association (APTA) clinical guidelines published—heel pain, Achilles tendinopathy, ankle sprain). However, in other ways, evidence may be viewed as weak (eg, evidence for selected manual therapy techniques). The recommendations put forth in this consensus document are a product of the time in which they written, and hence, are expected to change as our current knowledge base and practice evolve. Copy written documents have been referenced and not included. It is anticipated that revisions to this document will be needed on a regular basis. It will be reviewed in 3 to 5 years.

Method of Document Development The Foot and Ankle Special Interest Group of the Orthopaedic Section put forward a motion in February 2012 to “Establish a multi‐member Task Force charged with recommending the standard curriculum of foot/ankle content for graduates of an entry‐level physical therapy program.” A 35 member “community” of people from across the country expressed an interest in participating in response to open calls from the Orthopaedic Section for volunteers. This initial group participated in an online discussion that started the process of identifying and gathering the necessary information to establish these curricular guidelines.

In the summer of 2012, a smaller “writing” group met in a face‐to‐face, multi‐day meeting focused on curricular development and writing these specific guidelines as a consensus document. Hence, the reader is cautioned that not all of the document is supported by evidence from the 4 Foot and Ankle Curricular Guidelines 2015 literature, although it has been adapted to be consistent with evidence where it exists. The guidelines were developed following the format of the Normative Model.1 The first authors organized and documented the development process, and searched for evidence supporting or refuting that proposed by the Task Force. That evidence is referenced in this document.

Task Force Guiding Principles The guiding principles for curricular guidelines development were as follows: 1. The basics of anatomy and physiology are considered foundational sciences that support these curricular guidelines, and therefore, are not covered in detail but referred to only as necessary to provide some of the needed context. 2. The content covered is not intended to be solely covered in a single course, but rather is recommended to be threaded throughout the curriculum as it fits within the various curricular models that exist. It is likely that certain courses may be a “good fit” for large portions of the content (courses that focus on musculoskeletal examination and intervention). However, individual programs may choose to deliver or apply the content in other courses. For example, an orthotic course may include content, or a geriatrics course may contain a case study describing an older adult living in a nursing home who has ankle pain.

The writers of these recommendations were cognizant of the risk of “curricular obesity” and made a conscious attempt to identify the most essential entry‐level skills related to the foot and ankle. The goal was to have a document to provide guidance and a set of recommendations that would be immediately helpful to the educator and that could be implemented in curricula. The Task Force acknowledges that important areas have not been included, or covered comprehensively enough (ie, shoe fitting and prescription, wound care, or computerized data collection methods such as plantar pressure measurement). These may be addressed in future revisions.

RECOMMENDATIONS FOR PROFESSIONAL PHYSICAL THERAPY CURRICULA FOR THE FOOT AND ANKLE Organization of the Curricular Guidelines The Guidelines have been organized in a table format, or clinical matrix, to make it an easy reference tool. The first column labeled “Primary Content” is material that is recommended for inclusion in entry‐level professional physical therapist curricula. The “Terminal Behavioral Objectives” column provides recommendations for foot and ankle learning objectives that ideally should be achieved by graduates of an entry‐ level Doctorate of Physical Therapy (DPT) program. The final two columns, “Instructional Objectives for the Classroom” and the “Instructional 5 Foot and Ankle Curricular Guidelines 2015 Objectives for the Clinic” provide examples (not an exhaustive list) of objectives to be achieved in these respective settings to facilitate development of the Terminal Behavior Objectives. The matrix is organized by the components of the Patient/Client Management Model from the Guide to Physical Therapist Practice2 including sections organized by diagnosis and then by intervention. Prognosis/Goal writing was not addressed in specifics. Foot and Ankle Clinical Sciences Matrix Primary Content Terminal Behavioral Objectives Example Instructional Example Instructional The student will: Objectives for the Classroom Objectives for the Clinic The student will: The student will: Examination ‐ History Patient/client history and review of Determine the severity, Describe the components of the By the final clinical experience, medical record using the domains of irritability, nature, and stage and history (including symptom perform a history (including the International Classification stability of the complaints of the investigation and review of symptom investigation and Framework (ICF) model.3 patient and understand their systems) and how it relates to review of systems rated at entry‐ relevance in the domains of the the domains of the ICF model. level by the clinical instructor on System reviews based on ICF model.3 the Physical Therapist Clinical patient/client needs. Generate (synthesize) a Performance Instrument (PT Recognize the components of the complete history (including CPI).4 Use standardized tests and measures history (including symptom symptom investigation and from the Guide to Physical Therapist investigation and review of review of systems) to determine Compare and contrast the Practice (as available). systems) that may be part of the the local, remote, referred, or findings from the history medical diagnosis and PT systemic origins of the patient’s (including symptom Consider referral if patient has: diagnosis considering the issues complaint. investigation and review of (1) night sweats, related to the benign senescent systems) to help determine if (2) sleep disturbance, forgetfulness impairments that Recall the components of the the patient is: (3) change in neurologic function, may require examination. Systems Review and correctly (1) appropriate for PT, (4) progressive weakness and/or perform the aspects of the (2) appropriate for PT with sensatory changes, Select appropriate system examination enabling them to referral to others, or (5) diabetes ‐ Charcot foot, or examination techniques for the determine potential local, (3) not appropriate for PT deep vein thrombosis (DVT) ‐ integumentary, cardiopulmonary, remote, referred, or systemic and requires referral screening using Wells’ neurological, and musculoskeletal origins of the patient’s elsewhere. Criteria.5‐8 systems to determine needed PT complaint. examination procedures and Determine the appropriate tests appropriate diagnosis, prognosis, and measures for screening and plan of care. specific to the foot and ankle.

6 Foot and Ankle Curricular Guidelines 2015 Examination ‐ Systems review 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 conditions objective clinical exam findings  Weight change body systems to screen for beyond the scope of physical to make the determination that Metabolism ‐ diabetes mellitus conditions beyond the scope of therapist practice. the patient is: hemoglobin A1C >7%9 physical therapist practice that (1) appropriate for PT, require a referral to another Simulated case examples to (2) appropriate for PT with Musculoskeletal health care provider. recognize selected components. referral to others, or  Fractures (3) not appropriate for PT o Ottawa Ankle Rules10‐12 and requires referral  Avulsion13 elsewhere.  Severe pain with weight bearing  Non‐mechanical pain  Systemic arthritis (ie, gout)  Rheumatic diseases

Neurological  Dermatomal versus non‐ dermatomal (ie, stocking glove)  Sensation testing 5.07 monofilament testing  Vibration ‐ 128 Hz tuning fork  Myotomal patterns of weakness versus peripheral nerve injury pattern (ie, common fibular nerve lesion)  Complex Regional Pain Syndrome14

Cardiopulmonary  DVT ‐ screening Wells’ Criteria5‐7  Peripheral vascular disease 7 Foot and Ankle Curricular Guidelines 2015 Integumentary  Infection  Open wounds15  Abnormal postoperative wounds  Skin and nail inspection

Psychosocial  Depression (or other cognitive or psychological concerns)  Alcohol use  Problematic caretaker dynamics (ie, extreme expectations/neglect)  Financial considerations Examination – Tests and measures Inspection/Observation: Perform an inspection of the feet Identify clinical signs of Interpret and integrate  Swelling ‐ Figure 8 test, and ankles that includes noting, inflammation in the foot and inspection and observation volumetric measures, testing, or measuring when ankle. results to develop the circumference measures, appropriate: evaluation, diagnosis, and plan Pitting edema? ‐ yes or no (1) swelling or Identify signs of a reduced of care for patients with foot and  Integument ‐ Color and (2) integument autonomic response in the foot ankle dysfunction. texture: Noting discoloration, a. color texture, and ankle. shiny skin, and/or ecchymosis. b. toe nails,  Toe nails ‐ Noting whether c. temperature, they are dystrophic and/or d. trophic changes, thickened. e. calluses.  Temperature ‐ Hot or cold, sweat response. Correlate inspection findings with Identify signs of vascular  Trophic changes and hair other exam findings to develop compromise. growth – Signs of vascular the evaluation, diagnosis, and problems. plan of care.  Calluses ‐ Formation or lack of calluses, exostosis, and/or bony overgrowth.

8 Foot and Ankle Curricular Guidelines 2015 Identify signs of infection and other integumentary problems.

Determine when to refer simulated patients to another health care provider for integumentary problems of the foot and ankle. Foot Posture /Deformity: Explain, conduct, and interpret Perform and score the Foot Perform, interpret, and integrate Overall Foot Posture Description measures of foot posture Posture Index. foot posture and deformity  Foot Posture Index16 including the Foot Posture Index. clinical findings correctly to  Weight bearing and nonweight Identify foot pronation and develop the evaluation, bearing visual assessment of Assess visually foot posture supination postures in weight diagnosis, and plan of care for hind foot (weight bearing and nonweight bearing and nonweight bearing. patients with foot and ankle  Varus and valgus bearing). dysfunction. Identify and describe various Midfoot/Forefoot Identify and explain the following foot deformities.  For medial longitudinal arch, foot and ankle deformities: both static (weight bearing  hallux valgus, and nonweight bearing) and  hammer toe, dynamic (movement)  claw toe, assessment are needed.  mallet toe, Familiarity with relevant skills,  overlapping/crossover tests, and measures (such as toes, palpation of subtalar joint  Morton's foot structure neutral, navicular height, (2nd toe longer than the navicular drop test, arch 1st), and height index, Coleman block).  metatarsus adductus.  Too many toes sign. Integrate foot posture measurement findings with other exam findings to develop the evaluation, diagnosis, and plan of

care. Toe Deformities  hallux valgus, 9 Foot and Ankle Curricular Guidelines 2015  hammer toe,  claw toe,  mallet toe,  overlapping/crossover,  Morton's foot structure (2nd toe longer than the 1st), or  metatarsus adducts. Movement Analysis: Perform a gait examination. Describe key components of a Perform gait examination and Gait examination and evaluation gait examination. evaluation of a patient.  Temporal spatial measures Identify demonstrated gait (including gait speed, step deviations. Identify and describe gait Identify and document gait length, stance time, foot angle, deviations on a patient video or deviations demonstrated by a step width, etc). Identify correctly normal vs as performed by a simulated patient.  Visual analysis using the abnormal motions of the ankle patient. Rancho Los Amigos method. and foot during the double leg Select appropriate gait  Identify common gait squat test. Perform gait examination examination procedures specific deviations related to the ankle efficiently with a classmate. to the patient condition and and foot (see Appendix 1). Identify correctly normal vs setting.  Stairs. abnormal motions of the entire Explain the rationale for lower extremity during the single selection of various gait Integrate gait examination Double leg squats17 leg squat test. examination procedures based findings with other tests and  Dorsiflexion range of motion on setting, severity, intensity, measures including those of (ROM). Integrate movement analysis nature, and stage of the patient patient functional status.  Visual analysis hind foot, findings with other exam findings problem. midfoot, and forefoot to develop the evaluation, Discriminate patients movement. diagnosis, and plan of care. Describe key components of appropriate for double and movement in the double and single leg squat testing. Single leg squats18,19 single leg squat tests.  Lower extremity alignment ‐ Perform double and/or single leg note femoral adduction/ Perform double and single leg squat test. internal rotation vs femoral squat tests with a classmate. abduction/external rotation. Identify and document Running Identify deviations on a patient movement patterns  Identify forefoot running video or performed by a demonstrated by a patient pattern. simulated patient during the performing the double and/or  Identify heel toe running pattern. double and single leg squat tests. single leg squat test. 10 Foot and Ankle Curricular Guidelines 2015 Range of Movement: Select the most appropriate Identify various tests and Perform range of movement/ Ankle Dorsiflexion passive and active ROM measures to thoroughly assess motion examination on a measurements for examination. patient impairments. patient. Weight bearing  Knee to wall‐ distance of toe to Recognize when dorsiflexion Describe the procedural Perform these tests and wall or inclinometer. motion is occurring at ankle joint components for measuring ROM. measures efficiently.  Knee straight ‐ inclinometer, and/or subtalar joint and the (consider block for forefoot). ramifications of motions at these Relate the measures to specific Provide rationale for tests and joints.22 anatomic structures being measures selected. Nonweight bearing assessed.  Knee extended ‐ supine Perform correctly selected tests Conduct self‐assessment of goniometry.20 and measures. Identify common procedural psycho‐motor skills and modify  Knee flexed and extended.21 errors when performing passive performance based on feedback. Interpret correctly objective or active ROM measurement. Ankle Plantar Flexion measurement findings. Perform accessory joint mobility Perform an examination of a examination on a patient. Nonweight bearing Identify the need for potential student in the classroom  Supine goniometry with the test and measure modification simulating ROM restrictions. Perform accessory motions distal arm aligned with the based on setting, severity, safely and efficiently. inferior aspect of calcaneus intensity, nature, and stage of Provide a rationale for choice of and forefoot separately. problem. ROM measures selected. Provide rationale for accessory motion examination. Subtalar Inversion/Eversion Articulate limits of valid and Correlate findings of ROM Nonweight bearing prone reliable of various ROM tests and measures to identified abnormal Conduct self‐assessment of  Inversion/eversion observe measures. motion patterns. psycho‐motor skills and modify qualitatively and/or using performance, based on goniometry. Identify joint end feel/motion Conduct self‐assessment of feedback. barriers to passive motion. psycho‐motor skills and modify Foot Inversion/Eversion performance based on feedback. Nonweight bearing supine ‐ supine Discriminate mobility findings as distal arm aligned with the 2nd hypomobile, hypermobile, or Analyze and discuss a patient‐ metatarsal.20 within normal limits. client video to identify modifications to ROM testing Hallux dorsiflexion Synthesize information from based on patient condition and  Nonweight bearing or weight ROM examination and accessory setting. bearing.23 movement testing to identify bony vs soft tissue restrictions. Describe the relationship of rear 11 Foot and Ankle Curricular Guidelines 2015 foot to forefoot biomechanical Medial longitudinal arch Integrate ROM and mobility axes and its influence on joint  Weight bearing ‐ navicular examination findings with other mobility and stability. drop test. exam findings when developing evaluation and plan of care. Perform mobility testing for the Midfoot motion (Calcaneocuboid joints listed for hypomobility/ and talonavicular joints) normal/hypermobility to Nonweight bearing determine the potential for  Assess forefoot movement manual therapy interventions. when the rear foot is everted and inverted. A normal test is Interpret findings of a joint when the foot is inverted and mobility examination on a stability increases (ie, less classmate. forefoot movement is noted). Conduct self‐assessment of Accessory Joint Movement24 psycho‐motor skills and modify performance based on feedback. Talocrural ‐ posterior glide test, anterior/posterior glides/distraction Subtalar‐ medial/lateral/anterior glides/distraction Talonavicular joint ‐ dorsal/plantar gliding Calcaneocuboid ‐ dorsal/plantar gliding 1st ray mobility ‐ dorsal/plantar glide hallux limitus/rigidus Distal tibiofibular ‐ anterior/posterior gliding Interphalangeal and metatarsal phalangeal joints ‐ distraction/ dorsal/plantar gliding Strength Measurement: Demonstrate competence in Interpret MMT and correlate Analyze MMT tests of the foot Manual muscle testing (MMT) performing MMT of the foot and findings with simulated foot and and ankle in patients with foot Ankle ankle. ankle conditions. and ankle dysfunction.

12 Foot and Ankle Curricular Guidelines 2015  Plantar flexion/dorsiflexion  Inversion/eversion Demonstrate the ability to Interpret heel rise test from Discriminate modifications to  Toe flexion/extension conduct and interpret heel raise video clips of patients with foot examination of muscle strength tests (single leg and double leg). and ankle dysfunction. based on a patient’s pathology, Hip/knee/trunk muscle activity as irritability, and/or severity. presumed by movement analysis. Describe and administer sports‐ Discuss when to apply various specific tests for return to play. MMT of the foot and ankle Generate hypotheses to address Heel Rise Test25,26 ‐ assessed for depending patients pathology, the probability a detected height, number of reps, rear foot Describe and administer irritability, and/or severity. weakness is directly caused by inversion or eversion position, functional tests for return to the pathology or is the result of medial vs lateral forefoot pressure, work. Discuss the limits of reliability a secondary condition (ie, arch height, and comparison to and validity associated with disuse). normative data (see Appendix 2). Describe and perform functional MMT of the foot and ankle. tests associated with the foot and Functional strength/return to ankle including: Discuss the cause of muscle activity. (1) squats, weakness in conditions (2) step ups, and associated with the foot and (3) hopping. ankle (secondary result of disuse or direct result of injury). Integrate strength findings with other exam findings when writing evaluation and plan of care. Special Tests: Select, perform, and interpret Describe the procedural Perform clinical special tests on Ankle appropriate clinical special tests components foot and ankle a patient.  Talocrural sprain to assist with evaluation of foot clinical special tests. o Anterior drawer and ankle conditions. Interpret special test results and o Talar tilt Accurately perform foot and integrate them into an  Syndesmotic sprain Correlate special test findings ankle clinical special tests. evaluation and plan of care. o Dorsiflexion/external with other exam findings to rotation develop an evaluation and plan of Discriminate validity and Conduct self‐assessment of o Squeeze test care. reliability of selected clinical psycho‐motor skills and modify special tests. performance based on feedback. Tinel sign27 Identify common procedural Windlass test27 errors when performing selected special tests.

13 Foot and Ankle Curricular Guidelines 2015 Ottawa Foot and Ankle Rules10‐12 Discriminate between foot and Thompson Test28 ankle special tests and determine appropriate tests for simulated patients. Palpation of Relevant Structures Identify key surface anatomical Discuss normal and potentially Perform an efficient examination NOTE: Connect to relevant diagnoses structures relevant to patient/ abnormal clinical findings of a patient/client with client presenting chief identified from a palpation foot/ankle pathology or Lateral Structures: complaint(s). examination given selected complaint. Fibula head/neck/shaft pathological scenarios. Fibularis longus/brevis muscles Prioritize and demonstrate the Conduct a physical examination Lateral malleolus ability to apply the basic concepts Perform an examination of a using palpation techniques that Anterior inferior tibiofibular joint of gross anatomy to the analysis student in the classroom that contribute to the formulation of Anterior inferior tibiofibular ligament of patient/client problems includes correct identification a differential diagnosis. Calcaneus related to musculoskeletal and palpation of relevant Peroneal tubercle system of the leg, ankle, and foot. osseous, musculotendinous, Provide written and verbal Calcaneofibular ligament and/or neurovascular structures. communication using correct Fibular tendons (longus/brevis) Differentiate normal vs abnormal terminology and description for Cuboid findings obtained from surface accurate recording of physical Styloid process 5th metatarsal anatomy palpation. examination findings. 5th metatarsal base/shaft/head Sinus tarsi Correlate palpation findings with Conduct self‐assessment of Extensor digitorum brevis other exam findings to formulate psycho‐motor skills and modify Anterior talofibular ligament an evaluation and plan of care. performance based on feedback.

Dorsal Structures: Anterior compartment muscles 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 muscle Talar neck Navicular

14 Foot and Ankle Curricular Guidelines 2015 1st, 2nd, 3rd 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 muscle 1st MTP joint

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

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

Vascular Structures: Popliteal artery Posterior tibial artery 15 Foot and Ankle Curricular Guidelines 2015 Dorsalis pedis artery Capillary refill

Recognize the link between palpation and diagnosis.

Understand that when available, confirmatory/diagnostic testing should be completed. Neurologic Examination: Understand the proper selection Discuss normal and potentially Perform neurologic examination  Reflexes of the tests and measures is abnormal clinical findings measures on a patient.  Myotome dependent on: identified from each of the tests  Tinel’s sign (1) chief complaint/history used in this area of examination Perform test and measures  Tarsal Tunnel Tests (including symptom using clinical scenarios. efficiently and correctly interpret o Dorsiflexion with investigation systems results. eversion29 review), Perform these examination tests o Plantar flexion with (2) demographics, correctly and safely. Conduct self‐assessment of inversion30 (3) signs and symptoms, and psycho‐motor skills and modify (4) functional level of patient. Interpret whether neurologic performance based on feedback. SLUMP/Straight Leg Raise Test ‐ finding(s) in the foot and ankle Neural tension testing to screen for are related to another condition Interpret and integrate the proximal nerve entrapment of body systems. results into the evaluation and contribution to the foot and ankle plan of care. chief complaint.31 Balance: Understand selection of the tests Discuss normal and potentially Perform balance measures on a  Romberg – Sharpened and measures is dependent on: abnormal clinical findings patient. Romberg (1) chief complaint/history identified from each of the tests  Single leg stance or one legged (symptom investigation used in this area of examination Perform balance tests and stance test32 (see Appendix 3) and systems review), using clinical scenarios. measures and efficiently and  Balance Error Scoring System33 (2) demographics, correctly interpret results. o Eyes closed/eyes open (3) signs and symptoms, and Perform these examination tests o Head neck rotation (4) functional level of patient. correctly and safely. Conduct self‐assessment of o Surfaces – foam/no foam psycho‐motor skills and modify o Assess for ankle, knee, and Determine the need for a more performance based on feedback. hip strategy in‐depth, fall risk testing in selected patients. Interpret and integrate the 16 Foot and Ankle Curricular Guidelines 2015 Star Excursion Balance Test34 results in an evaluation and plan of care. Hop to Stabilization

Testing for fall risk – (Berg Balance Score, Timed Up and Go, Tinetti Balance & Gait Assessment)35

Senior Fitness Test36 Lower Quarter Screen (LQS) Recognize the potential for Perform the components of a Perform a LQS on a patient to referred pain into the foot and LQS with a classmate. rule in/out referred pain and the ankle for means of specific need for specific examination of examination of other body Recognize a referred pain other body regions. regions, diagnosis, or potential pattern based on LQS referral to another health care examination results. provider. Functional Outcome Measures Understand selection of the tests Discuss ways in which these Interpret and integrate the Baseline data collection of relevant and measures is dependent on: outcome measures might be results in an evaluation and plan outcome measures: (1) chief complaint/history integrated into the clinical of care.  Foot and Ankle Ability (symptom investigation system of data collection. Measure (FAAM‐ADL and and systems review), Sports) or Foot and Ankle (2) demographics, Understand the importance of Disability Index (3) signs and symptoms, collecting and documenting  Lower Extremity Functional (4) functional level of patient, these data at baseline, Scale and periodically and at discharge, (5) patient goals. and factors that influence when these data collections occur. Evaluation ‐ Diagnosis Posterior Tibial Tendon Dysfunction Describe the continuum of Describe the location and Have experience practicing (PTTD) dysfunction. function of the tibialis posterior, clinical management of a and perform MMT and palpation tendinous structure. Discriminate between this of same. diagnosis and pertinent Describe exposure to an actual differential diagnoses (rules out Describe the associated patient, a case study, simulation the following): structural and movement of a foot tendon problem, or  stance phase pronation impairments including heel rise simulated case.

17 Foot and Ankle Curricular Guidelines 2015 syndrome without PTTD, test and associated gait  Charcot foot, or deviations. Select examination items  spastic pronation. consistent with severity and nature of the problem. Describe signs and symptoms, relevant history, and examination including:  tenderness along the tendon course,  reduced calcaneal inversion during heel rise,  weak inversion/plantar flexion, or  abnormal alignment/ movement. Plantar Fasciitis37 Describe the continuum of Describe location and function of Describe exposure to an actual dysfunction. the plantar fascia including the patient, a case study, or Windlass mechanism. simulation of a heel pain patient. Discriminate between this diagnosis and pertinent Perform palpation of the plantar Select examination items differential diagnoses (rules out fascia. consistent with severity and the following): nature of the problem.  calcaneal stress fracture, Describe associated structural  bone bruise, and movement impairments  fat pad atrophy, including those seen during gait.  Tarsal tunnel syndrome,  soft‐tissue, primary, or Perform an examination of metastatic bone tumors, potential sources of limited  Paget disease of bone, ankle dorsiflexion.  Sever’s injury, or  referred pain as a result of an S1 radiculopathy.

Describe signs and symptoms, relevant history and examination including: 18 Foot and Ankle Curricular Guidelines 2015  pain upon palpation of the proximal plantar fascia attachment,  first step pain, or  1st toe extension reproducing pain at the proximal or distal attachment of the plantar fascia. Achilles Tendinopathy38,39 Describe the continuum of Describe location and function of Describe experience in clinical tendinopathy and progression of the Achilles tendon. management of a tendinous symptoms. structure. Perform palpation and functional Discriminate between this testing (heel rise and MMT). Select examination items diagnosis and pertinent consistent with severity and differential diagnoses (rules out Perform palpation to determine nature of the problem for an the following): the anatomical location of the actual or simulated patient/case  acute Achilles tendon tendinopathy. study (see sample case study).39 rupture,  partial tear of the Achilles Describe the associated Discriminate between a tendon, structural and movement tendinous lesion and pertinent  retro‐calcaneal bursitis, impairments including deviations differential diagnoses (rule  posterior ankle in: gait, unilateral heel rise, in/out tendinous lesion). impingement, single limb hop, or ability to  irritation or neuroma of descend stairs. the sural nerve,  Os trigonum syndrome,  Achilles tendon ossification,  systemic inflammatory disease,  insertional Achilles tendinopathy, or  bony enlargement on back of the calcaneus (Haglund’s deformity). 19 Foot and Ankle Curricular Guidelines 2015 Describe 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 either increased or decreased dorsiflexion ROM, and  limited ability to perform repetitive unilateral heel raises compared to the contralateral side. Ankle Osteoarthritis (OA) Describe signs and symptoms, Describe the associated Describe experience in the  Nonsurgical relevant history and examination structural and movement clinical management of OA.  Post‐op for nonsurgical ankle OA: impairments.  pain during and after activity, Describe the surgical  continuum of joint management of OA including deformity and loss of osteochondral procedures, ankle motion, or replacement, or ankle fusion  prior history of ankle (while the current standard of instability or trauma. care is ankle fusion for end stage OA). Describe signs and symptoms, relevant history, and examination Post‐op: for post‐op OA: Describe and examine the 20 Foot and Ankle Curricular Guidelines 2015 Obtain relevant information tissues involved in the injury about surgical or medical and/or surgery including the management to identify influence of time on return to indications/contraindications for function. examination and intervention. Shin Splints/Medial Tibial Stress Describe signs and symptoms, Perform palpation of anterior Syndrome relevant history and examination compartment muscles. including:  pain in the front of the Perform palpation of the shin, anterior tibia where there is no  a patient who has high use muscle coverage. (high BMI or activity level) and poor foot alignment, Describe and perform  anterolateral lower leg demonstration of the actions of pain is often associated the three muscles in the anterior with the anterior compartment. compartment muscles, and/or Perform correct stretch of each  anteromedial lower leg muscle in the anterior pain may be indicative of a compartment including stress fracture. elongation over all the joints each crosses. Discriminate between this diagnosis and pertinent Describe when to refer the patient differential diagnoses (rules out to orthopaedics for diagnosis and compartment syndrome). management of a potential stress fracture. Chronic Ankle Instability/Functional Describe signs and symptoms, Perform balance and Describe exposure to either an and Mechanical24,40 relevant history, and examination proprioception testing. actual patient with ankle related to chronic (functional and instability, a case study, or mechanical) ankle instability Perform a group of tests to simulation of a patient with including: assess stability of ankle chronic ankle instability.  patients with feelings of ligaments. instability, Select examination items  impaired balance and consistent with severity and proprioception, and/or nature of the problem.

21 Foot and Ankle Curricular Guidelines 2015  decreased passive or active ROM.

Discriminate between this diagnosis and pertinent differential diagnoses (rules out the following):  peroneal (fibularis) tendon pathology,  accessory ossicles,  Tarsal coalition,  sinus tarsi syndrome,  subtalar sprains with or without instability,  spring or bifurcate ligament damage, and/or  ankle impingement. Tarsal Tunnel Discriminate between this Perform palpation of posterior Describe exposure to either an diagnosis and pertinent tibial nerve. actual patient, a case study, or differential diagnoses (rules out simulation of a foot and ankle plantar fasciitis). Perform the Tinel’s and case in which they must choose provocative Tinel’s tests. to rule out involvement of the Describe signs and symptoms, posterior tibial nerve as a source relevant history, and examination of symptoms. related to medical management including:  distal production of symptoms with tapping (Tinel’s Test) of the posterior tibial nerve pathway,29,30  symptoms reproduced with sustained dorsiflexion‐eversion of the foot, and  provocative Tinel’s test: 22 Foot and Ankle Curricular Guidelines 2015 symptoms reproduced during tapping of the nerve pathway with the foot in dorsiflexion, maximal calcaneal eversion, and toes extended.29,30 Lateral Ankle Sprain and Describe continuum of Describe the function of the Describe having had exposure to Syndesmotic/High Ankle Sprain dysfunction of lateral ankle anterior talo‐fibular and an actual patient, a case study, sprains and high ankle/ calcaneofibular ligaments. simulation of a patient with syndesmotic sprain. ankle sprain or syndesmotic/ Perform palpation of the high ankle sprain. Describe signs and symptoms, calcaneofibular and the anterior relevant history, and examination inferior tibiofibular ligament. including:  pain with palpation of the Perform a measurement of involved ligaments, swelling of the ankle using the  mechanism of injury – figure of eight – in 20° of plantar inversion/plantar flexion flexion. (lateral ankle sprain) vs dorsiflexion and eversion Perform a combination of tests (high ankle sprain/ to assess ligament stability syndesmotic), and/or including: talar tilt, anterior  reproduction of ankle drawer for lateral ankle sprain instability or pain with and external rotation, and special tests. squeeze test for high ankle sprain/syndesmotic sprain. Discriminate between this diagnosis and pertinent Describe the Ottawa Ankle Rules differential diagnoses (rules out and when to refer a patient for the following): radiograph.  peroneal tear,  medial collateral ligament Provide rationale for selecting ankle sprain, examination items consistent  Lis Franc with severity and nature of the fracture/dislocation, problem. 23 Foot and Ankle Curricular Guidelines 2015  subtalar sprain,  Achilles tendon rupture,  lateral talar process injury, and/or  anterior process of the calcaneus injury. Hallux Abducto‐Valgus (HAV) Describe the continuum of Describe the location and dysfunction that can be function of the 1st addressed by a physical therapist. metatarsophalangeal (MTP) and 1st ray. Discriminate between this diagnosis and pertinent Describe the associated differential diagnoses (rules out structural and movement the following): impairments including:  sesamoid stress fracture,  palpation,  avascular necrosis,  gait,  osteochondral fractures,  static foot alignment,  chondromalacia, and/or  metatarsalgia,  1st MTP passive ROM  nerve impingement, (PROM).  infection,  bursitis, Perform an examination of 1st  sesamoiditis, and/or MTP joint motion.  bipartite sesamoids.41 Hallux Limitus Describe the continuum and Describe the location and Describe exposure to an actual etiology of this dysfunction. function of the 1st MTP, patient, a case study, a sesamoids, and 1st ray. simulation of hallux limitus. Describe signs and symptoms, relevant history, and examination Describe the associated Support selecting examination including: structural and movement items consistent with severity  limited accessory motion impairments including results of and nature of the problem. of the 1st MTP and/or ray, performing:  associated proximal  palpation, Perform an examination of the alignment and  gait examination, motion of the 1st MTP joint. compensations related to  static foot alignment reduced heel rise in gait examination, 24 Foot and Ankle Curricular Guidelines 2015 and during function,  1st MTP PROM and/or examination, and/or  atypical function and  flexor hallucis longus position of the sesamoid manual muscle testing. apparatus.41 Perform an examination of 1st MTP joint motion. Metatarsalgia Describe the continuum of Describe the location and Describe having had exposure to dysfunction. function of the distal plantar either an actual patient, a case fascia, flexor digitorum longus study, or simulation of forefoot Discriminate between this (FDL), MTP joint capsule, pain. diagnosis and pertinent interdigital nerve, and fat pad. differential diagnoses (rules out Select examination items the following): Describe the associated consistent with severity and  interdigital neuroma, structural and movement nature of the problem.  plantar keratosis, impairments including results of  Frieberg’s disease, performing:  metatarsal stress fracture,  palpation,  inflammatory arthropathy  gait examination, (such as rheumatoid  manual muscle testing of arthritis seronegative intrinsic foot muscle spondyloarthropathy, or strength, crystalline‐induced  Mulder’s test,42 and/or arthritis),  Tinel’s sign.29,30  tarsal coalition,  vertical talus, and/or  accessory navicular.43

Describe signs and symptoms, relevant history, and examination including:  pain upon palpation of the distal 2nd to 3rd metatarsal heads, plantar MTP, and FDL,  special tests including 25 Foot and Ankle Curricular Guidelines 2015 Mulders test,42 and/or  pertinent gait abnormality. Neuropathic (Diabetic) Foot Describe signs and symptoms, Perform the following Perform a screen for diabetes relevant history, and examination examination items in the foot: during the history. including:  visual examination of skin  loss of protective and nails, Describe, and as appropriate, sensation on at least an  sensory examination of observe precautions for aspect of the plantar the foot, insensate feet during surface of the foot  palpation of pulses, examination and intervention. (generally stocking/glove), and/or  signs of autonomic system  passive and active ROM. Describe having had exposure to dysfunction (eg, hair loss, an actual patient, a case study, loss of sweating), and/or Perform a footwear examination simulation, or in‐class patient lab  diagnosis that can result in discriminating between of an individual with a loss of peripheral appropriate and inappropriate neuropathic foot. sensation (diabetes, high footwear and orthosis BMI, idiopathic). components. Perform examination of need for assistive device. Describe signs and symptoms of Describe deformity and potential associated complications: consequences of each deformity  ulcer formation, in people with this diagnosis (eg,  neuropathic Charcot hammer/ claw toe, medial and arthropathy, lateral midfoot and hind foot  joint deformity, deformity).  impaired balance,  peripheral vascular List and identify strengths and disease/ischemia, weaknesses of off‐loading  loss of joint mobility, devices to treat plantar ulcers  loss of foot bone mineral [eg, total contact castings, density, and/or walker boots, Charcot Restraint  delayed bone and tissue Orthotic Walker (CROW)]. healing. Calcaneal Apophysitis (Sever’s Describe the continuum and Describe that this problem Describe exposure to an actual Injury)/Calcaneal Epiphyseal etiology of this dysfunction from warrants intervention and that if patient or a case study of Sever’s Fracture apophysitis through epiphyseal it is a fracture it may require Injury that includes its PT fracture. immobilization for 8 weeks management. 26 Foot and Ankle Curricular Guidelines 2015 followed by rehabilitation Explain that this type of fracture (stretching, strengthening, cannot be diagnosed through x‐ balance work, etc). ray, but rather is made through signs and symptoms and Describe that the mechanism of responses to management. injury is that the heel cord is tight and pulls the calcaneal Describe signs and symptoms, epiphysis apart. relevant history, and examination including: Perform appropriate secondary  pain at the heel, usually tests to address force right at the posterior most distribution. tip,  patient is a child of an age Describe/perform intervention when their calcaneus has to address aberrant motion not fully fused (5‐14 including fabrication/ years), adaptation of temporary foot  history of high activity orthoses and heel lifts to support level and/or growth spurt, medial arch and/or hind foot. and  patient stands with heels in eversion relative to subtalar neutral and may have associated dysfunctions, such as functional or real leg length discrepancy, shin splints, proximal compensations and associated pains and dysfunctions. Some evidence has shown that these children are putting more weight on their heels during gait.44

27 Foot and Ankle Curricular Guidelines 2015 Fracture (5th metatarsal,45 Describe signs and symptoms, Describe signs and symptoms, Describe having had experience navicular, midfoot) relevant history and screening relevant history, and with PT clinical management examination including: examination of fracture when post fracture.  pain with palpation, performing palpation of bony  inability to weight bear for structures of the foot and ankle. 4 steps, and/or  high incidence of non‐ Describe a timeline to guide union. progression of care following the medical or surgical management Describe signs and symptoms, of a fracture. relevant history, and examination related to medical management including to obtain relevant information about surgical or medical management to identify indications/contraindications for PT examination, intervention. Equinus related to any or all of the Describe signs and symptoms, Discriminate between those that Describe having had exposure to following: relevant history, and examination do, and do not, attain heel strike an actual patient or a case study  passive tightness of plantar related to medical management during initial contact phase of involving clinical management of flexors, including: gait. an equinus foot problem  dynamic tightness of plantar  PROM dorsiflexion less including discriminating between flexors (spasticity), than 10° with the knee Describe all the plantar flexor origins of the equinus. This  poorly timed dorsiflexion extended avoiding muscles that could be tight, involves performing, or activity, or pronation, active at the wrong time, or describing, an examination that  weak or absent dorsiflexors.  lack of heel strike during shortening too much. discriminates between tight initial contact phase of plantar flexor muscle(s), joint gait, Perform PROM measurements of limitation (s), poorly timed  early heel off during gait dorsiflexion with and without plantar or dorsiflexion, or (mild muscle shortening), pronation, with and without excessive plantar flexion activity.  stands with heels on knee flexion. ground and pronation or Discriminate between specific supination, walks on toes Describe the likely presence of situations when referral is (moderate muscle initial resistance (R1) vs ultimate warranted being specific as to shortening), and PROM (R2) in patients with the type of referral (PT with  stands and walks on toes spasticity. neurological expertise, MD 28 Foot and Ankle Curricular Guidelines 2015 (severe muscle skilled in management of shortening). spasticity including botulinum toxin injections, orthopaedic Describe need to work on motor surgery, neurosurgery, and/or control in patients needing that orthosis fabrication). intervention including potentially using FES based “neuro‐ Describe that which prosthetic” technologies such as discriminates a patient with Bioness or WalkAide Walking plantar flexor spasticity from Systems. other patients. Stance Phase Foot Supination Describe signs and symptoms, Discriminate pronation during Support selecting examination Syndrome relevant history, and examination the stated movements from items consistent with severity including: other motions. and nature of the problem.  related source diagnosis including tibial stress Perform appropriate secondary Discriminate excessive or poorly fracture, plantar fasciitis, tests to reduce aberrant motion timed foot pronation from other metatarsal (MT) stress (verbal/tactile cueing, taping, motions during gait in a patient. fracture/metatarsalgia 1 and orthosis fabrication and/or and 5, sesamoiditis, use). Describe having had exposure to fibularis tendinopathy/ actual, simulated, and/or a tear, Achilles Recognize and describe the relevant case study of foot tendinopathy, HAV, relationship between center of pronation syndrome. bunionette, hallux limitus; mass displacement and foot  hind foot inversion, movement during gait.46 talonavicular elevated, forefoot adduction, plantar flexion 1st ray, reduced lateral arch height during gait, hopping, running, and stepping;  callus formation at 1st and 5th metatarsal heads;  footwear worn on lateral border;  force distribution and/or addressing aberrant

29 Foot and Ankle Curricular Guidelines 2015 motion reduces signs and symptoms; and/or  associated proximal malalignment and compensation (functional leg length discrepancies, lateral femoral rotation). Plan of Care ‐ Intervention Therapeutic Exercises Select and perform appropriate Discuss rationale for selecting Design, implement, and progress  Balance therapeutic exercises. specific therapeutic exercises, an appropriate plan of care.  Strengthening including dosage.  Stretching Demonstrate alternative Monitor patient response to  Endurance strategies for applying different Demonstrate the ability to interventions and modify as  Functional training interventions: instruct or perform selected appropriate.  Work hardening47  apply principles of safe interventions. practice to patient/client Use objective measures to care base on needs, Discuss the principles of exercise document change.  deliver interventions based progression. on the best evidence available and practice Practice providing instruction guidelines, and related to special interventions  demonstrate knowledge of for the foot/ankle, including (but how to find this evidence. not limited to):  stretching of Recognize and describe the gastrocnemius protecting relationship between center of the mid‐foot, mass displacement and foot  stretching the plantar movement during gait.46 fascia,  foot intrinsic/extrinsic strengthening, and/or  proximal muscle strengthening including muscles of the core, pelvis, and full lower extremity.

30 Foot and Ankle Curricular Guidelines 2015 Addressing Abnormal Motion Discuss the rationale and best Excessive Motion As available, observe or  Excessive Motion available evidence for each of the Describe the indications/ participate in the prescription, o Bracing interventions used to control contraindications, fabrication, modification, or o Strapping motion. recommendations, and dispensing of bracing: o Foot orthoses considerations related to bracing  KAFO,  Limited Motion Discuss indications and the foot and ankle:  AFO, o Mobilization contraindications for motion  knee ankle foot orthosis  cam walker (Boot), o Manipulation control, including bracing and (KAFO),  stirrup, or strapping.  ankle foot orthosis (AFO),  lace‐up.  cam walker (Boot), Recognize the implications of  stirrup, or Observe or participate in the interventions on the various  lace‐up. prescription, fabrication, segments of the kinetic chain. modification, or dispensing of Describe indications/ foot orthoses: Select and perform appropriate contraindications for  custom, joint mobilization techniques strapping/taping of foot and  customizable aimed at increasing motion. ankle, practice one of the prefabricated, following techniques:  prefabricated, or Discuss the rationale, indications,  Ankle Instability  accommodative. and contraindications for o Stirrup manipulation. o Basket weave Demonstrate proper technique o Heel lock when performing at least one  Medial Arch joint mobilization of the o Low‐dye foot/ankle complex. o Cross X o Reverse six  Edema o Compression wrap with pressure gradient  Musculotendinous support (Achilles wrap)

Recognize a patient case where management with foot orthoses would be appropriate.

31 Foot and Ankle Curricular Guidelines 2015 Understand the mechanism by which a foot orthosis restrains or encourages motion.

Observe/discuss methods of fabrication, modification, and fitting of a foot orthosis.

Fabricate a slipper cast and assess forefoot to hind foot alignment based on this cast.

Limited Motion Demonstrate correct hand placement and technique when providing grade I‐IV joint mobilizations to all articulations of the foot/ankle, 1st MTP, and inferior and superior tibiofibular joints.

Discuss the rationale for mobilization parameters chosen.

Identify indications for and safely perform manipulations:  Talocrural distraction  Subtalar joint  Cuboid whip Modalities Discuss indications, Monitor patient response to contraindications, and modalities and make precautions for using therapeutic modifications as necessary. modalities.

Select and perform appropriate therapeutic modalities.

32 Foot and Ankle Curricular Guidelines 2015 Patient Education Discuss specific clinical conditions Provide instruction regarding Discuss footwear considerations with the patient and/or family, precautions with loss of for athletes or patients with: including etiology, intervention sensation (eg, do not use foot to  Diabetes options, and prognosis. assess temperature of bath  Peripheral neuropathy water, at least daily examination  Peripheral edema Educate patient regarding of plantar foot skin integrity,  Upper motor neuron appropriate self‐management wear protective footwear lesions strategies. whenever walking). o Spasticity o Flaccidity Identify and discuss risk factors  Trauma and strategies for injury  Arthritic conditions prevention. o Osteoarthritis o Rheumatoid arthritis Footwear Identify and discuss the structural Demonstrate shoe fitting Recommend footwear and/or features of a shoe. knowledge with specific footwear modifications to attention to: address a particular clinical Discuss critical features of proper  Length condition: shoe fitting.  Toe box width  Running population  Toe box depth o Stability Describe the indications/  Curvature of the last o Motion control contraindications and o Cushioning ramifications of various forms of Make recommendations for  Diabetic population footwear and footwear footwear options based on o Cushioning modifications, (including ankle patient presentation: o Pressure distribution foot orthoses, cam walkers,  Diabetic population o Adequate toe box splints, or foot orthoses ‐  Pronation syndrome width/depth prefabricated, customizable or  Supination syndrome  Refer to appropriate custom), and other specialized  Neurologic population other providers as footwear, or casting.  Arthritic population necessary.

Describe reasons and options for Discuss the rationale for various referral (including those to features of a shoe, orthosis, or physicians, other therapists, other footwear modification. orthotists, or shoemakers). Identify the specific components of a shoe: 33 Foot and Ankle Curricular Guidelines 2015  Toe box  Heel counter  Vamp  Mid‐sole  Sock liner

34 Foot and Ankle Curricular Guidelines 2015 Appendix 1A. Foot and Ankle Special Interest Group Gait Form Key48‐50

Gait Velocity: NOTES Stride length: NOTES Cadence: NOTES Normal or Abnormal Equal? Yes‐‐‐‐NO Normal or Abnormal Cause If no, what is cause? Cause Phase of Gait‐ Initial Contact Mid Stance Terminal Stance Pre Swing ‐ Initial Swing, Reference Limb Loading Response Initial Swing Mid Swing, Circle Left or Right Terminal Swing Task of Gait Weight Acceptance Single Limb Support Forward Weight Shift Limb Advancement Limb Advancement Normal Heel strikes‐takes weight Stable ‐ normal Heel off/ (Acceleration) (Deceleration) Hallux extension Hallux extension/ Full, controlled step Functional Limb contacts‐takes weight Stable – even if not Effective forward weight Toe off Limb clears – then WNL shift Limb accelerates and lifts decelerates ROCKER Heel rocker Ankle rocker Forefoot rocker Forefoot rocker Ankle Motion: Normal Strikes in relative DF moves into PF From PF into DF of ankle DF of ankle reaches peak Motion to 25° of PF Ankle remains in PF via foot to ground faster than tibia (via lower leg moving of 5‐10° and starts to PF assists knee flex (with during initial swing but is moves forward over foot) quick hip flexion to moving into DF, need shorten limb) knee flexion to clear the limb Ankle Motion: Common Uncontrolled PF Excessive DF (knee No heel rise prior to Lack of PF contributes to Toe drag in initial swing Abnormal Low foot contact* flexion in mid stance) contralateral contact less knee flexion and loss Failure to achieve Findings Forefoot contact Early heel rise Contact area too lateral of forefoot rocker neutral ankle for initial No forward lower leg contact progression over foot. Foot Motion: Normal Foot pronation (best seen with Early mid stance Rise of heel off the ground MTP joints continue to Foot comes off the calcaneal eversion and unlock of pronation may continue, should see supination to extend, weight should ground in the position it midtarsal joints) should see pronation allow the foot to be rigid progress over the 1st maintained in pre swing cease late mid stance with decrease weight MTP joint, supination of Good place to look for and supination begin bearing contact Windlass hind foot is maintained excessive pronation mechanism Foot Motion: Abnormal Excessive calcaneal eversion Midtarsal joints remain Midtarsal joints remain Lack MTP joint extension Foot comes off ground in Limited calcaneal eversion unlocked unlocked Excessive MTP extension excessive pronation Excessive midtarsal joint unlock Midtarsal joints remain 1st ray does not PF Roll off the side of 1st Foot comes off the Limited midtarsal joint unlock locked Midtarsal joints remain MTP joint ground in excessive Excessive inversion of locked Roll off lateral forefoot supination hind foot continues 1st ray in too much PF Excessive eversion of Hallux does not start to hind foot continues extend Phase of Gait ‐ Pre to Initial Swing Initial to Mid Swing Mid to Terminal Swing Initial Contact Loading Mid and Terminal Stance Contralateral Limb Response *“Low foot” – refers to no forefoot contact, but not enough ankle dorsiflexion Abbreviations: WNL, within normal limits; PF, plantar flexion; DF, dorsiflexion; MTP metatarsophalangeal

35 Foot and Ankle Curricular Guidelines 2015 Appendix 1B. Foot and Ankle Special Interest Group Gait Form Gait Velocity: NOTES Stride length: NOTES Cadence: NOTES Normal or Abnormal Equal? Yes‐‐‐‐NO Normal or Abnormal Cause If no, what is cause? Cause Phase of Gait Initial Contact Mid Stance Terminal Stance Pre Swing – Initial Swing, Reference Limb Loading Response Initial Swing Mid Swing, Circle Left or Right Terminal Swing Task of Gait Weight Acceptance Single Limb Support Forward Weight Shift Limb Advancement Limb Advancement (Acceleration) (Deceleration) Normal Yes‐‐‐NO Yes‐‐‐NO Yes‐‐‐NO Yes‐‐‐NO Yes‐‐‐NO Functional Yes‐‐‐NO Yes‐‐‐N Yes‐‐‐NO Yes‐‐‐NO Yes‐‐‐NO

ROCKER Heel rocker Ankle rocker Forefoot rocker Forefoot rocker Normal Yes‐‐‐NO Yes‐‐‐NO Yes‐‐‐NO Yes‐‐‐NO

ANKLE MOTION 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 MOTION 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? Phase of Gait ‐ Pre to Initial Swing Initial to Mid Swing Mid to Terminal Swing Initial Contact Mid and Terminal Stance Contralateral Limb Loading Response

36 Foot and Ankle Curricular Guidelines 2015 Appendix 2. Average Normative 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 position. The test was 200651 (n = 30) terminated if the participant leaned forward touching the string at the level of the (mean age = 24 ± 5.7) pectorals three times, the ipsilateral knee flexed, the dorsal aspect of the foot did not contact the string for 3 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 = 203) 27.9 ± 11.1 Each subject was allowed to touch the examiner with a single finger for balance. 199552 (mean age men = The test was terminated if the subject leaned or pushed down on the examiner, 34.7 ± 8.5, the subject's knee flexed, the plantar flexion range of motion decreased by more mean age women = than 50% of the starting range of motion (measured quantitatively), or the subject 29.3 ± 5.0) quit or asked to stop. Jan, 200553 Adults (n = 180) Male One examiner provided the finger‐touch support and counted the total number (21‐ 80 years old) 21 ‐ 40 = 22.1 ± 9.8 heel rises accomplished. Another examiner observed the participant laterally for 41 ‐ 60 = 12.1 ± 6.6 any extraneous trunk lean or knee flexion. The third examiner read the electro‐ 61 ‐ 80 = 4.1 ± 1.9 goniometer output on the monitor and terminated the test if the plantar flexion angle became less than 50% of the maximum angle. Female 21 ‐ 40 = 16.1 ± 6.7 41 ‐ 60 = 9.3 ± 3.6 61 ‐ 80 = 2.7 ± 1.5

37 Foot and Ankle Curricular Guidelines 2015 Appendix 3. Normative Values for the Single Limb Balance Test Age Gender Eyes Open Mean of 3 Trials Eyes Closed Mean of 3 Trials Mean Mean Single Limb Balance (in seconds)32 18‐39 Male 43.5 ± 3.8 8.5 ± 9.1 Female 43.2 ± 6.0 10.2 ± 9.6 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

REFERENCES 1. A Normative Model of Physical Therapist Professional Education: Version 2004. Alexandria, VA: American Physical Therapy Association; 2004. 2. The Guide to Physical Therapist Practice. http://www.apta.org/Guide/. Accessed October 12, 2014. 3. International Classification of Functioning, Disability, and Health. http://www.apta.org/ICF/. Accessed October 12, 2014. 4. Physical Therapist Clinical Performance Instrument. http://www.apta.org/PTCPI/. Accessed October 12, 2014. 5. Bates SM, Jaeschke R, Stevens SM, et al. Diagnosis of DVT: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence‐based Clinical Practice Guidelines. Chest. 2012;141(Suppl 2):e351S–e418S. 6. Riddle DL, Hillner BE, Wells PS, Johnson RE, Hoffman HJ, Zuelzer WA. Diagnosis of lower‐extremity deep vein thrombosis in outpatients with musculoskeletal disorders: a national survey study of physical therapists. Phys Ther. 2004;84(8):717–728. 7. Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep‐vein thrombosis in clinical management. Lancet. 1997;350(9094):1795–1798. 8. Scarvelis D, Wells P. Diagnosis and treatment of deep‐vein thrombosis. CMAJ. 2006;175(9):1087–1092. 9. American Diabetes Association. A1C and eAG. http://www.diabetes.org/living‐with‐diabetes/treatment‐and‐care/blood‐glucose‐ control/a1c/. Accessed October 12, 2014. 10. Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid‐foot: systematic review. BMJ. 2003;32(7386):417. 11. Dowling S, Spooner CH, Liang Y, et al. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta‐ analysis. Acad Emerg Med. 2009;16(4):277–287. 12. Blackham JEJ, Claridge T, Benger JR. Can patients apply the Ottawa ankle rules to themselves? Emerg Med J. 2008;25(11):750–751. 38 Foot and Ankle Curricular Guidelines 2015 13. Haraguchi N, Toga H, Shiba N, Kato F. Avulsion fracture of the lateral ankle ligament complex in severe inversion injury: incidence and clinical outcome. Am J Sports Med. 2007;35(7):1144‐1152. 14. Harden RN, Oaklander AL, Burton AW, et al. Complex regional pain syndrome: practical diagnostic and treatment guidelines, 4th edition. Pain Med. 2013;14(2):180–229. 15. Hampton S. An introduction to various types of leg ulcers and their management. Br J Nurs. 2006;15(11): S9‐S13. 16. The Foot Posture Index. Easy quantification of standing foot posture. Six item version (FPI‐6). User Guide and Manual. http://www.biomechanics‐education.com/journals/Foot%20posture%20index.pdf. Accessed October 5, 2014. 17. Macrum EC. The Relationship Between Dorsiflexion Range of Motion and Lower Extremity Movement Patterns and Muscle Activation. Dissertation UNC‐Chapel Hill, UMI Microfilm #1454430, Proquest; 2008. 18. Livengood AL, DiMattia MA, Uhl TL. “Dynamic Trendelenburg:” Single‐Leg‐Squat Test for gluteus medius strength. Athl Ther Today. 2004;9(1):60‐61. 19. DiMattia MA, Livengood AL, Uhl TL, Mattacola CG, Malone TL. What are the validity of the Single‐Leg‐Squat Test and its relationship to hip‐abduction strength? J Sport Rehabil. 2005;14(2):108‐123. 20. Norkin CC, White DJ. Measurement of Joint Motion: A Guide to Goniometry. 4th ed. Philadelphia PA: F.A. Davis; 2009. 21. DiGiovanni CW, Kuo R, Tejwani N, et al. Isolated gastrocnemius tightness. J Bone Joint Surg Am. 2002;84‐A(6):962‐970. 22. Lundberg A, Goldie I, Kalin B, Selvik G. Kinematics of the ankle/foot complex: plantar flexion and dorsiflexion. Foot Ankle. 1989;9(4):194‐ 200. 23. Nawoczenski DA, Baumhauer JF, Umberger BR. Relationship between clinical measurements and motion of the first metatarsophalangeal joint during gait. J Bone Joint Surg Am. 1999;81(3):370‐376. 24. Martin RL, Davenport TE, Paulseth S, Wukich DK, Godges JJ; Orthopaedic Section American Physical Therapy Association. Ankle stability and movement coordination impairments: ankle ligament sprains. J Orthop Sports Phys Ther. 2013;43(9):A1–A40. 25. Lunsford BR, Perry J. The standing heel‐rise test for ankle plantar flexion: criterion for normal. Phys Ther. 1995;75(8):694‐698. 26. Jan M, Chai H, Lin YF, et al. Effects of age and sex on the results of an ankle plantar‐flexor manual muscle test. Phys Ther. 2005;85(10):1078‐1084. 27. Neumann D. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 2nd ed. St. Louis, MO: Mosby Publishing Inc.; 2010:609‐613. 28. Starkey C, Brown SD, Ryan J. Examination of Orthopedic and Athletic Injuries. 3rd ed. Philadelphia, PA: F.A. Davis; 2010:270. 29. Kinoshita M, Okuda R, Morikawa J, Jotoku T, Abe M. The dorsiflexion‐eversion test for diagnosis of tarsal tunnel syndrome. J Bone Joint Surg Am. 2001;83‐A(12):1835‐1839. 30. Abouelela AA, Zohiery AK. The triple compression stress test for diagnosis of tarsal tunnel syndrome. Foot (Edinb). 2012;22(3):146‐149. 31. Majlesis J, Togay H, Unalan H. Toprak S. The sensitivity and specificity of the SLUMP and straight leg raised tests in patients with lumbar disc herniation. J Clin Rhematol. 2008;14(2):87‐91. 32. Springer BA, Marin R, Cyhan T, Roberts H, Gill NW. Normative values for the unipedal stance test with eyes open and closed. J Geriatr Phys Ther. 2007;30(1):8‐15. 33. Bell DR, Guskiewicz KM, Clark MA, Padua DA. Systematic review of the balance error scoring system. Sports Health. 2011;3(3):287‐295. 34. Gribble PA, Hertel J, Plisky P. Using the Star Excursion Balance Test to assess dynamic postural‐control deficits and outcomes in lower extremity injury: a literature and systematic review. J Athl Train. 2012;47(3):339–357. 39 Foot and Ankle Curricular Guidelines 2015 35. Rehabilitation Measures Database. http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=899. Accessed June 11, 2015. 36. Jones CJ, Rikli RE. Measuring functional fitness of older adults. J Active Aging. 2002;1:24‐30. 37. Martin RL, Davenport TE, Reischl SF, et al. Heel pain—plantar fasciitis: revision 2014. J Orthop Sports Phys Ther. 2014;44(11):A1–A33. 38. Carcia CR, Martin RL, Houck J, Wukich DK; Orthopaedic Section of the American Physical Therapy Association. Achilles pain, stiffness, and muscle power deficits: Achilles tendinitis. J Orthop Sports Phys Ther. 2010;40(9):A1‐26. 39. Christenson RE. Effectiveness of specific soft tissue mobilizations for the management of Achilles tendinosis: single case study— experimental design. Man Ther. 2007;12(1):63‐71. 40. Kerkhoffs GM, van den Bekerom M, Elders LA, et al. Diagnosis, treatment and prevention of ankle sprains: an evidence‐based clinical guideline. Br J Sports Med. 2012;46(12):854‐860. 41. Sims AL, Kurup HV. Painful Sesamoid of the great toe. World J Orthop. 2014;5(2):146‐150. 42. Torriani M, Kattapuram SV. Dynamic sonography of the forefoot: The sonographic Mulder sign. AJR Am J Roentgenol. 2003;180:1121‐ 1123. 43. Miller TT, Staron RB, Feldman F, Parisien M, Glucksman WJ, Gandolfo LH. The symptomatic accessory tarsal navicular bone; assessment with MR imaging. Radiology. 1995;195(3):849‐853. 44. Becerro‐de‐Bengoa‐Vallejo R, Losa‐Iglesias ME, Rodriguez‐Sanz D. Static and dynamic plantar pressures in children with and without sever disease: a case‐control study. Phys Ther. 2014;94(6):818‐826. 45. Zwitser EW, Breederveld RS. Fractures of the fifth metatarsal; diagnosis and treatment. Injury. 2010;41:555–562. 46. Silverstein LS. The effect of neutral position foot orthoses on gait of children with Down Syndrome. Dissertation, Hahnemann University, Philadelphia, PA, University Microfilm number 9400128, University Microfilms International, Proquest; 1993. 47. Ankle and foot disorders. In: Hegmann KT, eds. Occupational Medicine Practice Guidelines. 3rd ed. Elk Grove Village, IL: American College of Occupational and Environmental Medicine (ACOEM); 2011:1‐268. 48. Brunnekreef JJ, van Uden CJ, van Moorsel S, Kooloos JG. Reliability of videotaped observational gait analysis in patients with orthopedic impairments. BMC Musculoskelet Disord. 2005;6:17. 49. Cornwall MW, McPoil TG, Fishco WD, Hunt L, Lane C, O’Donnell D. Reliability of visual measurement of forefoot alignment. Foot Ankle Int. 2004;25(10):745‐748. 50. Nielsen RG, Rathleff MS, Moelgaard CM, et al. Video based analysis of dynamic midfoot function and its relationship with Foot Posture Index scores. Gait Posture. 2010;31(1):126‐130. 51. Madeley LT, Munteanu SE, Bonanno DR. Endurance of the ankle joint plantar flexor muscles in athletes with medial tibial stress syndrome: a case‐control study. J Sci Med Sport. 2007;10(6):356‐362. 52. Lunsford BR, Perry J. The standing heel rise test for ankle plantarflexion: criterion for normal. Phys Ther. 1995;75(8):694‐698. 53. Jan MH, Chai HM, Lin YF, et al. Effects of age and sex on the results of an ankle plantar‐flexor manual muscle test. Phys Ther. 2005;85(10):1078‐1084.

40 Foot and Ankle Curricular Guidelines 2015