3/30/2017

Russ Bartholomew PT ,DPT OCS  8:00-8:30 Overview of key principles from Day 1

 8:30 -10:00 Gait assessment

 10:00- 11:00 Plantar Fasciitis

 11:00-12:30 Meeting

 12:30-1:30 Lunch

 1:30 -2:30Achilles Tendinopathy

 2:30 – 4:00 Posterior Tibial Tendon Dysfunction , Bunionectomy , Hallux rigidus

 4:00 – 5:00 Cuboid Syndrome and Sinus Tarsi Syndrome  5:00 to end ,Exercise Lab

 The “Leonardo Perspective “  2 jobs of the foot  Stabilization Principles Applied to the Foot ( intrinsics, near extrinsic , distant extrinsic) 1)Closed Chain Dorsiflexion  Motor Learning 2)Knee Flexion at Loading Response  Fryette’s Law of the Foot 3)Hip extension at terminal stance  The torque converter concept of subtalar joint  First ray stability  STJN Magnetic North

1 3/30/2017

Gait Lab

 Foundation before roof

 Closed chain is the destination

 Facilitation versus strengthening

 Top down AND bottom up ( “The butt is the steering wheel of the foot “)

 Tri-Plane

 Stabilization principles / ( Not excessive pronation but lack of pronation control (Jam 2006 )

2 3/30/2017

 Pain as a guideline

 Is it really an “Itis “ ? ( If not why use anti- inflammatory treatment modalities ?)

 Add what is missing /create the environment.

 Self efficacy (The patient must understand and be educated in order to be expected to be compliant)

3 3/30/2017

 TENSION (abnormal foot position or compensation for loss of flexibility . Surface of walking and running , shoe issues , weight gain.

 DOSAGE ( frequency , distance , speed or weight)

 Loss of lengthening of the Achilles complex/mechanical loss of dorsiflexion. (Tension)  Eccentric weakness of the Achilles complex ( Tension)  Excessive Prolonged Pronation (EPP). Think control versus motion . As we discussed in intrinsic stabilization . (Tension)  Cavus foot type ( Tension )  Weight gain of obesity .( Tension and Dosage )  Change in running /walking volume (Dosage )  Change in walking /running surface (Dosage and tension )

4 3/30/2017

 Original description of this entity was  Shoe gear (Tension /Shock ) “ Painful Heel “  Fatigue / prolonged standing ( Tension and  Papers on this subject began to describe dosage ) inflammation being present , but there was no  Proximal pronatory control weakness ( Hips as clinical .)histologic evidence that supports part of the Core ) inflammation as the underlying issue.  Emerging evidence on intrinsic muscle  “Itis” infers inflammation . Clinical signs of weakness / atrophy ( Chang 2012 ) inflammation: pain , heat , redness , swelling PLUS histologic findings( leukocyte accumulation macrophages ,lymphocytes , plasma and vessel proliferation )

 Lemont H, Ammirati K, Usen N. Plantar fasciitis: a  MRI evidence of lack of inflammation :Grasel et degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc 2003;93(3):234-237. al: These authors ruled out inflammation as a ( Myxoid degeneration , fragmentation .) cause because of the linearity and low  Schepsis AA, Leach RE, Gorzyca J. Plantar fasciitis. prevalence of signal intensity within the fascia. Etiology, treatment, surgical results, and review of the literature. Clin Orthop. 1991;(266):185-196. They concluded that the changes noted are best (Fibrosis and thickening ) interpreted as perifascial edema due to  Snider MP, Clancy WG, McBeath AA. Plantar fascia microtears in the plantar fascia in the area of its release for chronic plantar fasciitis in runners. Am J Sports Med. 1983;11(4):215-219. insertion into the calcaneus. (Collagen necrosis, angiofibroblastic hyperplasia and matrix calcification ) .

5 3/30/2017

NORMAL COLLAGEN DEGENERATED  Acevedo and Beskin reported that in a group of 765 patients with a clinical diagnosis of plantar fasciitis, 51 were diagnosed as having a plantar fascia rupture. Of these 51 ruptures, 44 (86%) were associated with corticosteroid injection

POST-STEROID NORMAL INJECTION

6 3/30/2017

Subjective /History : Examination ( Objective )  Pain located in the plantar heel ( not just pain  Specific palpation of the calcaneal tubercle and somewhere in the foot ) along the plantar fascia middle/medial band . ( windlass will help locate)  “Get up and go” pain.  Active and passive dorsiflexion ROM .  Increased after prolonged weight bearing . (  Tarsal tunnel clearing .( Phalen’s and Terrible in the morning , better after up a few Tinel/AND screening ) hours and then terrible in the evening ).  Windlass  Recent increase in weight bearing activity (  Navicular drop/FPI ( Planus or Cavus dosage) causation )

 Subjective : Plantar fasciitis worse with first few steps , entrapment with prolonged activity .  Manual= A (E*)  Specific Palpation ( plantar or more proximal and medial. Parallel with  Stretching= A (B) foot or oblique )  Tinel at Tunnel and Abductor  Hallucis . Taping= A (C)  Windlass.  Orthotics = A (A)  AND tests  Symptoms don’t resolve when you address impairments . ( Stay out of  Night splints = A (B) the rut …if not getting better reflect )  Modalities = D (B)

* Often it is a mixed presentation as the stresses that lead to many foot diagnosis are the same .

7 3/30/2017

Manual Therapy= Strong ( from weak )

 Cleland : Techniques to restore joint motions at the talocrural joint ( closed chain dorsiflexion), subtalar joint, and mid-tarsal joint as well as elongation of plantar fascia )

 Soft tissue ( Renan-Ordine 2011)

 AND techniques ( Meyer 2002 and Young 2001)

 Randomized clinical  2 centers : NH and NZ  Good external validity as  The MPEX group it mimics typical manual experienced both trial .  2 study groups : therapy practice , but significant and clinically  N= 60 Both : Gastroc/ soleus poor internal validity as meaningful  Prior to this study no stretch ,plantar fascia there were a lot of improvements in LEFS randomized clinical stretch , strengthening variables in “impairment scores at 4 weeks and 6 trails of manual therapy of intrinsics . based “ treatment months that were interventions for EPAX= US, Ionto with techniques . significantly better than plantar heel pain Dexamethasone the EPAX. ( thus low level of MTEX= Soft tissue Authors noted that future evidence noted by mobilization, rearfoot studies should seek to McPoil ) identify which specific eversion mobilization, manual techniques and and impairment based exercises are most hip, knee , ankle and effective foot techniques.

8 3/30/2017

OTHER MANUAL TECHNIQUES MANUAL TECHNIQUES BASED ON IMPAIRMENT  Knee flexion mob with  Hip posterior glide  Plantar fascia and FHL  A/P talocrural stretch and tissue mobilization 1 and 2 ( valgus IR  Figure 4 hip anterior glide mobilization . (plantar talocrural dorsiflexion  Knee flexion mob with soft tissue restriction ) restriction) varus ER  Prone internal rotation  Distal Tibiofibular with extension mob  Lateral glide/eversion  Knee extension mob ( tibiofibular restriction ) mobilization .(ankle  Patellofemoral mob  Cuboid manipulation /rearfoot complex  Proximal tib-fib restriction ) ( intertarsal restriction ) manipulation  P/D tarsal mobilization  Rearfoot distraction  Hip caudal glide 90-90 manipulation ( ( intertarsal restriction ) belt talocrural joint motion  Tibialis Posterior restriction ) stretch

ADVERSE NEURAL  Provides short term DYNAMICS ( AND ) clinical benefit of 2 weeks to 4 months (  TED Landorf 2006/ Sweeting  SID 2011)  PIP  No difference between  Slump sustained @ 3 min versus  SLR intermittent 20 sec x 3  Pragmatic info :  Technique  Dynamic progression .

9 3/30/2017

WINDLASS STRETCH SELF MASSAGE MCCLURE ET. AL .

 This article is a great review of the effects of immobilization as well as the effects of excessive tension on peri- articular soft tissues ( PAT ) .  Peri-articular tissues are designed to withstand tensile stress.  If tissue is deprived of tensile stress or there is excessive stress ,morphologic, biomechanical and biochemical changes occur .

 Loss of GAGs ( key components of connective tissue ), and water cause intermolecular and intramolecular cross links to form . This limits extensibility of tissue which further leads to degeneration .

10 3/30/2017

 There is a loss of degradation / synthesis balance .

 Frost proposes the theory of “ minimally effective strain”…not too much and not too little

This is the theoretical basis for the treatment techniques to follow .

CHOICES

 Reduces pain with patients Use or don’t use ? with “get up and go pain. “ Short term effect ( van de ( Hawke2008 , Lynch Water2010/Van Lunen 2011 ) 1998 )  K tape /Rock tap : effective but for less time (Tsia 2010)  Designed to reduce tensioning stress overload by Custom vs. Prefabricated ? compressing tarsals ( as would (Pfeffer 1999, Martin 2014 ) occur with girding intrinsic muscles ) and by creating a tripod foot with first ray plantar flexion. Long term or short term ?  Also created a girder under ( Landorf 2006) the bridge .

11 3/30/2017

Iontophoresis  Short term relief ( 2-4  Progressive loading program for home weeks )  Moderate Evidence  1-3 month duration

 2008 recommendation : Only recommend for those of 6 month or greater duration. THE QUESTION IS WHY ???? Itis or  Night splinting ( “The Sock” Osis ???? )www.thesock.com

 Symptom not the problem

12 3/30/2017

 The “ cut knuckle “ ; pain with tension on the release will result in altered gait with reduced pronation and eventual “lateral column strain “

 Treat with motor relearning ,desensitization , and functional remodeling of the healing tissue .

Restore dorsiflexion Tape /Orthosis  Achilles focus  Use for short term unloading  Talocrural focus Motor Learning ( F evidence )  Both  Pronatory control neuromotor re-education Address Cavus /Planus  Intrinsic , near extrinsic , distant extrinsic . Regional  Cavus =Mobilize first ray /STJ =facilitate pronation interdependence is both mobility and control .  Planus = Stabilize . Internal ( NMR ) versus external ( tape , orthotic ) Home exercises Soft tissue local Progressive  ASTYM calf , parallel fiber pf , cross friction insertion , windlass – MWM windlass .

13 3/30/2017

 Normal tendons have spindle shaped tendon cells, interspersed with highly organized extracellular matrix. The matrix is made up of tight bundles of long strands of Type I collagen .

14 3/30/2017

TENDONS SUBJECT TO OVERUSE

 Increased ground  Increased large substance . proteoglycans  Disrupted collagen  Increased tendon cells bundles .  INCREASED  Decreased type I vascularity collagen and increased ( Ohberg 2002) Type III ( thinner and less able to bundle )  Increased Fibroblasts

THE RESULT

 Inferior Collagen  The previous slide describes the tendons poor response   Defective Vessels ( thick to overuse with slow and incomplete healing and lack walled , tortuous, with of extracellular organization . This was initially called small lumen ) tendon degeneration by Ledbetter , but more appropriately should be called “ failed healing  The tendon is overall less load tolerant . response “as described by Clancy .

15 3/30/2017

ACUTE INJURY OVERUSE INJURY

3 standard phases of  Does not follow the 3 standard phases . healing :  Why? It is theorized that  1) Inflammation micro-injury may fail to stimulate an adequate inflammatory response  2) Proliferation required to begin the reparative cycle . ( subsequent surgery may  3) Maturation have it’s effect by actually injuring the tendon to stimulate the process)

 Degenerative model ; degenerative changes in the tendon cause pain  Many studies have noted the absence of inflammation and describe areas of mucoid  Mechanical model : Disrupted collagen fibers are degeneration, neovascularization and the pain generators disordered collagen fibers in the painful Achilles tendon. ( Astrom 1995 , ,Movin 1997)  Biochemical model : Local anoxia and or inability  So again it appears that this problem is lack of to phagocytize /remove cellular byproducts cause inflammation and thus a failed healing pain response .  Neurogenic Inflammation : Increased neurotransmitters ( glutamate, substance P , calcitonin gene related peptides ) in the sensory fibers of the injured area ….. FDN ???

16 3/30/2017

 Pronation as compensation  Reduced Dorsiflexion / Achilles length vs.  Pronation and the frontal plane Talocrural Mechanics. Less than 11.5 degrees knee extended . ( Kaufman 1999 )  Econcentric contractions

 Abnormal STJ motion. > 32 degrees of inversion ( Kaufman ). ( Kvist 1994) Total arc of motion <25 degrees .

 Plantar flexor strength ( Mahieu 2006, Silbernagel 2006 )

 Pronation ( Mc Crory 1999,Kvist 1994 , Clement  Training errors 1984 )

 Shoes  Ultrasound detectable differences in tendon structure . ( Fredberg 2002)  Running surface

 Comorbidities :obesity, hypertension, increased  Direct blow cholesterol, and diabetes.

 Recent Cipro (Fluroquinalone) /Levaquin

17 3/30/2017

True Dorsiflexion  Achilles tear/rupture  Partial tear  Retrocalcaneal bursitis  Posterior impingement  Sural nerve  Os trigonum  Accessory soleus  Achilles tendon ossification  Systemic inflammatory disease  Insertional tendinopathy .

 Restore length of Achilles to improve eccentric  Eccentrics =A lengthening capabilities; ( Contract /relax , low  Laser =B load prolonged stretches) ( Stergioulas 2008)  Restore /remodel collagen fiber alignment  Iontophoresis =B (create a functional flexible scar ). Friction ( Netter 2003) massage.  Stretching =C  Correct biomechanical faults . ( Park 2006, Norregaard 2007)  A progressive program to gradually load the Achilles tendon in a controlled manner.

18 3/30/2017

 Exercise appears to be the  Orthotics = C only stimulus to date that (Mayer2007.Donoghue positively influences collagen alignment 2008) ( Kannus )  Manual Therapy = F

 Rest will decrease pain but effects the tissue negatively and reduces collagen strength making it susceptible to re-injury ( Frost ; Minimally Effective Strain Concept )

Variables of Eccentric NEW RESEARCH OLD THOUGHTS Exercise : SUPPORTED THOUGHTS  Speed  Pain was an indicator of  Pain an indicator of  Load increased inflammation desired stress on the  Used pain production  Symptom Level “failed healing “ as the failure level for tendon. exercise intensity .  Use lack of pain Example : heel raise generation as an progression 2 legged to one legged which indicator to increase caused pain stayed at 2 intensity or level. legged .

19 3/30/2017

 Used Alfredson’s VARIABLES ALFREDSON’S PROGRAM program but gradually  Reps, sets, days , load,  3x15 with straight knee increased to 3 sets of 15 3x15 bent knee . 2x/day over 5-7 days to reduce speed , position . for 12 weeks . Done off the edge of step . Pain the initial muscle acceptable as long as it soreness ( which is  Meyers systematic wasn’t “debilitating “ different from tendon review failed to  All patients in the study pain ) . determine the experienced initial muscle soreness. effectiveness of various  When exercise no longer dosages . produced pain weight was added .

 Multiple angle isometrics ( every 20 degrees )

 Manual resisted concentric  2 leg up 2 leg down, slow, flat  Manual resisted concentric/eccentric  2 leg up 2 leg down fast flat  Closed chain progression to flat surface  2 leg up 1 leg down slow flat  Closed chain off step edge .  2 leg up 1 leg down fast, flat  Weighted

20 3/30/2017

 2 leg up 1 leg down  Transverse/frontal slow , 2 inch step plane lunges   2 leg up 1 leg down fast Step throughs on a 2 inch step wedge  Terminal stance  Single leg up/down supination-pronation slow 2 inch step (SUPRO)  Single leg up and down  Repeat heel raise fast 2 inch step progression with weight

 Altered Pain Perception  The mechanism behind ( Desensitization ) the positive effects of eccentrics for treating  Neovascularization Alteration  Further supports the tendinopathy is largely ( Alfredson 2005): There are histologic findings of neovessels neovascularization unexplained .(Roos 2004) and related nerve in-growth in tendon Theoretically, the vessels theory of eccentric effect Suggested Mechanisms: and nerves could be traumatically damaged during the eccentric  Muscle Stiffness Changes training regimen (180 repetitions/day), when travelling (McNeil –Alexander) The from the soft tissue outside the questions are should we tendon into the dense tendinosis tissue. This is supported by follow stretch ? Is stretching up vascular studies where different than elongation ? patients with good clinical results had no remaining neovessels and those that failed still had neovessels .

21 3/30/2017

OHBERG 2002

 3.8 years after completed eccentric program as described by Alfredson , histologic studies found normal tendon thickness and normal tendon structure . It remodeled !!!

22 3/30/2017

 Studies have shown histologicaly that rather than an inflammatory process , this is a degeneration of the tendon with the tendon becoming fibrotic .

 Causes of degeneration : Repeated micro- trauma, increased mechanical demands from compensation. Poor blood supply.

 Stage I : Tendon is intact but inflamed  Neuropathy ( diabetic and idiopathic)  Degenerative joint disease secondary to OA,  Stage II : Tendon is dysfunctional and there is a acquired flat foot deformity which is passively fracture , or mechanical dysfunction correctable . (compensation for rearfoot /forefoot varus etc.)  Middle aged females  Stage III : Flat foot deformity is fixed and there are degenerative changes in the subtalar joint.  HTN  Steroid injections  Stage IV : (Myerson ) Fixed flat foot deformity with degenerative changes also present in the ankle joint.

23 3/30/2017

 Foot posture Index  Recognize and “ diagnose” it .  Staging  Treat acute inflammation (iontophoresis )  Dynamic  Strengthen the tibialis posterior progressively  Don’t miss because the pain is lateral (isometric shortened range, multiple angle isometrics, manual resisted concentric, manual  Facilitate PT resisted concentric/eccentric , weight bearing concentric/eccentric in gait stages , fast speed momentum controlling dynamic exercises ).  Treat the “chain” including “ the core “

 Stretch muscle imbalances ( Achilles complex )  Set the environment for successful ankle –foot orthoses fitting . ( emphysize that this is a chronic and progressive problem . Compliance  External support / orthotics /taping is key)  Talocrural motion .  Home exercises  Resupination maximization.  All of the issues addressed in a stage I ( anti- inflammatory PRN )

24 3/30/2017

 Accommodation /compensation  Treat above the subtalar joint .

 AFO needs to unload tibialis posterior tendon  Primary soft tissue repair. Is there and maximize the inversion position of the heel augmentation with the (lock the key ) and reduce forefoot abduction . FHL ?  Activation of the PT ( Shortened position to neutral )  Progression of weight bearing forces  “Helper “ training , intrinsics, other near extrinsics and distant extrinsics.

25 3/30/2017

 Lengthens the lateral columns mechanically raising the arch .

 Improved early activation of the PT ( less passive tension

 Unstable foot at push off  Medial to lateral load of great toe MTP joint versus preferred plantar load

26 3/30/2017

 Poor first ray loading/pain avoidance  Schuh R, Hofstaetter SG, Adams SB, Pichler F,  Hallux rigidus Kristen K-H, Trnka H-J. Rehabilitation after hallux valgus surgery: importance of physical  Achilles inflexibility therapy to restore weight bearing of the first  Edema ray during the stance phase. Phys. Ther.  Hypersensitivity/vascular changes 2009;89(9):934-945.  Adherent scars

 The purpose of operative  1 year post Austin correction is to reduce malalignment of the first ray bunionectomy , , THEREBY RESTORING ITS decreased load under FUNCTION IN WEIGHT the hallux . BEARING AMBULATION ( Schuh 2009) (Bryant 2005)  Recent plantar pressure  3 years post chevron distribution studies indicate bunionectomy ,56% of that despite improvements in radiographic parameters ( patients did not use “successful surgery “) their great toe for push restoration of function of the off. (Schuh 2009 ) first ray and great toe does not occur

27 3/30/2017

 Decreased strength and force generation of the plantar flexors.  Lateral transfer of force  Accessory motion of over the lateral first MTP metatarsals ( smaller  Gait assess :ankle rocker and less equipped) /frontal plane ankle resulting in rocker metatarsalgia  Toe rocker  “Lateral column strain “  Great toe extension and flexion  Hallux Limitus

 Rathberger post operative  Active push off training shoe 4 weeks (weight bearing while reduced  Selective peroneus longus forefoot stress) strengthening ( I disagree   Compression sock to with the Schuh Soft tissue mobilization reduce swelling . explanation of why , it is at scar and plantar plate  First PT 4 weeks PO about stable base for  Weight bearing first Lymphatic drainage , supination ) metatarsal on fixed muscle pump and  Anterior tibialis eccentric great toe mob ( reverse ice/elevation to reduce control exercises concave on convex rule) edema.  Manual therapy to  Mid-stance concentric  Subsequent visits : improve first ray plantar supination training . Gait training with phases flexion and MTP flexion  First ray loading lunge of gait and extension . matrix .

28 3/30/2017

 Anatomy : Wedge shaped . Strong ligament complex . OBLIQUE MID-TARSAL Pulley for peroneus longus tendon . (CALCANEAL CUBOID)

 52 degrees from the  PL also stabilizes the CC joint when functioning correctly . transverse

 There are fibroadipose folds or labra between the CC and  57 degrees from the sagittal cubometatarsal joint . These may get impinged. (Lidtke 2004)  Contraction of PL from mid- stance to late propulsion  There is also a labrum between exerts eversion torque on the calcaneous and cuboid Cuboid . This assists with taking up 35 % of joint space . load transfer from lateral to ( Hollander 1998) medial ( Forefoot loading )

 Chronic pronation increases the moment  Inversion of the arm of the PL thus calcaneous with relative causing disproportionate eversion of the Cuboid ( eversion force on Cuboid .  This may perpetuate the forceful PL contraction lateral foot pain once the to “right the foot “ syndrome has developed . ( Leonardo )  80 % of patients with cuboid syndrome present with pronated feet (Newell 1981 )

29 3/30/2017

 Midtarsal Instability SUBJECTIVE OBJECTIVE  Obesity  Symptoms much like  Pronation alignment  Ill-fitting orthotics ankle sprain . Lateral ( 80 %) foot pain . CC joint , 4  Slight sulcus on dorsum  Exercise intensity and or 5 cuboid or prominence on plantar  Training on uneven surfaces metatarsal joint .  Asymmetric accessory  History of inversion  Ankle /Foot sprain injury or chronic motion . pronation .  Pain on PL resistance .  Walking on pebble or  Tenderness along PL pearl.  Antalgia at propulsion

SPECIAL TESTS ( JENNINGS 2005 ) CUBOID WHIP

 Midtarsal adduction test :  Cup dorsum of the foot .  Stabilize calcaneus with Thumbs on the plantar proximal hand and adduct medial aspect of the the forefoot , moving the cuboid ( inversion vector ) cuboid away from . Patient knee flexed to 70- calcaneus ( opening around 90 degrees . Ankle neutral the superior to inferior axis . “Whip” foot into inversion and plantar  Supination Test flexion with low  Mimic the pill of the PL amplitude high velocity along the oblique midtarsal thrust to cuboid . May axis into eversion and hear a pop ( usually hear a inversion. squeal)

30 3/30/2017

AFTER CARE

 Short course of taping  Pain from excessive to support foot stabilize motion in the STJ midtarsal joint . caused by STJ synovitis  Cuboid padding or infiltration of fibrotic ( fulcrum ) tissue into the sinus tarsi ( Helgeson 2009 )  Intrinsic strengthening  Anatomy

 Correct pronatory faults

SUBTALAR JOINT SCREW-LIKE ACTION TORQUE CONVERSION

 48 degrees from the Rotation of the tibia transverse plane converted to pronation/supination

 42 degrees from the frontal plane

 16 degrees from the sagittal plane

31 3/30/2017

SUBJECTIVE OBJECTIVE

   Pain at sinus tarsi ( pain on Single or multiple ankle Previous ankle sprain or motion ) sprains . 10-25 % of abrupt stop after jump  Pain over sinus tarsi at end chronic talocrural joint or fall ( shear ) range plantar flexion with supination . instability patients also  Failed lateral ankle  Stress test / STJ stability test ( have STJ instability . Therman 1997) stabilization .  Supine ankle in 10 degrees df ( ( Keefe 2002) stable TC ) .Forefoot stabilized  Feeling of instability on .Inversion and Internal rotation  force applied to calcaneus . Cause intrinsic ligament uneven ground, Forefoot is then inverted . Positive is excessive medial shift injury resulting in STJ stepping off curb or of calcaneus and reproduction of instability running and sprinting . symptoms . Single leg standing with rotation .

SUBJECTIVE  Cuboid syndrome

 Pain localized to the sinus tarsi .  Peroneal tendon  Feelings of instability subluxation with weight bearing pronation and supination movements  Avulsion / Jones / Stress fracture 5 th  History of trauma to the ankle .  Anterior /lateral impingement .

32 3/30/2017

 Balance and proprioception training  Foot stabilization  Orthotics / Tape  Total LE pronatory control  Correct TC and mid-foot immobility  First Ray stabilization/ Propulsion stabilization

 Attain = Find positions the  Technique : Patient prone . athlete is able to attain in a Start in maximal stable fashion . dorsiflexion place  Maintain = Develop patient’s foot on your coordinated IM and eccentric thigh and have them contractions of muscle plantar flexion into crossing the target joints graded manual resistance to maximal plantar .( Move in and out of the flexion . Isometric hold position . then slow eccentric return  Sustain =Integrating all the . neuromuscular subsystems .  Target : Activation of Moving in and out under the Achilles complex . First influence of drivers ( level of eccentric momentum, external progression perturbations etc.) Opening and closing the chain .

33 3/30/2017

 Technique : Sitting with knee extended , heel as a pivot on the floor .Wrap  Technique : Patient prone , band around the foot at place your thenar eminence the metatarsal head level at the base of their first met with the band coming off head . Forefoot begins the base of the first met . inverted. Patient pushes Grasp and hold the band down into first ray plantar on tension. Start with flexion/forefoot eversion to forefoot inverted / first neutral ( foot on floor ray dorsiflexed . Pull the position ).Slow return to start . first ray down into the resistance to the “ ray on  Target : Activation of peroneus longus / IM hold . the floor “position . Hold IM and return to start .

 Progression of hip abductor exercises starting in open chain  In standing stride with progressing to more involved forward functional closed chain .  Focus on eccentric AT,  Clam shells , clam shell then shut off and with band , clam shell eccentric PT/ with band at ankle , open clam shell with band  SLR  Standing band abduction  Side stepping band at forefoot  Adduction excursion

34 3/30/2017

 Technique : Seated at the edge of the chair , tibia  Technique : As with PL over foot ( late mid-stance squish , while ) . Place a putty “target “ maintaining the squish ( under first MTP or your first ray stability ) finger tips . Have patient Supinate the STJ to raise the arch without pull the first MTP down to excessive extrinsic the floor ( first ray plantar activity . flexion ) “squishing “ the target and hold .  Target : Limiting distant extrinsic influence .  Target : PL activation, Ability to “lock the foot awareness of load for push off without avoidance . losing first ray stability .

 Technique : As per the  Technique: Vary tibial Squish and lock , now angle by how far raise the heel toward the edge of the chair you go , to work  Target : Putting it all on phases ( early together : first ray to the loading , mid-stance , floor and stable , STJ terminal stance ) for supinated/lifted / control of pronation and locked , and terminal power of supination . stance/ toe rocker May add putty for target /feedback for load avoidance .  Perturbations .  Ouija board .

35 3/30/2017

 Technique : Cue  Technique : Patient to keep heel of target foot on patient to maintain floor and step other leg neutral arch without forward and back . compensation . Do  Target : Smooth ankle proper functional rocker ( counteract “boot gait “ ), elongate Achilles . squat . Can work on eccentric  Hard surface /soft Achilles deceleration of the tibia by adding driver  Target : Elongate . Achilles as well at PT  Can facilitate pronation and “re-supination “in without STJ phase of gait compensation .  Progress to toe rocker .

 Technique : Intensify  Technique : Mimic the the windlass effect heel rocker with slow and MWM effect on controlled plantar the plantar fascia by flexion with eccentric control of AT , then preloading the fascia AT shut off and initial with toe extension . eccentric PT controlled pronation .  Target : End stage  Target : The AT plantar fascia stretch overuse patient or /WMW . poorly control foot drop.

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 Technique : Do a two  Technique : Position legged heel raise with the tibia in neutral a tennis ball between df/pf . Emphasize heels , “squeezing eccentric lowering some air out of the into pronation under ball” as you raise , to control with manual emphasize inversion resistance . of the calcaneus and raising of the arch .  Target : PT control  Target PT activation and intrinsic unlock progression under control

 Technique : Position  Technique : Have the tibial in patient assume dorsiflexion to mimic intrinsic stable terminal stance . position and maintain Emphasize concentric while doing a forward supination to “lock “ lunge . the foot in preparation  May add vectors to for push off , with stress frontal and manual resistance . transverse planes  Target : Stable foot for Target :Maintain stage toe rocker and moving in and out propulsion under control .

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 Technique : Have  Technique : As with patient attain a raised the lunge , attain arch/ neutral position neutral arch and keep without compensation. it while controlled  The plus is you can reach with opposite touch down the back big toe in multiple toe to assist until able to do single leg . directions .

Target: Intrinsic  Target :Maintain level stabilization of foot stability progression to standing

 Technique : Pre-load  Technique : a 1a the Achilles into ankle progression to up rocker/terminal with 2 down with one stance by leaning . Note if they can shift forward onto the wall and dropping hips weight to target leg toward the wall .Slow with no “Achilles smooth heel raise lag” then able to  Progress to up with 2 progress . down with one .  Target :Achilles Target : Progression of progression eccentric loads

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WHERE I’M GOING FROM HERE

 Learning more about motor learning from my neuro colleagues.  FDN with the intrinsics ( James 2013 )  Diagnostic ultrasound ( Tsia 2010 )  Cold laser ( Stergioulas )  Further support of intrinsic training .

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