Manual muscle test The ankle joint, the fingers Mgr. Veronika Mrkvicová (physiotherapist) Examination Methods in Rehabilitation, 16.11.2019 http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/image_article_collectio ns/anatomy_pages/foot.jpg The ankle joint http://www.eorthopod.com/sites/default/files/images/ankle_fusion_anatomy03.jpg http://www.orthopediatrics.com/binary/org/ORTHOPEDIATRICS/images/page/Congenital_Flatfoot_(Pes_Plan us)04.jpg Ankle joint movements • Image result for ankle movements The muscles of the ankle joint http://www.footdoctorsmass.com/images/bones,%20muscle,%20tendons.jpg Ankle plantar flexion •Gastrocnemius Soleus Gastrocnemius Soleus Ankle plantar flexion - gastrocnemius •Origin •Medial head from posterior nonarticular surface of medial femoral condyle •Lateral head from lateral surface of femoral lateral condyle • •Insertion •The two heads unite into a broad aponeurosis which eventually unites with the deep tendon of the soleus to form the Achilles tendon, inserting on the middle 1/3 of the posterior calcaneal surface • •Action •Powerful plantar flexor of ankle • •Innervation •Tibial nerve (S1, S2) (S1, S2) Gastrocnemius Ankle plantar flexion – grade 5, 4, 3 •Position: patient lying prone, lower limbs extended, feet out of the table •Fixation: lower part of the shank (front side) •Movement: ankle plantar flexion in full range of motion •Resistance: PT puts resistance against the heel movement, differentiates the grades according the amount of resistance, fingers are relaxed Ankle plantar flexion – grade 2 Position: patient lying on the tested side, tested lower limb extended in knee and hip joint, untested lower limb flexed in knee and hip joint, lying on the table Fixation: lower part of the shank (front side) Movement: ankle plantar flexion in full range of motion, pushing on the table Ankle plantar flexion – grade 1,0 •Position: lying on the tested side, tested lower limb extended in the knee and hip joint •Attempt to move: PT palpates a trace of contraction during patients attempt to flex the ankle • Ankle plantar flexion – notes: •It is necessary to move the heel up, not just the foot down Ankle plantar flexion - soleus •Origin •Posterior aspect of fibular head, upper 1/4 - 1/3 of posterior surface of fibula, middle 1/3 of medial border of tibial shaft, and from posterior surface of a tendinous arch spanning the two sites of bone origin • •Insertion •Eventually unites with the gastrocnemius aponeurosis to form the Achilles tendon, inserting on the middle 1/3 of the posterior calcaneal surface • •Action •Powerful plantar flexor of ankle • •Innervation •Tibial nerve (S1, S2) (S1, S2) Soleus Ankle plantar flexion – grade 5,4,3 (a.) Position: patient lying prone, untested lower limb extended, feet out of the table, tested lower limb flexed in the knee joint Fixation: lower part of the shank (front side) Movement: ankle plantar flexion in full range of motion Resistance: PT puts resistance against the heel movement, differentiates the grades according the amount of resistance, fingers are relaxed Ankle plantar flexion – grade 5,4,3 (b.) Position: patient sits on the chair, feet on the floor Fixation: not necessary Movement: ankle plantar flexion in full range of motion, heel up, fingers stays on the floor Resistance: PT puts resistance at the knee , against its the movement up, differentiates the grades according the amount of resistance Ankle plantar flexion – grade 2 Position: patient lying on the tested side, tested lower limb flexed in knee joint, untested lower limb flexed in knee and hip joint, lying on the table Fixation: lower part of the shank (front side) Movement: ankle plantar flexion in full range of motion, pushing on the table Ankle plantar flexion – grade 1,0 •Position: lying on the tested side, tested lower limb flexed in the knee joint •Attempt to move: PT palpates a trace of contraction during patients attempt to flex the ankle • Ankle extension with supination Tibialis anterior •Origin •Lateral condyle of tibia, proximal 1/2 - 2/3 or lateral surface of tibial shaft, interosseous membrane, and the deep surface of the fascia cruris • •Insertion •Medial and plantar surfaces of 1st cuneiform and on base of first metatarsal • •Action •Dorsiflexor of ankle and invertor of foot • •Innervation •Deep peroneal nerve (L4, L5, S1) (L4, L5, S1) Tibialis Anterior Ankle extension with supination – grade 5,4 •Position: patient sits, shins away from the table, knee 90° flexed, central position of the foot, no contact with the ground •Fixation: lower part of the shin (from behind) •Movement: ankle extension with supination (fingers free) •Resistance: PT puts resistance at the medial part of the foot against the movement Ankle extension with supination – grade 3 •Position: patient sits, shins away from the table, knee 90° flexed, central position of the foot, no contact with the ground •Fixation: lower part of the shin (from behind) •Movement: ankle extension with supination (fingers free) Ankle extension with supination – grade 2 •Position: patient lyies on the tested side, knee and hip slightly flexed, lateral part of the foot on the table •Fixation: lower part of the shin, no contact of the heel on the table •Movement: ankle extension with supination by pushing the foot on the table Ankle extension with supination – grade 1,0 •Position: patient lyies supine, foot in central position, away from the table •Fixation: distal part of the calf •Attempt to move: PT palpates a trace of contraction at the level of talocrural joint Ankle extension with supination - notes •Fixation of the leg is necessary •A proper direction of the resistance •Knee has to be flexed •Muscles of the fingers has to be relaxed Supination in plantar flexion Tibialis posterior •Origin •Posterior aspect of interosseous membrane, superior 2/3 of medial posterior surface of fibula, superior aspect of posterior surface of tibia, and from intermuscular septum between muscles of posterior compartment and deep transverse septum • •Insertion •Splits into two slips after passing inferior to plantar calcaneonavicular ligament; superficial slip inserts on the tuberosity of the navicular bone and sometimes medial cuneiform; deeper slip divides again into slips inserting on plantar surfaces of metatarsals 2 - 4 and second cuneiform • •Action •Principal invertor of foot; also adducts foot, plantar flexes ankle, and helps to supinate the foot • •Innervation •Tibial nerve (L4, L5) (L4, L5) Tibialis Posterior Supination in plantar flexion – grade 5,4 •Position: patient lyies on the tested side, knee slightly flexed, foot away from the table •Fixation: lower part of the shin •Movement: foot supination in plantar flexion in full range of motion, fingers flexed •Resistance: PT puts resistance on medial part of the foot against the movement Supination in plantar flexion – grade 3 •Position: patient lyies on the tested side, knee slightly flexed, foot away from the table •Fixation: lower part of the shin •Movement: foot supination in plantar flexion in full range of motion, fingers flexed • Supination in plantar flexion – grade 2 •Position: patient lyies supine, ankle flexion, foot away from the table, knee slightly flexed •Fixation: lower part of the calf •Movement: supination in plantar flexion Supination in plantar flexion – grade 1,0 •Position: patient lyies supine, ankle flexion, foot away from the table, knee slightly flexed •Fixation: lower part of the calf •Attempt to move: PT palpates a trace of contraction during patients attempt to move, over the medial knuckle Supination in plantar flexion - notes •Foot has to be away from the table •Ankle and knee has to be in flexion •Proper fixation is necessary •Correct direction of the resistance is important Plantar pronation •Peroneus longus Peroneus brevis Peroneus Longus Peroneus Brevis Peroneus longus •Origin •Head of fibula, upper 1/2 - 2/3 of lateral fibular shaft surface •also anterior and posterior intermuscular septa of leg • •Insertion •Plantar posterolateral aspect of medial cuneiform •lateral side of 1st metatarsal base • •Action •Everts foot and plantar flexes ankle •also helps to support the transverse arch of the foot • •Innervation •Superficial peroneal nerve (L5, S1, S2) •may also receive additional innervation from common or deep peroneal nerves (L5, S1, S2) Peroneus brevis •Origin •Inferior 2/3 of lateral fibular surface •anterior and posterior intermuscular septa of leg • •Insertion •Lateral surface of styloid process of 5th metatarsal base • •Action •Everts foot and plantar flexes ankle • •Innervation •Superficial peroneal nerve (L5, S1, S2) (L5, S1, S2) Plantar pronation – grade 5,4 •Position: patient lyies on the untested side, untested lower limb flexed, tested lower limb in knee and ankle flexion, foot away from the table, fingers relaxed •Fixation: lower part of the shin •Movement: pronation in plantar flexion in full range of motion •Resistance: PT puts resistance at lateral part of the foot against the movement Plantar pronation – grade 3 •Position: patient lyies on the untested side, untested lower limb flexed, tested lower limb in knee and ankle flexion, foot away from the table, fingers relaxed •Fixation: lower part of the shin •Movement: pronation in plantar flexion in full range of motion • Plantar pronation – grade 2 •Position: patient lyies supine, ankle flexion, foot away from the table, knee slightly flexed •Fixation: lower part of the calf •Movement: pronation in plantar flexion in full range of motion Plantar pronation – grade 1,0 •Position: patient lyies supine, ankle flexion, foot away from the table, knee slightly flexed •Fixation: lower part of the calf •Attempt to move: PT palpates the tendon at the area of lateral knuckle • Plantar pronation - notes •Fixation of the shin is necessary •Ankle has to be in flexion •Fingers has to be relaxed The muscles of the foot • http://www.worldwiderunners.com/wp-content/uploads/2014/09/View-of-the-Foot-Muscles-600x345.jpg Fingers movements Image result for big toe movements Metatarsophalangeal (MP) joints of the fingers http://orthoinfo.aaos.org/figures/A00645F02.jpg MP joints flexion •Lumbricals https://o.quizlet.com/asgLZfT5lYL2Yi9rCKsjhQ_m.png Lumbricals •Origin: • 1st: Med. side of 1st tendon of FDL • 2nd: Adjacent sides of 1st-2nd tendons of FD • 3rd: Adjacent sides of 2nd-3rd tendons of FD • 4th: Adjacent sides of 3rd-4th tendons of FDL • •Insertion: •Extensor Wing and Extensor Trifurcation of 1st-4th tendons of EDL (1st Lumbrical - 1st tendon of EDL, etc.) • •Action: •Plantarflex PP, Extend MP, Extend DP of lessor digits •Tighten wings & slacken sling of Extensor Hood • •Innervation: •1st: 1st Plantar Common Digital branch of Medial Plantar Nerve •2nd-4th: Deep branch of Lateral Plantar Nerve MP joints flexion – grade 5,4 •Position: patient lyies supine (or sits), knee slightly flexed, foot in central position •Fixation: metatarses •Movement: II.-V. MP joints flexion in full range of motion •Resistance: PT puts resistance at the plantar side of proximal phalanges against the movement MP joints flexion – grade 3,2 •Position: patient lyies supine (or sits), knee slightly flexed, foot in central position •Fixation: metatarses •Movement: II.-V. MP joints flexion in full range of motion • MP joints flexion – grade 1,0 •Position: patient lyies supine (or sits), knee slightly flexed, foot in central position •Attempt to move: palpation of tendons is difficult, observe the tremble of the fingers during patients attempt to move • MP joints flexion - notes •Fixation of metatarses is necessary •No movement of IP joints •Correct position of the foot • I. MP joint flexion https://lh4.googleusercontent.com/-YcSKOiBeGmE/UtVKhmSMYDI/AAAAAAAATH8/kC7QJwMedUM/s481/66.jpg Flexor hallucis brevis Flexor hallucis brevis •Origin: •Y-shaped tendon •Lateral arm: Plantar surface of Cuboid and 3rd Cuneiform •Medial arm: Plantar component of tendon of Tibialis Posterior • •Insertion: •Lateral tendon: Lat. Sesamoid, Plantar Plate, Conjoined tendon of AdH, contribute to Extensor Hood •Medial tendon: Med. Sesamoid, Plantar Plate, tendon of AbH, contribute to Extensor Hood •United tendon: Plantar surface of Base of PP of Hallux • •Action: •Plantarflex PP of Hallux • •Innervation: •Plantar Digital branch of Medial Plantar Nerve I. MP joint flexion – grade 5,4 •Position: patient lyies supine (or sits), knee and hip slightly flexed, foot in central position •Fixation: I. metatars (from the sides) •Movement: I. MP joint flexion in full range of motion •Resistance: PT puts resistance at the plantar side of proximal phalang of the thumb against the movement I. MP joint flexion – grade 3,2 •Position: patient lyies supine (or sits), knee and hip slightly flexed, foot in central position •Fixation: I. metatars (from the sides) •Movement: I. MP joint flexion in full range of motion • I. MP joint flexion – grade 1,0 •Position: patient lyies supine (or sits), knee slightly flexed, foot in central position •Attempt to move: palpation of tendons is difficult, observe the tremble of the thumb during patients attempt to move • MP joints extension Extensor Digitorum Longus Extensor digitorum longus Extensor digitorum brevis Extensor hallucis brevis https://33.media.tumblr.com/tumblr_m9feulepeL1qggnse.jpg Extensor digitorum longus •Origin •Lateral condyle of fibula, upper 2/3 - 3/4 of medial fibular shaft surface, upper part of interosseous membrane, fascia cruris, and anterior intermuscular septum • •Insertion •Splits into 4 tendon slips after inferior extensor retinaculum, each of which insert on dorsum of middle and distal phalanges as part of extensor expansion complex • •Action •Extend toes 2 - 5 and dorsiflexes ankle • •Innervation •Deep peroneal nerve (L4, L5, S1) (L4, L5, S1) Extensor Digitorum Longus Extensor digitorum brevis •Origin: Sinus Tarsi of the Calcaneus Interosseous Talocalcaneal Ligament Inferior Extensor Retinaculum •Insertion: Lateral side of EDL tendons at Base of PP of Toes 2-4 Contribute to Extensor Hood • •Action: Dorsiflex Phalanges of Toes 2-4 • •Innervation: Lateral Terminal Branch of Deep Fibular Nerve • Extensor hallucis brevis •Origin: Sinus Tarsi of the Calcaneus Interosseous Talocalcaneal Ligament Inferior Extensor Retinaculum •Insertion: • Dorsum of the Base of the Proximal Phalanx of the Hallux • •Action: Dorsiflex Proximal Phalanx of Hallux • •Innervation: Lateral Terminal Branch of Deep Fibular Nerve MP joints extension – grade 5,4 •Position: patient lyies supine (or sits), knee slightly flexed, foot in central position •Fixation: metatarses (from plantar side) •Movement: MP joints extension in full range of motion •Resistance: PT puts resistance at the dorsal side of proximal phalanges against the movement MP joints extension – grade 3,2 Position: patient lyies supine (or sits), knee slightly flexed, foot in central position Fixation: metatarses (from plantar side) Movement: MP joints extension in full range of motion MP joints extension – grade 1,0 •Position: patient lyies supine (or sits), knee slightly flexed, foot in central position •Attempt to move: palpation of tendons at dorsal side of foot (at the area of metatars) • MP joints adduction Adductor hallucis Plantar interossei https://o.quizlet.com/Na6T79S.QNVjKiv3WXyyKA_m.png https://o.quizlet.com/AeodzTIcgFWylybjegmABA_m.jpg Plantar interossei •Origin: Inf. surface of Base & Med. surface of Shaft of 3rd, 4th, 5th MT (1st PI -> 3rd MT, etc.) • •Insertion: Med. side of Base of PP of 3rd, 4th, 5th Toe (1st PI -> PP of 3rd Toe, etc.) Extensor Hood of Toes (3rd, 4th, 5th) • •Action: Adduct 3rd, 4th, 5th Toe (P-Ad vs D-Ab) • •Innervation: 1st-2nd: Deep branch of Lateral Plantar Nerve 3rd: Plantar Digital branch of Superficial branch of Lateral Plantar Nerve Adductor hallucis •Origin: Oblique head: Plantar surface of Base of 2-4 MT, tendon sheath of FL Transverse head: Plantar plate of 3-5 MTP, Deep Transverse MT Lig. • •Insertion: Heads conjoin at 1st interspace prox. to MTP & course through split in Deep Transverse MT Lig Fibers blend with lateral tendon of FHB, Lat. Sesamoid, Plantar Plate, contribute to Extensor Hood Insert on Lat.Plant. aspect of Base of PP of Hallux • •Action: Adducts Hallux Aid in Plantarflexion of Hallux Assist in pulling MT heads together • •Innervation: Deep branch of Lateral Plantar Nerve MP joints adduction – grade 5,4 •Position: patient lyies supine (or sits), knee extended, foot in central position •Fixation: fingers in abduction •Movement: MP joints adduction •Resistance: PT puts resistance at the phalanges against the movement (the movement is adduction to the second finger) MP joints adduction – grade 3,2,1,0 •For grade 3,2,1,0 we just want to see the ability of the patient to make an adduction (notice that adduction of the fingers can be passive action) MP joints abduction Dorsal interosseals https://o.quizlet.com/rt7LOEpN3MV8.aV4o2WiHQ_m.jpg https://o.quizlet.com/8w9ewj8hHbU2yq1hfPZhhQ_m.png Abductor hallucis Abductor digiti minimi Dorsal interosseals •Origin: 1st: Adjacent sides of 1st-2nd MT 2nd: Adjacent sides of 2nd-3rd MT 3rd: Adjacent sides of 3rd-4th MT 4th: Adjacent sides of 4th-5th MT •Insertion: 1st: Med. side of Base of PP of 2nd Toe 2nd: Lat side of Base of PP of 2nd Toe 3rd: Lat side of Base of PP of 3rd Toe 4th: Lat side of Base of PP of 4th Toe Extensor Hood of Toes (2nd, 2nd, 3rd, 4th) •Action: Abduct 2nd, 3rd, 4th Toes (P-Ad vs D-Ab) •Innervation: 1st-3rd: Deep branch of Lateral Plantar Nerve 4th: Plantar Digital branch of Superfical branch of Lateral Plantar Nerve Abductor hallucis •Origin: Med. Process of Calcaneal Tuberosity Flexor Retinaculum Deep Surface of Plantar Aponeurosis Tuberosity of Navicular • •Insertion: Fibers blend with med. tendon of FHB, med. Sesamoid, Plantar Plate, Extensor Hood Insert on Med.Plant. aspect of Base of PP of Hallux • •Action: Abduct Hallux Aid in Plantarflexion of Hallux • •Innervation: Medial Plantar Nerve Abductor digiti minimi •Origin: Lat. margin of Med. Process of Calcaneal Tuberosity Lat. Process of Calcaneal Tuberosity Deep Surface of Plantar Aponeurosis Tuberosity of Base of 5th MT •Insertion: Lateral aspect of Base of PP of 5th Toe •Action: Abduct 5th Toes •Innervation: Lateral Plantar Nerve (before Sup. & Deep divisions) MP joints abduction – grade 5,4 •Position: patient lyies supine (or sits), knee extended, foot in central position •Fixation: not necessary •Movement: MP joints abduction •Resistance: PT puts resistance at the phalanges against the movement MP joints abduction – grade 3,2 Position: patient lyies supine (or sits), knee extended, foot in central position Fixation: calf from the dorsal side (the ankle in central position) Movement: MP joints abduction MP joints abduction – grade 1,0 Position: patient lyies supine (or sits), knee slightly flexed, foot in central position Attempt to move: palpation of abductor hallucis and abductor digiti minimi, observe the tremble of the fingers during patients attempt to move [USEMAP] Interphalangeal joints (IP) of the fingers http://www.eorthopod.com/images/ContentImages/foot/foot_claw/foot_clawtoes_anat02.jpg Proximal interphalangeal joints (PIP) flexion •Flexor digitorum brevis Flexor Digitorum Brevis Flexor digitorum brevis •Origin • Medial process of calcaneal tuberosity • •Insertion • Middle phalanx of 2nd through 5th toes • •Action • Flexes the MP joint of the 2nd through 5th digit • •Innervation • Tibial nerve • Fingers PIP flexion – grade 5,4 •Position: patient lyies supine (or sits), foot in central position •Fixation: PT fix metatarses (with the fingers on dorsal side of the foot) and proximal phalangs (with the thumb on plantar side of the foot) •Movement: II.-V. PIP joint flexion in full range of motion •Resistance: PT puts resistance at the plantar side of middle phalanges (II.-V.) against the movement Fingers PIP flexion – grade 3,2 (1,0) Position: patient lyies supine (or sits), foot in central position Fixation: PT fix metatarses (with the fingers on dorsal side of the foot) and proximal phalangs (with the thumb on plantar side of the foot) Movement: II.-V. PIP joint flexion in full range of motion Grade 1,0: observe the tremble of the fingers during patients attempt to move Distal interphalangeal joints (DIP) flexion •Flexor digitorum longus Flexor Digitorum Longus Flexor digitorum longus •Origin •Posterior surface of tibia distal to popliteal line • •Insertion •Splits into four slips after passing through medial intermuscular septum of plantar surface of foot •these slips then insert on plantar surface of bases of 2nd - 5th distal phalanges • •Action •Flexes toes 2 - 5; also helps in plantar flexion of ankle • •Innervation •Tibial nerve (S2, S3) • Flexor Digitorum Longus Fingers DIP flexion – grade 5,4 •Position: patient lyies supine (or sits), foot in central position •Fixation: PT fix metatarses (with the fingers on dorsal side of the foot) and middle phalangs (with the thumb on plantar side of the foot) •Movement: II.-V. DIP joint flexion in full range of motion •Resistance: PT puts resistance at the plantar side of distal phalanges (II.-V.) against the movement Fingers DIP flexion – grade 3,2 (1,0) •Position: patient lyies supine (or sits), foot in central position •Fixation: PT fix metatarses (with the fingers on dorsal side of the foot) and middle phalangs (with the thumb on plantar side of the foot) •Movement: II.-V. DIP joint flexion in full range of motion • •Grade 1,0: observe the tremble of the fingers during patients attempt to move Toe interphalangeal joint (IP) flexion Flexor hallucis longus http://www.rad.washington.edu/academics/academic-sections/msk/muscle-atlas/lower-body/flexor-halluc is-longus/atlasImage_large Flexor hallucis longus •Origin •Inferior 2/3 of posterior surface of fibula, lower part of interosseous membrane • •Insertion •Plantar surface of base of distal phalanx of great toe • •Action •Flexes great toe, helps to supinate ankle, and is a very weak plantar flexor of ankle • •Innervation •Tibial nerve (S2, S3) (S2, S3) Toe IP flexion – grade 5,4 •Position: patient lyies supine (or sits), foot in central position •Fixation: PT fix proximal phalang of the toe from the sides, MP joint slightly hyperextended •Movement: toe IP joint flexion •Resistance: PT puts resistance at the plantar side of distal phalang against the movement Toe IP flexion – grade 3,2 •Position: patient lyies supine (or sits), foot in central position •Fixation: PT fix proximal phalang of the toe from the sides, MP joint slightly hyperextended •Movement: toe IP joint flexion • Toe IP flexion – grade 1,0 •Observe the tremble of the toe during patients attempt to move, or palpate the trace of contraction on the plantar side of proximal phalang • Toe interphalangeal joint (IP) extension •Extensor hallucis longus Extensor Hallucis Longus Extensor hallucis longus •Origin •Anterior surface of the fibula and the adjacent interosseous membrane • •Insertion •Base and dorsal center of distal phalanx of great toe • •Action •Extends great toe and dorsiflexes ankle • •Innervation •Deep peroneal nerve (L4, L5, S1) (L4, L5, S1) Extensor Hallucis Longus Toe IP extension – grade 5,4 •Position: patient lyies supine (or sits), foot in central position •Fixation: PT fix proximal phalang of the toe from the sides •Movement: toe IP joint extension •Resistance: PT puts resistance at the dorsal side of distal phalang against the movement Toe IP extension – grade 3,2 •Position: patient lyies supine (or sits), foot in central position •Fixation: PT fix proximal phalang of the toe from the sides •Movement: toe IP joint extension • Toe IP extension – grade 1,0 •PT palpates the trace of contraction on the level of MP joint of the toe (dorsal side) • Movement of the fingers and toe – notes: •Foot has to be in a central position •It is necessary to fix properly Thank you for your attention J http://www.inspire-fitness.com.au/blog/wp-content/uploads/2014/08/865147480.jpg