Talar Tilts
These passive tests are designed to stress the primary ligaments of the talocrural joint in an orderly and systematic manner. (Hartley, vol. 1)
Medial (Deltoid) Talar Tilts
This medial ligament is fan-shaped and made up of three portions. It does not tear easily. In fact, when the test is positive, it is more likely a periosteal tear or an avulsion fracture than an actual tearing of the ligament itself. With an avulsion fracture, the joint is then hypermobile on the medial side.
1. Middle Fibres 2. Anterior Fibres 3. Posterior Fibres
Have client’s foot in neutral. Support leg above ankle and grasp calcaneus. 1. With foot in neutral, slowly evert foot, testing predominately middle fibres. 2. Slowly plantar flex and then evert foot to test anterior fibres. 3. Dorsiflex and evert foot to test posterior fibres. Positive sign is pain, or excessive movement.
Lateral Talar Tilts
Anterior Talofibular Testing Posterior Talofibular
Ligament Test Calcaneofibular Ligament Ligament Test
Passively move client’s foot into plantar flexion and inversion.
Positive sign is pain is felt along ligament or at its attachments.
Client’s foot is in slight dorsiflexion.
Bring foot into inversion. Pain felt along site of ligament is a positive sign. This strong ligament is injured often only after anterior talofibular has already lost its integrity.
Passively dorsiflex foot. With other hand, grasp calcaneus, and invert foot while drawing heel posteriorly.
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Comprehensive Assessment for Massage Therapists
CHAPTER I ANKLE & FOOT
Anterior Draw Test
This is another way to test the anterior talofibular ligament. The name comes from the movement performed during testing. Besides testing for injury to the ligament, the advantage of this test is that it will show instability from a ruptured anterior talofibular ligament. A ruptured ligament may not elicit pain that is specific to that ligament’s location.
Anterior Draw Test Of Ankle
With client high-sitting, stabilize lower leg with one hand just above ankle and cupping calcaneus with other hand;
now draw heel toward you, thereby placing a stretch on ligament. Positive sign is pain (where ligament is located) and/or hypermobility of joint seen and felt by heel moving forward.
Alternative Positioning For Anterior Draw Test
You can perform test with client in supine position. Place towel roll or pillow under knee to release any tension in gastrocnemius and soleus. While stabilizing lower leg, cup calcaneus in other hand and draw it forward. Positive sign is pain felt along the course of ligament, and/or hypermobility noted as head of talus moves forward,
sometimes with a “clunk.” Note: without towel roll under knee, gastrocnemius-soleus can be in spasm and prevent calcaneus from moving forward.
ANKLE & FOOT CHAPTER I
Wedge Test
This tests the integrity of the anterior inferior tibiofibular ligament. It can be injured by jumping down from too great a height, or having the foot excessively dorsiflexed. The test is meant to push the head of the talus up between the tibia and fibula, putting tension on the ligament between them, reproducing the action that causes the sprain. It is good to perform the wedge test as it eliminates the anterior talofibular ligament as the source of the pain.
Wedge Test By Dorsiflexion
If client agrees, you can passively dorsiflex foot and apply O-P.
This will cause larger anterior portion of talus to press malleoli apart, putting tension through anterior inferior talofibular ligament. Client is then instructed to point to exact place where pain is felt if test is positive.
Alternative Wedge Test
This is a progressively provocative testing of the anterior inferior tibiofibular ligament. If the client is apprehensive about the dorsiflexion test, you can do the following. Have the client’s foot in neutral while they are supine with the ankle off the table.
1. Mild Provocation
With one hand, apply pressure to bottom of calcaneus superiorly.
2. Moderate Provocation
If above produces no pain at site of ligament, then you may increase provocation by hitting bottom of heel with a quick, mild blow or tap.
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Comprehensive Assessment for Massage Therapists
CHAPTER I ANKLE & FOOT
Achilles Tendon Rupture Test (Thompson’s Test)
Below is a simple classic test that has been used to see if the Achilles tendon has ruptured. However, if it has totally ruptured, the gastrocnemius (and soleus) often ‘slide up’ into a ball shape giving the back of the leg a distinctive look on the affected side. The test is required only if there is a partial rupture.
Have client prone with feet off table. With both hands, squeeze calf and look to see if foot plantar flexes. If it does not plantar flex, test is positive and that means that there is a severe tear or complete rupture of Achilles tendon.
(Refer client to their doctor or emergency department.)
With a complete rupture of any tendon, remember that there may be no pain present, as the nerves themselves can be severed. The client may complain of having had the sensation of a ball rolling up the back of the leg, or that it felt like someone kicked them, or felt a slithering sensation up the calf.
These sensations are caused by the muscle shortening when its attachment is ruptured.
Squeeze Test For Morton’s Neuroma
This is to test for the presence of a neuroma between the metatarsal heads, usually between the third and fourth metatarsals. This is called a Morton’s Neuroma.
Squeeze Test For Neuroma
Encircle forefoot with both hands while keeping it relatively flat, and squeeze metatarsal heads together. Do not let forefoot arch with pressure applied. If this creates a sharp pain between second and third, or third and fourth metatarsals, then test is positive.
ANKLE & FOOT CHAPTER I
Testing For Tarsal Tunnel Syndrome (Tinel’s Sign)
Tarsal tunnel syndrome is when there is swelling in the tendon sheaths, compressing the tibial nerve behind the medial malleoli. This causes pain, usually felt into the bottom of the foot. The client may experience weakness of intrinsic muscles of the plantar surface of the foot. The compression occurs in a ‘tunnel,’ the ‘walls’ of which are made up of the tough connective tissue of the retinaculum of the ankle as it wraps around the lower portion of the malleoli, and by both the bony malleoli and the bony calcaneous. This is much like the carpal tunnel in the wrist. The syndrome usually occurs in those who go “en pointe” such as dancers, and gymnasts. The tibialis anterior, flexor digitorum and hallucis muscles are overused, to the point where the sheaths behind the malleoli swell and compress the tibial nerve.
1. Positioning For Tarsal Tunnel Test 2. Tapping Over Tarsal Tunnel
Using either tips of index and third finger held together, or using a reflex hammer, percuss (tap) several times behind medial malleoli. Positive sign is pain and or paresthesia felt distal to area tapped.
Testing For Pulses In Foot
If the client’s foot feels cold, or is blue, edematous or numb/tingling, then test for appropriate blood flow into the foot.
1. Testing the tibial pulse is done to check the quality of the blood flow into the bottom (plantar area) of the foot. This pulse is fairly strong and highly palpable in most people.
2. Testing the dorsal pedal pulse assesses the quality of blood flow into the dorsum of the foot. The pulse is palpated just laterally to the external hallux longus tendon, as the arterial vessel passes over the talus and navicular bones. To locate the hallux longus tendon, resist the client’s attempt to extend their big toe. The tendon becomes very prominent.
1. Testing Tibial Pulse 2. Testing Dorsal Pedal Pulse
Palpate lightly about 1 inch above medial malleoli. Palpate over the dorsal pedal artery.