Osteopathy Practical Technique Bridging Course

Session 2: Leg, Ankle and Foot

Part A: Introduction to the surface anatomy of the leg, ankle and

foot region
References:
Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. 6th Ed. Philadelphia:Wolters
Kluwer/Lippincott Williams & Wilkins. 2010. Ch 5
Lumley JSP. Surface Anatomy. The anatomical basis of clinical examination. 4th Ed.
Edinburgh:Churchill Livingstone. 2008. Pg 114-125
Biel A. Trail Guide to the Body. 4th Ed. Boulder:Books of Discovery. 2010. Ch 7
Chila AG. Editor. Foundations of Osteopathic Medicine. 3rd Ed. Philadelphia:
Williams & Wilkins. 2011. Ch 42

Lippincott

Structures of the Ankle and Foot Region that need to be known

The following list contains the structures to be covered in this lecture and associated
practical class. You will need to use the above references, or other suitable texts, to outline
the details required. For muscles and ligaments you will need to know their origin*, insertion*
and action. Some of the structures have been covered in previous lectures.
*Note the origin and insertion may be known as proximal, distal, superior or inferior
attachment in some texts. See SG2 for an example of the information required.
Bones:

Leg: tibia, fibula

Ankle and Foot: Talus, calcaneus, navicular, cuboid, cuneiforms [medial,
intermediate, lateral], metatarsals, phalanges

Landmarks:

Medial malleolus, lateral malleolus, navicular tubercle/tuberosity,

sustentaculum tali, talocrural joint, base of 5th metatarsal

Muscles:

gastrocnemius, soleus, popliteus, peroneus longus, tibialis anterior,

flexor digitorum brevis

Ligaments:

calcaneonavicular ligament, deltoid ligament, Achilles tendons, extensor

retinacula, plantar aponeurosis

Pulses:

Although there are two pulses in the foot region, we will not be covering them
in this course. They will be covered later in the program.

Palpation of the Tibia

Patient position: supine, flex the patients knee so that the foot rests on the treatment table
Practitioner position: standing at the side of the table, level with the patients knee and
facing toward the patient.
Applicator:
pad of the fingers and or thumb
Procedure:
a. locate the patella and place the applicator of each hand half way down
from the superior aspect of the patella
b. let the applicator of each hand slide off the patella, one medially and one
laterally
c. let the applicator sink into the tissues in a posterior direction
d. note if your applicator is over the joint space (the tissues will give and you
will sink a little further), or if you are on bone.
e. if you are on the joint space, let your applicators move inferiorly until you
encounter the superior surface of the tibia
f. this surface, is the edge of the tibial plateau. Palpate along the proximal
end of the tibia in a medial and lateral direction.
g. you will note that the patella ligament/tendon runs across the middle of the
anterior edge of the tibial plateau
h. bring your applicators to mid-line and locate the patella ligament/tendon.
i. move inferiorly along the patella ligament until you encounter the bony
protuberance that it inserts into. This is the tibial tuberosity. Explore the
shape of this tuberosity
j. continue to move your fingers inferiorly along the shaft of the tibia. Note
that the medial aspect of the shaft of the tibia is superficial and can be
palpated. The lateral aspect of the shaft of the tibia is covered with muscle.
k. when you have reached the distal end of the shaft of the tibia, move your
applicator medially and palpate the medial malleolus. Explore all the surfaces
that are palpable, noting the shape and texture of the distal end of the tibia.
Palpation of the Fibula
Patient position: supine, flex the patients knee so that the foot rests on the treatment table.
Note the lower extremity can be straight, however, it is usually to palpate the tibia and fibula
at the same time, so the knee flexed is the most common position to palpate the fibula in.
Practitioner position: standing at the side of the table, level with the patients knee and
facing toward the patient.
Applicator:
pad of the fingers and or thumb
Procedure:
a. locate the tibial tuberosity with your applicator
b. slide the applicator laterally toward the lateral aspect of the leg.
c. you will palpate the lateral aspect of the proximal end of the tibia (lies just
inferior to the tibial plateau) and as you continue to move laterally you will
encounter the head of the fibula
d. explore the head of the fibula (anterior, lateral, posterior and superior
surfaces). Note the texture of the structures that attach on to the head of the
fibula. Name the attachments.
e. let the applicator move inferiorly down the lateral side of the patients leg.
You will note that muscles cover the shaft of the fibula and that it cannot be
palpated directly until you are near the distal end. See if you can get a sense
of where the shaft of the fibula lies and palpate as much of the distal end as
possible.
f. at the end of the shaft explore the lateral malleolus. Explore all the surfaces
that are palpable and note how it varies from the medial malleolus.

Palpation of the bones of the Ankle

Patient position: supine
Practitioner position: standing at the side of the table, level with the patients foot and facing
toward the patient.
Applicator:
pad of the fingers and or thumb
Procedure:
a. locate the malleoli (medial and lateral) and slide the applicators posteriorly
and inferiorly so you are palpating the bone of the heel the calcaneus.
b. move the applicators over the medial and lateral surfaces of the calcaneus
c. with the ankle in a neutral position, move the applicators on the medial
side of the calcaneus so that they are in line with the medial malleolus and
approximately 2 cm below it
d. invert the foot so that the tissues over the medial aspect of the ankle relax
and let your applicator sink toward the bone of the calcaneus until it
encounters the bony ridge of the sustentaculum tali.
e. explore the different textures of the different structures that are located
around the sustentaculum tali
f. return the ankle to a neutral position and explore the plantar surface of the
calcaneus by sliding the applicators to the plantar surface of the heel
g. maintaining the neutral position, move the applicators back to the
medial aspect of the calcaneus and move them anteriorly (toward the toes)
until you are approximately 4 cm anterior to the medial malleolus.
h. your applicators will have moved over part of the talus, and this may
feel like you have moved over a small gap or dip
i. you will then encounter the navicular. Explore the navicular and the
navicular tuberosity which is almost in line with the sustentaculum tali.
j. continue to palpate toward the base of the first metatarsal and note the
joint line between the navicular and the medial cuneiform. Explore all the
palpable surfaces of the medial cuneiform.
k. move to the dorsal surface of the medial cuneiform and move laterally.
Palpate the joint line between the medial and middle cuneiform, located at the
base of the second metatarsal bone.
l. continue to move laterally and palpate the lateral cuneiform located at the
base of the third metatarsal bone.
m. continue to move laterally and palpate the joint between the lateral
cuneiform and the cuboid. Explore the cuboid noting its association with the
calcaneus posteriorly and the base of the fifth metatarsal bone anteriorly.
Palpation of the Foot Bones
Patient position: supine
Practitioner position: standing at the end of the table, facing toward the patients foot.
Applicator:
pad of the fingers and or thumb
Procedure:
a. using both hands, palpate the head of the metatarsal bones (starting from 1
and 5 and moving centrally)
b. move your applicators to the head of first metatarsal bone and palpate
along the shaft. Note the difference in structures anteriorly and posteriorly, as
well as medially and laterally.
c. continue to move toward the ankle and palpate the base of the metatarsal
bone, noting its association with the cuneiform and metatarsal bone lateral to
it.

d. repeat this for the other four metatarsal bones, noting the association with
either the cuneiforms or cuboid. Note the tubercle of the fifth metatarsal bone
at its base.
e. return to the head of the metatarsal and palpate the small phalanges of the
toes.

Palpation of the Achilles Tendon

Patient position: prone
Practitioner position: standing at the side of the table, level with the patients foot and facing
toward the patient.
Applicator:
pad of the fingers and or thumb
Procedure:
a. locate the posterior aspect of the calcaneus
b. move the applicator in a cephalad direction until it encounters the fibrous
tissue of the tendon of the Achilles
c. move the applicators medially and laterally and explore the width and
depth of the tendon
d. continue in a cephalad direction and note when the tendon merges with
the fibres of the gastrocnemius and when it travels over the distal aspect of
the soleus
Palpation of the Gastrocnemius and Soleus Muscles (Triceps Surae)
Patient position: prone
Practitioner position: standing at the side of the table, level with the patients leg and facing
toward the patient or the foot of the table facing toward the head of the patient
Applicator:
pad of the fingers and or thumb
Procedure:
a. have the patient lying prone with their foot hanging over the end of the
treatment table. You can instruct the patient to turn their head to one side if
they are unable to keep it in the face hole. If you are going to be long, suggest
they turn their head from side to side periodically to ensure their neck does
not become stiff.
b. locate the superior part of the posterior aspect of the calcaneus
c. slide your applicator in a cephalad direction until you contact the Achilles
or calcaneal tendon. Note its width, length and thickness
d. continue to palpate in a cephalad direction until you reach the first
indications of a change to muscle tissue
e. have the patient plantar flex their foot (point their foot) to contract the
triceps surae. You can stand at the foot of the table, facing the head of the
patient, and allow the foot to press against your thigh to enhance the
contraction.
f. palpate the tendon fibres as the travel over the distal aspect of the soleus
muscle and merge with the belly of the gastrocnemius muscle. Note that the
soleus muscle lies deep to the gastrocnemius. Once you have an
understanding of the muscles shape and size ask the patient to release the
contraction and let the foot return to a neutral position.
g. continue your palpation, in a cephalad direction, of the posterior surface
until you feel the bifurcation of the gastrocnemius as it separates to attach
either side of the femur (femoral condyles) posteriorly.
h. palpate the superior insertions of the gastrocnemious
i. passively flex the patients knee and rest the hand closest to the patients
foot on the dorsal aspect of the foot (you will have part of your forearm on the
foot as well)

j. ask the patient to gently push against your hand/forearm while you resist
the movement
k. slide your applicators in a caudad direction along the lateral aspect of the
soleus and gastrocnemius and note how the fibres of the gastrocnemius are
relatively relaxed in comparison to the soleus muscle which is contracting.
This is a good way of helping to identify the two muscles.
l. explore the two muscles noting where one begins and the other ends.
Palpation of the Popliteus Muscle
Patient position: prone, with knee flexed
Practitioner position: standing at the side of the table, level with the patients knee and
facing toward the patient.
Applicator:
pad of the fingers and or thumb
Procedure:
a. locate the tibial tuberosity
b. slide your applicator medially and then onto the posterior surface of the
tibia
c. push away the soleus and gastrocnemius and palpate the medial aspect of
the popliteus
Alternative procedure:
a. ask the patient to lie supine with their knee flexed and foot resting
on the treatment table
b. stand on at the side of the bent knee
c. locate the head of the gastrocnemius on either side of the tibia
d. let your fingers move toward the mid line and sink in the space of the
popliteal fossa toward the tibia
e. you may be able to palpate the tendon or part of the popliteal muscle in
this position.
Palpation of the Peroneus Longus* Muscle
Patient position: side lying
Practitioner position: standing at the side of the table, level with the patients leg and facing
toward the patient.
Applicator:
pad of the fingers and or thumb
Procedure:
a. locate the fibula head and the lateral malleolus
b. ask the patient to evert their foot
c. note the contraction of the lateral muscles along the line between the fibula
head and lateral malleoli. Ask the patient to relax the foot and then evert the
foot several times to observe the contraction
d. these muscles will be the peroneal muscles (longus and brevis)
e. palpate from the fibula head toward the malleoli along the muscle belly of
the peroneus longus muscle
f. note when it merges into its tendon and continues over the peroneus
brevis
g. follow the tendon as it passes behind the lateral malleoli.
h. the tendon moves toward the base of the 5th metatarsal and then under
the cuboid to attach on the posterior aspect of the base of the 1st metatarsal
bone. Note: peroneus brevis tendon attaches to the base of the 5th
metatarsal bone.
*Also known as fibularis longus

Palpation of Tibialis Anterior

Patient position: supine
Practitioner position: standing at the side of the table, level with the patients leg and facing
toward the patient.
Applicator:
pad of the fingers and or thumb
Procedure:
a. locate the shaft of the tibia just below the tibial tuberosity
b. slide the applicator laterally and on to the muscle of the tibialis anterior
c. to contract the muscle ask the patient to dorsi flex their foot
d. palpate the belly, medial and lateral aspect of the tibialis anterior and
follow it inferiorly and note when it becomes tendinous
d. follow the tendon as it crosses to the medial side of the ankle and over the
medial cuneiform
Palpation of the Flexor Digitorum Brevis
Patient position: supine
Practitioner position: standing or sitting at the foot of the table and facing toward the
patients head.
Applicator:
pad of the fingers and or thumb
Procedure:
a. locate the plantar surface of the calcaneus (heel) and the metatarsals 2-5.
b. place the applicators on the plantar surface of the calcaneus and move the
applicator toward the toes
c. let the applicators sink into the arch of the foot and palpate through the
layers
d. ask the patient to flex and extend their toes while palpating for the
contraction of the flexor digitorum brevis on flexion of the toes and relaxation
on extension.
e. it may be difficult to palpate this muscle due to its depth

Palpation of the Plantar Aponeurosis

Patient position: supine
Practitioner position standing or sitting at the foot of the table and facing toward the patients
head.
Applicator:
pad of the fingers and or thumb
Procedure:
a. locate the dorsal aspect of the calcaneus and the ball of the foot
b. starting at the calcaneus, let the applicators move slowly toward the toes
until they slide off the calcaneus
c. let the applicator sink just through the superficial layers until they
encounter the fibres of the plantar aponeurosis (do not go as deep as is
required to reach the flexor digitum brevis)
d. by passively extending and flexing the toes you can explore the tension of
the plantar aponeurosis.
Palpation of the Calcaneonavicular Ligament
Patient position: supine
Practitioner position: standing at the side of the table, level with the patients foot and facing
toward the patient.
Applicator:
pad of the fingers and or thumb

Procedure:

a. locate the sustentaculum tali on the medial aspect of the calcaneus and
the navicular tubercle
b. invert the patients foot so that the medial tissues relax
c. let the applicator sink through the layers of tissue between the
sustentaculum tali and the navicular tubercle and note the texture of the
calcaneonavicular ligament. If you contact bone you are too deep. Reduce
your pressure slightly and feel for the fibrous nature of the ligament.

Palpation of the Deltoid Ligament

Patient position: supine
Practitioner position: standing at the side of the table, level with the patients foot and facing
toward the patient.
Applicator:
pad of the fingers and or thumb
Procedure:
a. locate the medial malleoli and the sustentaculum tali
b. place the applicator between these two bony landmarks and sink through
the tissues until you encounter the fibrous texture of the deltoid ligament
c. move your finger posteriorly and palpate the ligament as it attaches to the
talus
d. move your fingers anteriorly and palpate the ligament as it attaches to the
talus anteriorly and navicular bone

Palpation of the Extensor Retinaculum

Patient position: supine
Practitioner position: standing at the side of the table, level with the patients foot and facing
toward the patient.
Applicator:
pad of the fingers and or thumb
Procedure:
a. locate the medial and lateral malleoli
b. ask the patient to dorsi flex their foot and at the same time extend their
toes (move them toward their head) to enhance the ability to palpate the
extensor retinaculum as it crosses the anterior tendons of the ankle
c. place your applicator approximately 2 cm above the medial malleolus and
palpate the tissue of the extensor retinaculums superior aspect.
d. move your applicator across the retinaculum until you reach its attachment
above the lateral malleolus
e. slide your applicator inferiorly to the malleoli until you encounter the fibres
of the inferior aspect of the extensor retinaculum. Explore the fibres of the
inferior extensor retinaculum

PART B:

Patient Handling and Range of Motion

Passive Range of Motion of the Patellofemoral Joint

Patient:
Practitioner:
Applicator:

supine
Supine standing at the same side of the table as the joint being assessed.
hands, finger and thumb pads

Procedure:

a. place your index finger and thumb pads on the medial and lateral surface
of the patella; one set at the superior end of the patella and the other on the
inferior end of the patella
b. to introduce a superior motion of the patella, gently push in a cephalad
direction on the inferior aspect of the patella. Be careful not to compress the
patella in a posterior direction, which would press it against the femur and
tibia
c. to introduce an inferior motion of the patella, gently push in a caudad
direction on the superior aspect of the patella. Be careful not to compress the
patella in a posterior direction, which would press it against the femur and
tibia
d. to introduce a medial motion of the patella, gently push on the lateral
aspect of the patella in a medial direction. Be careful not to compress the
patella in a posterior direction, which would press it against the femur and
tibia
e. to introduce a lateral motion of the patella, gently push on the medial
aspect of the patella in a lateral direction. Be careful not to compress the
patella in a posterior direction, which would press it against the femur and
tibia

Be careful not to compress the patella against the femur. In a healthy joint the patella should
float above the femur and move quite easily without a lot of effort or force being needed.
Caution is needed if there is a suspected instability of the patella.
Passive Range of Motion of the Superior Tibiofibular Joint
supine, with the knee flexed and foot resting on the table
Patient:
Practitioner: Supine standing at the same side of the table as the joint being assessed.
You may wish to sit on the patients foot if you need to stabilize the lower extremity to safely
and efficiently perform this range of motion.
Applicator:
finger and thumb; hand
Procedure:
a. to ensure the lower extremity does not move when the superior tibiofibular
joint is being assessed, sit on the patients foot. You may need to vary the
amount of flexion of the knee in order to get an accurate assessment of the
joints ability to move.
b. place your hand that is closest to the patient on the tibia. This will also
help to stabilize the structures
c. grasp the fibular head between your thumb and index finger. To get a
better grip flex your index finger and use the side of the finger to contact the
fibular head.
d. Caution: The common fibular or peroneal nerve runs across the posterior
aspect of the fibular head. Avoid too much pressure to ensure that the nerve
is not compressed and irritated.
e. To introduce posteromedial motion of the superior tibiofibular joint press
with your thumb, or anterior contact, and allow the fibular head to glide over
the tibia. You may need to apply pressure in a few different directions until
you find the exact plane that the joint sits in. Remember that the joint does not
lie in a true anterior-posterior plane.
f. To introduce anterolateral motion of the superior tibiofibular joint press with
your index finger, or posterior contact, and allow the fibular head to glide over
the tibia toward you. You may need to apply pressure in a few different
directions until you find the exact plane that the joint sits in. Remember that
the joint does not lie in a true anterior-posterior plane.

g. repeat steps e and f a few times until you have a good understanding of
the quality and quantity of joint motion.
This joint can be hypomobile and you may not feel a lot of movement at all. Remember that
there is generally only a small range of motion possible and the reason why you do not feel
motion at this joint is due to a significant restriction. This would be a good indication that
intervention or treatment is required. Remember the osteopathic principles; the restriction
may be due to a dysfunction in another structure and to restore normal function may mean
treating a structure other than the superior tib/fib joint. For example the inferior tibiofibular
joint, the talocrural joint, hypertonic iliotibial band.
Passive Range of Motion of the Inferior Tibiofibular Joint
Patient:
Practitioner:
Applicator:
Procedure:

supine, with lower extremity straight and resting on the table

standing at the same side of the table as the joint being assessed.
hands, fingers
a. to stabilize the joint, place the thenar eminence and the thumb along
the anterior aspect of the distal tibia (near the medial malleolus)
b. hold the lateral malleolus between your thumb and index finger.
c. have the patients ankle in a neutral position (as if they were standing on a
flat surface). You may need to introduce slight dorsi flexion with some
patients so that you get a good idea of the motion available at the inferior
tibiofibular joint
d. to introduce a posterior glide, gently but firmly press with your thumb, or
anterior contact, in a posterior direction on the lateral malleolus
e. to introduce an anterior glide, gently but firmly press with your index
finger, or posterior contact in an anterior direction on the lateral malleolus.
f. there is not a lot of motion available at this joint, however, in a functional
inferior tibiofibular joint there should be some motion available.

Please refresh your knowledge of the structure of the inferior tibiofibular and talocrural joints
so that you can understand why you are stabilizing the tibia and moving the fibular.
Active Range of Motion of the Ankle and Foot
Patient:
Practitioner:
Applicator:
Procedure:

seated
standing or sitting in front of the patient
a. to observe dorsiflexion ask the patient to bring their toes toward their
head or ceiling so that the dorsal surface of the foot moves toward the tibia
b. to observe plantar flexion ask the patient to bring their toes towards the
floor or point their toes so that the dorsal surface of the foot moves away from
the tibia
c. to observe inversion, ask the patient to move the foot so that the plantar
surface faces the opposite leg
d. to observe eversion, ask the patient to move their foot so that the plantar
surface faces away from the opposite leg

Passive Range of Motion of the Talocrural Joint

Patient:
seated, supine or prone
Practitioner: seated: standing or sitting beside or in front of the patient. Supine and prone:
standing at the same side of the table as the ankle being assessed.
Applicator:
hands and forearm
Procedure:
a. place one hand on the dorsal surface of the foot and the other hand on
Seated
the distal tibia/fibular. Ensure that the foot is in neutral (foot at right angle to
the leg)
b. hold the distal tibia/fibular steady and with the other hand move the foot
toward the floor and assess plantar flexion.
c. return the foot to neutral
d. retain your hold on the distal tibia/fibular and place the other hand on the
plantar surface of the foot.
e. bring the foot toward the leg to assess dorsiflexion.
f. return the foot to neutral
g. to assess inversion, gently press on the lateral aspect of the foot so that
the plantar surface moves in a medial direction
h. return the foot to neutral
i. to assess eversion, gently press on the medial aspect of the foot so that
the plantar surface moves in a lateral direction
Supine
a. hold the distal leg with one hand and place the other on the plantar
surface of the foot
b. bring the foot toward the leg and assess dorsiflexion
c. return the foot to neutral
d. hold the distal leg and place the other hand on the dorsal surface of the
foot
e. bring the foot toward the table, or floor, to assess plantar flexion
f. return the foot to neutral
g. to assess inversion, gently rotate the foot so that the plantar surface
moves medially
h. return the foot to neutral
i. to assess eversion, gently rotate the foot so that the plantar surface
moves laterally
j. return the foot to neutral
k. keep the hand at the distal leg and place the other hand under the
patients heel (posterior calcaneus) to stabilise ankle and monitor the
calcaneal ligament. You may wish to introduce a degree of dorsiflexion to the
ankle to help assess the anteroposterior glide
l. gently press in a posterior direction on the distal tibia. This produces a
posterior glide of the superior aspect of the talocrural joint in relation to the
talus.
m. release the pressure to return the ankle to neutral
n. to assess the anterior glide of the superior aspect of the talocrural joint
you can monitor the return motion and gently increase the movement by lifting
the tibia anteriorly (or toward the ceiling).
o. NOTE: it is important to ensure that your pressure is appropriate and you
are well balanced. Too much pressure, or pressure directed in the wrong
plane may damage the soft tissue structures of the ankle.
Prone
a. Place the patients knee at 90 degrees. Have the table at a height where
you can comfortably reach the joint without slouching or straining. This is
often at a level where the patients ankle is level with your sternum

b. to introduce dorsiflexion, place your forearm on the plantar surface of the

foot and hold the ankle, just proximal to the malleoli.
c. start with the foot in a neutral position; approximately 90 degrees to the
leg. This is approximately the position that foot and ankle would be in if the
patient was standing up.
d. press down on the planter aspect of the foot so that the dorsal surface
approaches the shaft of the tibia
e. return the foot to neutral and repeat step d a few times to assess
dorsiflexion
f. to introduce plantar flexion move the forearm off the plantar surface of
the foot and hold the dorsal surface of the foot with your hand. The other
hand remains just proximal to the malleoli
g. starting from the neutral position, push on the dorsal aspect of the foot so
that the foot moves toward the ceiling
h. continue the movement to its end range of motion and then return to
neutral position
i. repeat steps g and h a few times to allow you to fully understand the
quality and range of motion available

Passive Range of Motion of the Subtalar Joint (inversion and eversion)

Patient:
Practitioner:
Applicator:
Procedure:

supine
standing at the side of the end of the table
fingers and thumbs, and palm of hand
a. place one hand over the talocrural joint, anteriorly, so that the thumb lies
over one side of the ankle and the fingers lie on the other side of the ankle
b. place the other hand so that the palm of the hand rests on the dorsal
surface of the foot and the fingers wrap over the medial aspect of the foot and
contact the plantar surface
c. stabilise the ankle with the hand the hand over the talocrural joint
d. with the caudad hand (over the foot) gently press with the palm of the
hand medially so that you induce eversion
e. to initiate inversion, gently press with the fingers on the medial aspect of
the plantar surface of the foot, so that the plantar surface moves medially
f. repeat steps d and e a few times to determine the quality and quantity
of motion available at the subtalar joint.

Passive Range of Motion of the Tarsal Bones

Patient:
Practitioner:
Applicator:
Procedure:

supine
standing at the end of the table, near the patients feet
fingers and thumbs
a. place the pad of your thumbs on the tarsal bone you are going to assess;
for example, start with the navicular bone. Have one thumb on top of the
other.
b. the thumbs form the fulcrum around which you are going to create
movement

c. wrap the fingers around the side of the foot so that the finger pads are on
the plantar surface of the foot
d. take the foot into dorsiflexion, eversion, plantar flexion and inversion. This
can be done in a circular motion, or a figure of 8 motion.
e. repeat step d several times to gain information about the motion
available
f. repeat step d in the opposite sequence and assess the motion
g. repeat steps d to f for all the tarsal bones
Note: The motion introduced should be a smooth transition from one range of motion to the
next. The secret is to keep the thumbs steady, without moving them, so that the motion
occurs around where the thumbs contact the bone. You can place the ball, or distal aspect of
the foot on your abdomen and use your body to assist in the movement.
Passive Range of Motion of the Metatarsal Bones
Patient:
Practitioner:
Applicator:
Procedure:

supine
standing at the end of the table
fingers and thumbs
a. place the thumb of one hand on the anterior aspect of the head of the first
metatarsal bone and the index finger of the same hand on the posterior
surface of the head of the first metatarsal bone
b. place the thumb of the other hand on the anterior aspect of the head of
the second metatarsal bone and the index finger of the same hand on the
posterior surface of the head of the second metatarsal bone
c. bring your left hand anteriorly, while you bring the right hand posteriorly
so that you create a motion between the two heads of the metatarsal bones
d. move the bones in the opposite direction
e. repeat steps c and d several times until you have sufficient
understanding of the motion available
f. repeat steps c to e for the rest of the metatarsal bones
g. you can perform a similar movement at the metatarsal bases, however,
the movement should be minimal

Note: there is no true joint between the heads of the metatarsal bones, however movement
does occur. This assessment will provide information as to the ability of the foot to
accommodate that movement which is important when walking over rough surfaces.

Passive Range of Motion of the Phalanges

Patient:
Practitioner:
Applicator:
Procedure:

supine
standing at the end of the table
fingers and thumbs
a. place the pad of the thumb on the posterior aspect of the head of the
metatarsal proximal to the metatarsophalangeal joint
b. place the fingers of the same hand over the dorsal surface of the foot
c. hold the proximal phalanx with the thumb and index fingers of the other
hand
d. hold the metatarsal steady and move the proximal phalanx in dorsiflexion
(or extension), by bringing it in a dorsal or superior direction
e. to assess plantar flexion (or flexion), bring the phalanx in the opposite
direction.

f. repeat steps d and e several times for each phalanx

g. to introduce medial and lateral gapping of the metatarsophalangeal joints
hold the metatarsal bone with one hand and have the finger and thumb of the
other hand resting on either side of the proximal phalanx
h. gently introduce a medial and then a lateral movement at the
metatarsophalangeal joint.
i. repeat step h for each joint.