Recommendations for Professional Physical … for Professional Physical Therapy Curricula for the Foot and Ankle Clinical Sciences Matrix Primary Content Terminal Behavioral Objectives

Recommendations for Professional Physical Therapy Curricula for the Foot and Ankle

Clinical Sciences Matrix

Primary Content

Terminal Behavioral

Objectives

After the completion of the

content, the student will be able

to…

Example Instructional

Objectives for the classroom

Example Instructional

Objectives for the Clinic

Screening

General Constitutional signs

Fatigue

Fever

Malaise

Weight change

Musculoskeletal

Fractures

Ottawa ankle

Rules

Avulsion

Severe pain with

weight bearing

Non-mechanical pain

Systemic arthritides

(i.e. gout)

Rheumatic Diseases

Neurological

• Dermatomal versus

non-dermatomal (i.e.

stocking glove)

o Sensation

Select appropriate screening

examination for the

integumentary, cardiopulmonary,

neurological and musculoskeletal

body systems to screen for

conditions beyond the scope of

PT practice that require a referral

to another health care provider.

Recall and identify the clinical

signs and patient response to

written and verbal questions

which indicate health

conditions beyond the scope of

PT practice.

Simulated case examples to

recognize selected

components.

Apply results of written and

verbal responses to a review of

systems with subjective and

objective clinical exam

findings to make the

determination that the patient

is:

1. appropriate for PT

2. is appropriate for PT

with referral

3. not appropriate for PT

and requires referral

elsewhere.

testing 5.07

monofilament

testing

o Vibration - 128

Hz

Myotomal patterns of

weakness versus

peripheral nerve

injuries (i.e. common

fibular nerve lesion)

Cardiopulmonary

DVT - screening

WELLS Criteria.

Riddle et

Peripheral vascular

disease

Integumentary

Infection

open wounds

post operative wounds

abnormal skin and nail

inspection

Psychosocial

depression

alcohol use

Examination

Patient/Client history and

review of medical record

utilizing the domains of the

ICF model

System reviews based on

patient/client needs

Use of Standard Tests and

measures from Guide to PT

Practice

Specific to the Foot and Ankle

Region:

Red flags (specific to F&A)

1. night sweats

2. sleep disturbance

3. change in neurologic

function

4. change in

neurological status -

progressive weakness

and/or sensatory

changes

Yellow flags

Diabetes - Charcot foot

Progressive neurologic

change - progressive

weakness and/or sensation

changes

Determine the Severity,

Irritability, Nature and Stage of

the complaint of the patient and

understand their relevance in the

domains of the ICF model.

recognize the components of the

subjective examination that may

be part of the medical diagnosis

and PT diagnosis to distinguish

the b ----- s______ f______

(BSF) impairments that require

assessment.

Select appropriate systems

examination techniques for the

integumentary, cardiopulmonary,

neurological, and

musculoskeletal systems to assist

in the progression to the specific

PT examination procedures,

diagnosis, prognosis, and

treatment plan

The student will describe the

components of the subjective

examination and how the

subjective examination

questions relate to the domains

of the ICF model.

The student will generate

(synthesis) a complete

subjective examination to

determine the local, remote,

referred, or systemic origins of

the patient’s complaint.

The student will recall the

components of the screening

examination and correctly

performs a screening

examination to determine the

local, remote, referred, or

systemic origins of the

patient’s complaint.

By the final clinical

experience, the student will

perform a subjective patient

examination rated at entry-

level by the clinical instructor

on the CPI

The student will compare and

contrast the findings of the

subjective examination to help

determine if the patient is:

4. appropriate for PT

5. is appropriate for PT

with referral

6. not appropriate for PT

and requires referral

elsewhere.

The student determines the

appropriate tests and measures

for the screening specific to

the foot and ankle.

Comment [S3]: Subjective exam alone will not be sufficient to make the tx

vs refer determination.

Comment [S2]: I believe in PT Guide terminology a systems review is

decidedly different than the regional MS screen

Comment [S1]: These are also noted under red flags. Should it be under just one heading?

DVT - screening WELLS

Criteria. Riddle et al

Inspection/Observation

Swelling - Figure 8 test,

circumference measures,

Pitting edema - yes or no

Integument -

Color and texture:. Noting

discoloration, shiny and or

ecchymosis.

Toe nails noting whether they

are dystrophic and thickened.

Temperature - hot or cold,

sweat response

Trophic changes - hair growth -

vascular problems

Calluses: formation or lack of

calluses, exostosis and boney

overgrowth

Perform an inspection of the feet

and ankles that includes noting

and assessing when appropriate:

1. swelling

2. integument

a. color texture

b. toe nails

c. temperature

d. trophic changes

e. calluses

Correlate inspection findings

with other exam findings when

determining assessment and plan

of care

The student will:

Identify clinical signs of

inflammation in the foot and

ankle.

Identify signs of a reduced

autonomic response in the foot

and ankle. (insert picture)

Identify signs of vascular

compromise (insert picture)

Identify signs of infection and

other integumentary problems

Determine when to refer

simulated patients to another

healthcare provider for

integumentary problems of the

foot and ankle

Interpret and integrate

inspection and observation

results into assessment and

plan of care of patients with

foot and ankle dysfunction

Comment [S4]: Patient first language is generally accepted but not required.

Foot Posture

Assessments/deformity

Foot Posture

Foot Posture Index

Weight bearing and non-

weight bearing visual

assessment of hindfoot

varus and valgus

Forefoot

Too many toes sign

Medial longitudinal arch height

(visual or navicular height)

Toe deformities:

Hallux valgus

Hammer toe

Claw toe

Mallet toe

Overlapping/crossover

Morton's foot structure (2nd toe

longer than the 1st)

Metatarsus adducts

explain, conduct, and interpret

measures of foot posture

including:

Foot Posture Index

Visual assessment of foot posture

(weight bearing and non-weight

bearing)

identify and explain the following

foot and ankle deformities:

• Hallux valgus

• Hammer toe

• Claw toe

• Mallet toe

• Overlapping/crossover

toes

• Morton's foot structure

(2nd toe longer than the

1st)

• Metatarsus adductus

Correlate foot posture assessment

findings with other exam findings

when determining assessment

and plan of care

The student will:

perform and apply the Foot

Posture Index to assess foot

posture

identify foot pronation and

supination postures in weight

bearing and non-weight

bearing

identify and describe various

foot deformities

The student will correctly

perform, interpret, and

integrate foot posture and

deformity clinical findings

with the assessment and plan

of care of patients with foot

and ankle dysfunction

Movement Analysis

Gait assessment

• Spatiotemporal

measures

• Specific Visual

Analysis Rancho Los

Amigos method

• Common gait

deviations related to the

ankle and foot (see

appendix Gait)

• Gait speed

• Stairs

Double Leg squats

• DF ROM

• Visual analysis

hindfoot, midfoot and

forefoot movement

Single leg squats

• LE alignment - note

femoral

adduction/internal

rotation vs. femoral

abduction/external

rotation

Perform a gait assessment

Determine demonstrated gait

deviations

Correctly identify normal vs.

abnormal motions of the ankle

and foot during the double leg

squat test

Correctly identify normal vs.

abnormal motions of the entire

LE during the single leg squat

test

Correlate movement analysis

findings with other exam findings

when determining assessment

and plan of care

The student will:

Describe key components of a

gait assessment

Identify and describe gait

deviations performed by a

simulated patient or patient

video

Perform gait assessment

efficiently with a classmate

Explain the rationale for

selection of various gait

assessment procedures based

on setting, severity, intensity,

nature and stage

Describe key components of

movement in the double and

single leg squat tests

Perform double and single leg

squat tests with a classmate

Identify deviations performed

by a simulated patient or

patient video during the

double and single leg squat

tests

The student will:

Perform gait assessment with a

patient

Identify and document gait

deviations demonstrated by a

patient

Select appropriate gait

assessment procedures specific

to the patient condition and

setting

integrate gait assessment

findings with other tests and

measures and patient

functional status

Discriminate patients

appropriate for double and

single leg squat testing

Perform double and/or single

leg squat test

Identify and document

movement patterns

demonstrated by a patient on

double and/or single leg squat

test

Running

Range of Movement

Ankle Dorsiflexion

Weight bearing

Knee to wall- Distance of

toe to wall or inclinometer

Knee straight - inclinometer,

(consider block for forefoot)

Non-weight bearing

Knee straight - Supine

Goniometry (Di Giovanni,

Norkin & White 2003)

Ankle Plantar flexion

Non Weight bearing

Supine goniometry with the

distal arm aligned with the

inferior aspect of calcaneus

Select the most appropriate

ROM measurement for

examination.

Correctly perform selected tests

and measures

Correctly interprets objective

measurement findings

Identifies the need for potential

test and measure modification

based on setting, severity,

intensity, nature and stage

Discriminates valid and reliable

The student will:

Identify various tests and

measures to thoroughly assess

patient impairments

Describe the procedural

components for measuring

range of motion

Relate the anatomic structures

being assessed by specific

ROM measures

Identify common procedural

errors when performing ROM

measurement

The student will:

Perform ROM examination

measures on a patient

Perform ROM tests and

measures efficiently

Provide rational for ROM tests

and measures selected

Conducts self assessments of

psycho-motor skills and

modifies performance based on

feedback

(old article Steve said)

Subtalar Inversion/Eversion

Non-weight bearing prone -

inversion/eversion observe

qualitatively and/or

goniometry.

Foot Inversion/eversion

Non-weight bearing supine -

supine distal arm aligned with

the 2nd metatarsal (citation

from Martin) (Norkin &

White)

Hallux dorsiflexion-

Non-weight bearing or

Weight bearing

(DNawoczenski, 200?)

Medial longitudinal arch -

Weight bearing - Navicular

drop test

Midfoot motion

(Calcaneocuboid and

talonavicular joints)

Non-weight bearing

- assess forefoot movement

when the rear foot is everted

and inverted. A normal test is

when the foot is inverted and

stability increases (i.e. less

ROM tests and measures

Correctly identifies joint end

feel / motion barriers with

passive motion assessment

Perform an examination of a

student in the classroom

simulating ROM restrictions

Provide a rational for choice of

ROM measures selected

Correlates findings of ROM

measures to identified

abnormal motion patterns




feedback.

Analyze and discuss a patient-

client video to identify

modifications to ROM testing

based on patient condition and

setting

Comment [S5]: Need reference

Comment [S6]: Reference

Strength Assessment

Manual Muscle testing(MMT)

Ankle plantar

flexion/dorsiflexion/inversion/e

version/toe flexion/extension

Hip/knee/trunk as indicated

by movement analysis

to demonstrate competence in

performing MMT of the foot

and ankle

demonstrate the ability to

conduct and interpret heel raise

tests (single leg and double leg).

describe and administer sports

The student will:

interpret MMT and correlate

findings with simulated foot

and ankle conditions

interpret heel raise test results in

video clips of patients with foot


The student will:

analyze MMT tests of the foot

and ankle in patients with foot


discriminate modifications to

assessment of muscle strength

based on a patient’s pathology,

irritability, and/or severity.

forefoot movement is noted).

Accessory Joint Movement

Talocrural - posterior glide

test,anterior/posterior glides

/distraction

Subtalar- medial/lateral/anterior

glides/distraction

Talonavicular joint -

dorsal/plantar gliding

Calcaneocuboid -

dorsal/plantar gliding

First Ray mobility - dorsal

/plantar movement

Distal tibiofibular -

anterior/posterior gliding

Interphalangeal and Metatarsal

phalangeal joints -

distraction/dorsal/plantar

gliding

Discriminate mobility findings

as hypomobile, hypermobile or

within normal limits.

Synthesize information from

ROM assessment and accessory

movement testing to identify

bony versus soft tissue

restrictions

Correlate ROM and mobility

assessment findings with other

exam findings when

determining assessment and

plan of care

Describe the relationship of

rear foot to forefoot

biomechanical axes and it

influence on joint mobility and

stability

Perform mobility testing for the

joints listed for hypomobility

/normal/hypermobility to

determine the potential for

manual therapy interventions

Correctly interpret findings of a

joint mobility assessment on a

classmate




feedback.

Perform accessory joint

mobility assessment measures

on a patient

Perform accessory motion

safely and efficiently

Provide rational for accessory

motion assessment.




feedback.

Heel Rise Test - assessed for

height, number of reps, rear

foot inversion or eversion

position, medial versus lateral

forefoot pressure, arch height,

and comparison to normative

data

Functional strength/return to

activity

specific tests for return to play

describe and administer

functional tests for return to

work

to describe and perform

functional tests associated with

the foot and ankle including:

1) squats

2) step ups

3) hopping

Correlate strength assessment

findings with other exam

findings when determining

assessment and plan of care

discuss when to apply various

MMT of the foot and ankle

depending patients pathology,

irritability, and/or severity

discuss the reliability and

validity issues associated with

MMT of the foot and ankle.

discuss the cause of muscle

weakness in conditions

associated with the foot and

ankle (secondary result of

disuse or direct result of injury).

generate hypotheses to address

the probability a detected

weakness is directly caused by

the pathology or is the result of

a secondary effect (i.e. disuse).

Special Tests

Ankle -

• Talocrural sprain

o anterior drawer

o talar tilt

• Syndesmotic sprain -

o dorsiflexion/ext

ernal rotation

o squeeze

Tinel sign

Windlass test

Ottawa(recent version) Foot

select, perform, and interpret

appropriate clinical special tests

to assist with assessment of foot

and ankle conditions

Correlate special test findings



plan of care

The student will:

describe the procedural

components foot and ankle

clinical special tests

accurately perform foot and

ankle clinical special tests

discriminate validity and

reliability of selected clinical

special tests

identify common procedural

errors when performing selected

special tests

The student will:

perform clinical special tests

on a patient

interpret special test results for

integration into the assessment

and plan of care

conduct self assessments of



feedback.

and Ankle Rules

Thompson Test

Clinical Prediction Rule for

ankle instability

discriminate the appropriate use

of foot and ankle special tests

for simulated patients

Palpation of Relevant

Structures

NOTE: Connect to relevant

diagnoses

Lateral Structures:

Fibula head/neck/shaft

Fibularis longus/brevis mm

Lateral malleolus

Anterior inferior tibiofibular

joint


ligament

Calcaneus

Peroneal tubercle

Calcaneofibular ligament

Fibular tendons

(Longus/Brevis)

Cuboid

Styloid process 5th metatarsal

5th metatarsal base/shaft/head

Sinus Tarsi

Extensor digitorum brevis

Anterior talofibular ligament

Identify key surface anatomical

structures relevant to

patient/client presenting chief

complaint(s).

Prioritize and demonstrate the

ability to apply the basic

concepts of gross anatomy to

the analysis of patient/client

problems related to

musculoskeletal system of the

leg, ankle, and foot.

Differentiate normal vs.

abnormal findings obtained

from surface anatomy

palpation.

Correlate palpation findings



plan of care

The student will:

Discuss normal and potentially

abnormal clinical findings

identified from a palpation

examination given selected

pathological scenarios.

Perform an examination of a

student in the classroom that

includes correct identification

and palpation of relevant

osseous, musculotendinous,

and/or neurovascular structures.

Perform an efficient

examination of a patient/client

with foot/ankle pathology or

complaint.

Conduct a physical

examination using palpation

techniques that contribute to

the formulation of the

differential diagnosis.

Provides written and verbal

communication utilizing

correct terminology and

description for accurate

recording of physical

examination findings.

Conducts self-assessments of



feedback.

Dorsal Structures:

Anterior compartment mm.


joint


ligament.

Anterior tibialis tendon

Extensor hallucis longus

tendon

Dorsalis pedis artery/pulse

Extensor digitorum longus

tendon

Extensor digitorum brevis m.

Talar neck

Navicular

1st, 2

nd, 3

rd cuneiforms

Metatarsals I-V base/shaft/head

1st metatarsal joint

Medial Structures:

Medial malleolus

Posterior tibialis tendon

Flexor digitorum longus

tendon

Posterior tibial artery/pulse

Deltoid ligament

Talus

Sustentaculum tali

Calcaneonavicular “Spring"

ligament

Navicular tuberosity

1st cuneiform

1st metatarsal base/shaft/head

Abductor hallucis m.

1st MTP joint

Posterior Structures:

Calcaneus

Achilles tendon

Retrocalcaneal bursa

Soleus m

Gastrocnemius m

Plantar Structures:

Calcaneus

Calcaneal fat pad

Calcaneal tubercle (medial)

Plantar fascia/aponeurosis

Metatarsal heads I-V

Sesamoids

Vascular:

-Popliteal Artery

-Posterior Tibial Artery

-Dorsalis Pedis Artery

-Capillary Refill

Link between palpation and

diagnosis. (Categorized above)

Confirmatory - should be done

at the end

Neurologic Examination

Reflexes

Myotome

Tinel's

Tarsal Tunnel Test-

dorsiflexion with eversion

inversion and plantar flexion

(space occupying lesion)

SLUMP/SLR to test for

proximal contribution to the

foot and ankle chief complaint

Understand the proper selection

of the tests and measures is

dependent on:

1. Chief

complaint/subjective

examination

2. Demographics

3. SINS

4. Functional level of

patient

The student will:



identified from each of the tests

used in this area of examination

using clinical scenarios.

Perform these examination

tests correctly and safely

interpret whether neurologic

finding(s) is/are specific to the

foot and ankle condition or

related to another condition of

the LE or body systems .

The student will:

Perform neurologic

examination measures on a

patient

Perform test and measures

efficiently and correctly

interpret results.

Conducts self assessments



feedback.

Interpret and integrate the

results with the assessment and

plan of care.

Balance -

--Romberg – Sharpened

Romberg

--Single leg stance

-----Eyes closed eyes open

-----head neck rotation

-----Surfaces - foam no foam

-----assess for ankle, knee and

hip strategy

Modified Star Excursion

Hop to Stabilization

Understand the proper selection

of the tests and measures is

dependent on:

1. Chief

complaint/subjective

examination

2. Demographics

3. SINS

4. Functional level of

patient

Determines the need for a more

in- depth fall risk assessment in

The student will:



identified from each of the tests

used in this area of examination

using clinical scenarios.

Perform these examination

tests correctly and safely

The student will:

Perform balance measures on a

patient

Perform test and measures

efficiently and correctly

interpret results.




feedback.

Assessment of falls risk -

BERG, TUG, Tinnetti,

Rickli and Jones

selected patients Interpret and integrate the

results with the assessment and

plan of care.

Lower Quarter Screen (LQS)

Recognize the potential for

referred pain into the foot and

ankle for means of specific

examination of other body

regions, diagnosis, or potential

referral to another healthcare

provider.

The student will:

correctly performthe

components of a lower quarter

screen with a classmate

recognize a referred pain

pattern based on LQS

examination results

The student will:

perform a lower quarter screen

on a patient to rule in /out

referred pain and the need for

specific examination of other

body regions

Evaluation

Diagnosis

PTTD

Describes the continuum of dysfunction

Discriminates between this diagnosis and

pertinent differential diagnoses (rules out

the following):

SPECIFICS?

Describes signs and symptoms,relevant

history and examination including:

• tenderness along the tendon

course

• reduced calcaneal inversion during

heel rise

• weak inversion/ PF

• Abnormal alignment and

Describes the location and

function of the TP and performs

MMT, and palpation of same.

Describes the associated

structural and movement

impairments including heel rise

test and gait deviations.

The student must have

experience practicing clinical

management of a tendinous

structure.

The student describes having

had exposure to an actual

patient, a case study,

simulation of a foot tendon

problem, or related hooked-

on- evidence case.

The student supports

Comment [S7]: Should this follow systems review earlier in the examination

matrix?

movement associated with

pronation

choosing examination items

consistent with severity and

nature of the problem

Plantar Fasciitis




the following):

• Calcaneal stress fracture

• Bone bruise

• Fat pad atrophy

• Tarsal tunnel syndrome

• Soft-tissue, primary, or metastatic

bone tumors

• Paget disease of bone

• Sever’s disease

Describes location and function

of the plantar fascia including the

Windlass mechanism. Performs

palpation of the plantar fascia

Describes associated structural

and movement impairments

including those seen during gait

Performs an Examination of

potential sources of limited ankle

dorsiflexion




simulation of a heel pain

patient, or related hooked-

on- evidence case.





• Referred pain as a result of an S1

radiculopathy

Describes signs and symptoms, relevant


• Pain upon palpation of the

proximal plantar fascia attachment

• First step pain

1st Toe extension reproduces pain at the

proximal or distal attachment of ? ? PF?

Achilles

Tendinopathy

Describes the continuum of tendinopathy

and progression of symptoms.



the following):

• Acute achilles tendon rupture

• Partial tear of the Achilles tendon

• Retrocalcaneal bursitis

• Posterior ankle impingement

• Irritation or neuroma of the sural

nerve

• Os trigonum syndrome

Describes location and function

of the Achilles tendon. Performs

palpation and functional testing

(heel rise and manual muscle

testing ).

Performs palpation to determine

the anatomical location of the

tendinopathy



impairments including deviations


had experience in clinical

management of a tendinous

structure





for an actual or simulated

patient/ case study.

(attached. hooked- on-

evidence case)

• Achilles tendon ossification

• Systemic inflammatory disease

• Insertional Achilles tendinopathy

• Boney enlargement on back of the

calcaneus (Haglunds deformity)



• Localized pain and stiffness

following periods of prolonged

inactivity

• Intermittent pain experienced

during activity and exercise

• Perceived tenderness

and pain upon palpation to the

Achilles tendon

• Positive Achilles Tendon

Palpation Test

• Decreased plantar flexor strength

with

associated either increased or

decreased dorsiflexion A? P?

range of motion

• limited ability to perform

repetitive unilateral heel raises

when compared to the

contralateral side

in: Gait, unilateral heel rise,

single limb hop, or ability to

descend stairs

The student discriminates

between a tendinous lesion

and pertinent differential

diagnoses (rules in/out

tendinous lesion)

Lateral ankle

sprain and

syndesmotic/high

ankle sprain

Describes continuum of dysfunction of

lateral ankle sprains and high

ankle/syndesmotic sprain

Describes the function of the

anterior talo-fibular and calcaneo-

fibular ligaments.

Performs palpation of the




simulation of a patient with

ankle sprain or



- Pain with palpation of the

involved ligaments (ATFL, CFL,

Ant tib-fib lig)

- Mechanism of injury –

inversion/plantarflexion (lateral

ankle sprain) versus dorsiflexion

and eversion (high ankle

sprain/syndesmotic)

- Reproduction of ankle instability

or pain with special tests



the following):

• Peroneal tear

• Medial collateral ligament

ankle sprain

• Lisfranc

Fracture/Dislocation

• Subtalar sprain

• Achilles tendon rupture

• Lateral talar process injury

• Anterior process of the

calcaneus injury

calcaneal-fibular and the anterior

tib-fib ligaments.

Performs a measurement of

swelling of the ankle using the

figure of eight – in 20 degrees of

plantar flexion

Performs a combination of tests

to assess ligament stability

including: talar tilt, anterior

drawer for lateral ankle sprain

and external rotation and squeeze

test for high ankle

sprain/syndesmotic sprain

Describes the Ottawa Ankle

Rules and when to refer a patient

for radiograph

Supports choosing examination

items consistent with severity and


syndesmotic/high ankle

sprain, or related hooked- on-

evidence case.

Hallux Abducto-

Valgus


that can be addressed by a PT


Describes the location function

and of the 1st MTP and 1st ray.





simulation of hallux valgus,


the following):

• sesamoid stress fracture,

• avascular necrosis,

• osteochondral fractures, and

chondromalacia,

• metatarsalgia, nerve impingement,

• infection,

• bursitis,

• sesamoiditis,

• bipartite sesamoids

(Hockenberry99, Dedmond 06).



• Palpation and observation

including medial eminence

tenderness,

• severity of HAV deformity,

• contribution of shoeware

• static foot type based on standing

alignment

• Gait pattern and weight

acceptance under 1st MTP


impairments including:

• Palpation

• Gait

• Static foot alignment

• 1st MTP ROM

or related hooked- on-

evidence case.




nature of the problem.

The student performs an

assessment of the stability of

an MTP joint.

Hallux Limitus

Describes the continuum and etiology of

this dysfunction



• Limited accessory motion of the

1st MTP and/or ray.

Describes the location function

and of the 1st MTP, sesamoids,

and 1st ray.



impairments including results of



patient, a case study, a

simulation of hallux limitus,

or related hooked- on-

evidence case.

• Associated proximal alignments

and compensations due to reduced

heel rise in gait and function.

• Atypical function and position of

the sesamoid apparatus

performing:

• palpation

• gait examination

• Static foot alignment

examination

• 1st MTP PROM

examination

• Flexor halluces longus

manual muscle testing





.

The student performs an

examination of the motion of

the 1st MTP joint.

Metatarsalgia Describes the continuum of dysfunction

and discriminates between this diagnosis

and pertinent differential diagnoses (rules

out the following):

• Interdigital neuroma,

• plantar keratosis,

• Frieberg’s disease,

• Metatarsal stress fracture,

inflammatory arthropathy(such as

rheumatoid arthritis, seronegative

spondyloarthropathy, or

crystalline-induced arthritis),

• tarsal coalition,

• vertical talus,

• or accessory navicular (Omey.

Glasoe 05)



• Pain upon palpation of the distal

Describes the location and

function of the distal plantar

fascia, FDL, MTP joint capsule,

interdigital nerve and fat pad.



impairments including results of

performing:

• Palpation

• Gait examination

• Manual Muscle testing of

intrinsic foot muscle

strength

• Mulders test

• Tinel test


had exposure to either an

actual patient, a case study,

simulation of forefoot pain, or

related hooked- on- evidence

case.

The patient supports choosing

examination items consistent

with severity and nature of

the problem.

2-3rd metatarsal heads, plantar

MTP, and FDL.

• Special tests including digital

Lachman, Drawer, or Mulders test

• Pertinent gait abnormality

Shin Splints/Medial

Tibial Stress

Syndrome



• Pain in the front of the shin.

• A patient who has high use (high

BMI or activity level) and poor

foot alignment.

• Anterolateral lower leg pain is

often associated with the anterior

compartment muscles.

• Anteromedial lower leg pain is

indicative of stress fracture.



the following):

• Compartment Syndrome

• Performs palpation of

anterior compartment

muscles.

• Performs palpation of the

anterior tibia where there

is no muscle coverage.

• Describes and performs

demonstration ofthe

actions of the three

muscles in the anterior

compartment.

• Performs correct stretch

of each muscle in the

anterior compartment

including elongation over

all the joints each crosses.

• Describes when to refer

the patient to orthopaedics

for diagnosis and

management of a potential

stress fracture.

Ankle

Osteoarthritis

(OA)- Non-surgical

Post-op


history and examination including for

Non-surgical ankle OA:

• Pain during and after activity

• Continuum of joint deformity and

loss of motion



impairments including:

description that surgical

management of OA can include

The students describes having

had experience in the clinical

management of OA.

• Prior history of ankle instability or

trauma


history and examination including for

Post-op OA:

• Obtains relevant information

about surgical or medical

management to identify

indications/contraindications for

examination and intervention

Osteochondral procedures, ankle

replacement, or ankle fusion

(while the current standard of

care is ankle fusion for end stage

OA)

Post-op –Describes and examines

the tissues involved in the injury

and/or surgery including the

influence of time on return to

function

Neuropathic

(Diabetic) Foot • Describes signs and symptoms,

relevant history and examination

including: Loss of protective

sensation on at least on aspect of

the plantar surface of the foot

(generally stocking/glove)

• Signs autonomic system

dysfunction (e.g. hair loss, loss of

sweating)

• Diagnosis that can result in loss of

peripheral sensation (diabetes,

heavy metal, alcohol, idiopathic)

Associated complications:

• Ulcer formation

• Neuropathic Charcot Arthropathy

• Joint deformity

• Impaired balance

• Peripheral vascular

disease/ischemia

• Loss of joint mobility

• Loss of foot bone mineral density

• Delayed bone and tissue healing

Performs the following

examination items in the foot:

• Visual exam of skin and

nails

• Sensory examination of

the foot

• Palpation of pulses

• Passive and active range

of motion

Performs a footwear examination

discriminating between

appropriate and inappropriate

footwear and orthosis

components

Describes deformity and potential

consequences of each deformity

in people with this diagnosis (e.g.

hammer/claw toe, medial and

lateral midfoot and hindfoot

deformity)

The student performs a screen

for diabetes during the history

The student describes and as

appropriate performs

precautions for insensate feet

during examination and

treatment.




simulation, or in class patient

lab of an individual with a

neuropathic foot.

Perform examination of need for

assistive device

Calcaneal

Apophysitis

(Sever’s

Disease)/calcaneal

epiphyseal fracture

Describes the continuum and etiology of

this dysfunction

from apophysitis through

epiphyseal fracture

• Explains that this type of

fracture cannot be diagnosed

through x ray, but rather is

made through signs and

symptoms and responses to

management.

• Describes signs and symptoms,


including: Pain at the heel;

usually right at the posterior most

tip

• Patient is a child of an age when

their calcaneus has not fully fused

(5-10 years)

• History of high activity level

and/or growth spirt

• Patient stands with heels in

eversion relative to subtalar

neutral

• Describes that this

problem warrants

intervention and that if it

is a fracture it may require

immobilization for eight

weeks followed by rehab

(stretching, strengthening,

balance work etc )

• Describes that the

mechanism of injury is

that the heel cord is tight

and pulls the calcaneal

epiphysis apart.

• Performs appropriate

secondary tests to address

force distribution and

aberrant motion including

fabrication/adaptation of

temporary foot orthoses

and heel lifts to support

medial arch and/or

hindfoot.

Student describes having had

exposure to an actual patient

or a case study of Sever’s

disease that includes its PT

management.

and associated dysfunctions

functional leg length discrepancy

shin splints

proximal compensations and

associated pains and dysfunctions

Fracture (5th

metatarsal,

navicular, midfoot)


history and screening examination

including:

• Pain with palpation

• Inability weight bear for 4 steps

• High incidence of non-union


history and examination related to

medical management including: :

• Obtain relevant information about

surgical or medical management

to identify indications/

contraindications for PT

examination, intervention

Describes signs and symptoms,


of fracture when performing

Palpation of boney

structures of the foot and

ankle

Student will describe a timeline

to guide progression of care

following the medical or surgical

management of a fracture.


had experience with the PT

clinical management of a

fracture.

Chronic Ankle

instability/

functional and

mechanical


history and examination related to chronic

(functional and mechanical) ankle

instability including including:

• patients with feelings of

instability,

• impaired balance and

proprioception,

• decreased passive or active range

of motion.


Performs balance and

proprioception testing.

Performs a group of tests to

assess stability of ankle

ligaments.



actual patient with ankle

instability, a case study, or

simulation of a patient with

chronic ankle instability.






the following):

• Peronal tendon pathology

• Accessory ossicles

• Tarsal coalition

• Sinus tarsi syndrome

• Subtalar sprains with or

without instability

• Spring or bifurcate

ligament damage

• Peronal tendon pathology

• Accessory ossicles

• Tarsal coalition

• Sinus tarsi syndrome

• Subtalar sprains with or

without instability

• Spring or bifurcate

ligament damage

• Ankle impingement

Tarsal Tunnel



the following):

• Plantar fasciitis



related to medical management

including: Distal production of

symptoms with tapping (Tinel’s)

of the posterior tibial nerve

pathway.

Performs palpation of posterior

tibial nerve

Performs the Tinel’s and

Provocative Tinel’s tests



actual patient, a case study, or

simulation of a foot and ankle

case in which they must

choose to rule out

involvement of the posterior

tibial nerve as a source of

symptoms.

• Symptoms reproduced

with sustained dorsiflexion-

eversion of the foot

• Provocative Tinel’s:

symptoms reproduced during

tapping of the nerve pathway with

the foot in dorsiflexion, maximal

calcaneal eversion, and toes

extended. (Kinoshita M, Okuda

R, Morikawa J et al. The

Dorsiflexion-Eversion Test for

Diagnosis of Tarsal Tunnel

Syndrome. J Bone Joint Surg Am.

2001; 83(12):1835-1839.)

Do we need this first and last bullet?

Equinus related to

any or all of the

following:

• Passive

tightness of

PF

• Dynamic

tightness of

PFors

(spasticity)

• Poorly timed

dorsiflexion

activity

• Weak or

absent

dorsiflexors


history and examination related to medical

management including:

• PROM DF less than 10 with the

knee extended avoiding pronation

• Lack of heel strike during gait

• Early heel off during gait (mild)

• Stands with heels on ground and

pronation or supination, walks on

toes (moderate)

• Stands and walks on toes. (severe)

Discriminates between those

that do, and do not, attain heel

strike during gait.

Describes all the plantar flexor

muscles that could be tight,

active at the wrong time, or

overly shortened.

Performs PROM measurements

of dorsiflexion with and without

pronation, with and without

knee flexion

Describes the likely presence of

initial resistance (R1), verses

ultimate PROM (R2) in patients

The student

describes having

had exposure to an

actual patient or a

case study

involving clinical

management

of an equinus foot

problem including

discriminating

between origins of

the equinus. This

involves

performing,

or describing, an

examination that

discriminates

with spasticity.

between tight

plantar flexor

muscle(s), joint

limitation (s),

poorly timed

plantar or

dorsiflexion, or

excessive plantar

flexion activity.

The student will

discriminate

between

specific situations

when referral is

warranted being

specific as to the

type of referral (PT

with neurological

expertise, to

physiatry

or other MD skilled

in medical

management of

spasticity including

botulinum toxin

injections,

orthopaedic

surgeon,

neurosurgeon,

or orthotist).

Hence, the student

will describe that

which discriminates

a patient with

plantar flexor

spasticity from

other patients.

Foot Supination

Syndrome



including: Related source

diagnosis including tibial stress

fracture, plantar fasciitis,

metatarsal (MT) stress

fracture/Metatarsalgia 1and 5,

sesamoiditis, fibularis

tendinopathy/tear, achilles

tendinopathy, Hallux abducto-

valgus, bunionette, Hallux limitus

• Hindfoot inversion, talo-navicular

elevated, forefoot adduction,

plantarflexion first ray, reduced

lateral arch height, during gait,

hopping, running, and stepping

• Callus formation at 1st and 5

th

metatarsal heads

• Footwear worn on lateral border

• Force distribution and/or

addressing aberrant motion

identified reduces signs and

Descriminates supination during

the stated movements from other

motions

Performs appropriate secondary

tests to address force distribution

and aberrant motion

(verbal/tactile cueing, taping, and

orthosis fabrication and/or use).






excessive or poorly timed

foot supination from other

motions during gait in a

patient.

The student must describe

having had exposure to

actual, simulated and/or a

relevant case study of foot

supination syndrome.

symptoms


and compensations (functional leg

length discrepancies, lateral

femoral rotation)

Foot Pronation

Syndrome



including: Related source

diagnosis including Medial tibial

stress syndrome , plantar fasciitis,

metatarsal stress

fracture/Metatarsalgia 2/3,

Neuroma, PTTD, Achilles

tendinopathy, Hallux Abducto-

valgus, Hallux Limitus, Fibularis

• Hindfoot eversion, talo-navicular

descent, and forefoot abduction

during gait, hopping, running, and

stepping

• Callus formation at metatarsal

heads 2nd and 3

rd, and medial side

of hallux

• Footwear worn on medial border

of the shoe and under 2nd and 3

rd

metatarsal.

• Correction of abberant motion

identified reduces signs and

symptoms


and compensations (functional leg

length discrepancies, medial tibial

and femoral rotation, ?ipselateral

Discriminates pronation during

the stated movements from other

motions.

Performs appropriate secondary

tests to reduce aberrant motion

(verbal/tactile cueing, taping, and

orthosis fabrication and/or use).






excessive or poorly timed

foot pronation from other

motions during gait in a

patient


had exposure to actual,

simulated and/or a relevant

case study of foot pronation

syndrome.

pelvic drop)

Prognosis

Plan of Care

Intervention

Therapeutic Exercises

• Balance

• Strengthening

• Stretching

• Endurance

• Select and perform

appropriate therapeutic

exercises

• Demonstrate strategies

for the interventions

• Apply principles of safe

practice to patient/client

care

• Deliver interventions

based on the best

evidence available and

practice guidelines

• Discuss rationale for

selecting specific

therapeutic exercises,

including dosage,

• Demonstrate the ability

to instruct or perform

selected interventions

• Discuss the principles of

exercise progression

• Recognize and be able

to instruct patient on

special interventions for

the foot/ankle, including

(but not limited to):

o Plantar fascia

stretching

o Gastroc stretching,

protecting the mid-

foot

o Foot intrinsic

strengthening

exercises

o Proximal muscle

strengthening

including core, pelvis

• Design, implement, and

progress an appropriate

treatment program

• Monitor patient

response to

interventions and

modify as appropriate

•

and LE

Padding

(e.g. MT cookies, heel lifts,

donuts)

• Understand the

principles of the use of

padding for clinical

conditions of the foot

and ankle

• Discuss the best

available evidence

regarding indications,

contraindications, and

precautions to utilizing

padding techniques

• Discuss the options to

alter pressure

distribution on the

plantar aspect of the foot

• Predict how different

types of padding may

affect motion or plantar

pressure distribution

• Demonstrate appropriate

placement of padding to

achieve the desired

effect

• Monitor patient

response to padding

and make modifications

as necessary

• Recognize when

referral to other

healthcare provider is

appropriate

•

Footwear • Identify and discuss the

structural features of a

shoe

• Discuss the criteria for

proper shoe fitting

• Describe the indications

for footwear

modifications,

specialized footwear,

casting, or proper

referral

•

• Evaluate the shoe fit of

an individual

o Length

o Toe box width

o Toe box depth

o Curvature of the

last

• Make recommendations

for footwear options

based on patient

presentation

o Diabetic

population

o Pronation

syndrome

o Supination

syndrome

o Neurologic

• Make recommendations

for footwear and/or

footwear modifications

to address a particular

clinical condition

o Running

population

� Stability

� Motion

control

� Cushioni

ng

�

o Diabetic

population

� Cushioni

ng

� Pressure

distributi

population

o Arthritic

population

o

• Discuss the rationale for

various features of a

shoe

• Identify the specific

components of a shoe

o Toe box

o Heel counter

o Vamp

o Mid-sole

o Sock liner

on

� Adequat

e toe box

width/

depth

�

• Refer to appropriate

healthcare provider as

necessary

Abnormal Motion

• Excessive Motion

o Bracing

o Strapping

o Foot Orthoses

• Limited Motion

o Mobilization

o Manipulation

• Discuss the rationale

and best available

evidence for each of the

interventions utilized to

control motion

• Discuss indications and

contraindications for

motion control,

including bracing and

strapping

• Recognize the

implications of

interventions on the

various components of

the kinetic chain


appropriate joint

mobilization techniques

related to limited motion

Excessive Motion


and recommendations

for bracing of the foot

and ankle

o AFO

o KAFO

o Boot

o Stirrup

o Lace-up


and recommendations

for strapping of the foot

and ankle

o Ankle Instability

� Stirrup

� Basketwe

ave

o

• As available, observe or

participate in the

prescription,

fabrication,

modification, or

dispensing of bracing:

o AFO

o KAFO

o Boot

o Stirrup

o Lace-up

• Discuss the rationale,

indications, and

contraindications for

manipulation

� Heel lock

o Medial Arch

� Low-Dye

� Cross X

� Reverse

Six

o Edema:

Compression

wrap with

pressure gradient

o Musculotendino

us

o support

(Achilles)

• Recognize a patient

(case) where foot

orthotic management

would be appropriate

• Understands the

mechanism by which a

foot orthosis restrains or

encourages motion

• Observe the fabrication,

modification, or fitting

of a foot orthotic

Limited Motion

• Demonstrates correct

hand placement and

technique when

providing grade I-IV

joint mobilizations to all

• As available, observe or

participate in the

prescription,

fabrication,

modification, or

dispensing of a foot

orthosis

o Custom

o Prefabricated

o Accomodative

• Demonstrate proper

technique when

performing at least one

articulations of the

foot/ankle, 1st MTP, and

inferior and superior

tibiofibular joints

• Discuss the rationale for

parameters chosen for

selected mobilization

techniques

• Identify indications for

and safely perform

manipulations:

o Talocrural

distraction

o Subtalar joint

o Cuboid whip

joint mobilization of

the foot/ankle complex

Modalities • Discuss indications,

contraindications, and

precautions for utilizing

therapeutic modalities


appropriate therapeutic

modalities

•

• Monitor patient

response to modalities

and make modifications

as necessary

Patient Education • Discuss specific clinical

conditions with the

patient and/or family,

including etiology,

intervention options, and

prognosis

• Educate patient

regarding appropriate

self-management

strategies

• Discuss footwear

considerations for

patients:

o Diabetes

o Peripheral

neuropathy

o Peripheral

edema

o UMN Lesions

� Spasticit

• Identify and discuss risk

factors and strategies for

injury prevention

y

� Flaccidit

y

o Trauma

o Arthritic

Conditions

� OA

� RA

o Athletes

Functional Training • •

APPENDICES

Appendix A

Table 18. Average values from various studies for a single heel rise test

Author Sample Average

Repetitions

Technique

Madeley,

2006199

Young athletes

(n = 30)

(mean age 24 ±

5.7 years old)

39 ± 11.7 Strings were used to document heel height and trunk

position. The test was terminated if the participant

leaned forward touching the string at the level of their

pectorals three times, the ipsilateral knee flexed, the

dorsal aspect of the foot did not contact the string for

three consecutive repetitions or the participant could no

longer continue. At this point, the number of heel-rise

repetitions that were performed was documented. One

trial was used for this test.

Lunsford,

1995199

Adults (n =

203)

(mean age men

= 34.7 ± 8.5,

women = 29.3 ±

5.0 years old)

27.9 ± 11.1

Each subject was allowed to touch the examiner with a

single finger for balance. The test was terminated if

the subject leaned or pushed down on the examiner, the

subject's knee flexed, the plantar-flexion range of

motion decreased by more than 50% of the starting

range of motion (measured quantitatively), or the

subject quit or asked to stop.

Jan,

2005143

Adults (n =

180)

(21- 80 years

old)

Male

21- 40 = 22.1 ± 9.8

41- 60 = 12.1 ± 6.6

61- 80 = 4.1 ± 1.9

Female

21- 40 = 16.1 ± 6.7

41- 60 = 9.3 ± 3.6

61- 80 = 2.7 ± 1.5

One examiner provided the finger-touch

support and counted the total number heel rises

accomplished. Another examiner observed the

participant laterally for any extraneous trunk lean or

knee flexion. The third examiner read the

electrogoniometer output on the monitor and

terminated the test if the plantar flexion angle became

less than 50% of the maximum angle.

Appendix B

Gait Velocity:

Normal or

Abnormal

Cause:

NOTES Stride length:

Equal? Yes----NO

If no, what is

cause?

NOTES Cadence:

Normal or

Abnormal

Cause:

NOTES

Task of Gait Weight

Acceptance

Single Limb

Support

Single Limb

Support

Limb

Advancement

Limb

Advancement

Phase of Gait

Reference Limb

Initial Contact

Loading Response

Mid Stance Terminal Stance Pre Swing Initial, Mid,

Terminal Swing

Contralateral

Limb

Pre Swing Initial to Mid

Swing

Mid to Terminal

Swing

Initial Contact

Loading Response

Mid and Terminal

Stance

ROCKER Heel rocker Ankle Rocker Forefoot rocker Forefoot rocker

Ankle: Normal Strikes in relative

DF moves into PF

via foot to ground

faster than tibia

moves forward

From PF into DF of

ankle

DF of ankle reaches

peak of 5-10

degrees

DF to 25 degrees of

PF to assist knee to

flex to shorten limb

Ankle remains in PF

during initial swing,

need knee flexion to

clear the limb

Ankle Abnormal

Common

Findings

1. Uncontrolled PF

2. Low Foot

Contact

3. Forefoot Contact

1. Excessive DF

(knee flexion in

mid stance)

2. Early Heel Rise

3. No forward tibial

progression

1. No heel rise prior

to C/L contact

2. Contact area

more lateral

Lack of PF

KEY: Decreased

knee flexion

Loss of FF rocker

Toe drag Int. Swing

Failure to achieve

neutral ankle for IC

Foot: Normal Foot pronation best

seen with calcaneal

eversion and unlock

of midtarsal joints

Early mid stance

pronation may

continue, should

see pronation cease

late mid stance and

supination begin

Rise of heel off the

ground should see

supination to allow

the foot to be rigid

with decrease WB

contact

Windlass

Mechanism

MTP joints continue

to extend, weight

should progress over

the 1st MTP joint,

supination is

maintained

Foot comes off the

ground in the

position it

maintained in pre

swing. Good place

to look for excessive

pronation

Foot: Abnormal 1. Excessive 1. Midtarsal joints 1. Midtarsal joints 1. Lack MTP joint 1. Foot comes off

calcaneal eversion

2. Limited calcaneal

eversion

3. Excessive MTJ

unlock

4. Limited MTJ

unlock

remain unlocked

2. Midtarsal joints

remain locked

3. Excessive

inversion of

hindfoot continues

4. Excessive

eversion of

hindfoot continues

remain unlocked

2. 1st Ray does not

PF

3. Midtarsal joints

remain locked

4. 1st ray in too

much PF

extension

2. Excessive MTP

extension

3. Roll off the side

of 1st MTP jt.

4. Roll off lateral

forefoot

ground in excessive

pronation

2. Foot comes off

the ground in

excessive supination

Gait Velocity:

Normal or

Abnormal

Cause:

NOTES Stride length:

Equal? Yes----NO

If no, what is

cause?

NOTES Cadence:

Normal or

Abnormal

Cause:

NOTES

Task of Gait Weight

Acceptance

Single Limb

Support

Single Limb

Support

Limb

Advancement

Limb

Advancement

Phase of Gait

Reference Limb

Initial Contact

Loading Response

Mid Stance Terminal Stance Pre Swing Initial, Mid,

Terminal Swing

Contralateral

Limb

Pre Swing Initial to Mid

Swing

Mid to Terminal

Swing

Initial Contact

Loading Response

Mid and Terminal

Stance

ROCKER Heel rocker Ankle Rocker Forefoot rocker Forefoot rocker

Normal Yes---NO Yes---NO Yes---NO Yes---NO Yes---NO

ANKLE JOINT


If NO what is

deviation?

What are possible

causes for the

deviation from

normal?

FOOT


If NO what is

deviation?

What are possible

causes for the

deviation from

normal?

Appendix C

Table 16. Normative values for the Single Limb Balance Test

Age Gender Eyes Open

Mean of 3 Trials

Eyes Closed

Mean of 3 Trials

Mean

Mean

Single Limb

Balance

(in seconds)317

18-39 Male

Female

43.5±3.8

43.2±6.0

8.5±9.1

10.2±9.6

40-49 Male

Female

40.4±10.1

40.1±11.5

7.4±6.7

7.3±7.4

50-59 Male

Female

36.0±12.8

38.1±12.4

5.0±5.6

4.5±3.8

60-69 Male

Female

25.1±16.5

28.7±16.7

2.5

3.1

70-79 Male

Female

11.3±11.2

18.3±15.3

2.2

1.9

80-89 Male

Female

7.4±10.7

5.6±8.4

1.4

1.3

Documents

Recommendations for Professional Physical … for Professional Physical Therapy Curricula for the Foot and Ankle Clinical Sciences Matrix Primary Content Terminal Behavioral Objectives