How would you treat this patient, what do you notice?
I think that we all agree that this patient lacks
dorsiflexion, especially since his knee is not in full extension causing his
fibular head to be off of the ground. When the knee flexes with dorsiflexion it
is compensation for a lack of dorsiflexion.
What would you treat?
If you asked me this question 5 years ago, I would have said
the following:
- Mobilize the gastroc/soleus
- Mobilize the talus
- Manipulate the talocrual joint
All of the above are valid answers, non of them are correct.
Today, using the principles of Diagnostic Motion Evaluation (DME) I would say mobilize; the proximal phalanx, and the metatarsal 2 and 3.
How do I know this?
The rule of Diagnostic Motion Evaluation states that in an
open chain activity the therapist should begin evaluating for motion distal to
proximal.
This picture reveals lots of motion (hypermobility) into
extension of the toes, another compensation for a lack of dorsiflexion. You can actually see a dent in the skin
between the base of the phalanges and the metatarsals. The restriction to motion is definitely not in
the toes.
There is no lifting of the metatarsals into dorsiflexion and
that is where this person’s restriction is.
Notice the difference in motion of
the metatarsals in this picture:
Before using DME I would waste valuable time treating valid
structures that could cause dysfunctional motion. Now I can easily find
dysfunction that is inhibiting motion or causing pain.
The link below shows a patient who I restored full dorsiflexion,
simply by treating her big toe. By the way she happens to also have Cerebral Palsy.
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