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NMT IV: Feet



ANTERIOR GLIDE OF THE CALCANEOUS
located posteriorly and may get stuck that way
if pt can't pronate or supinate consider this
hx of ankle sprain
evaluation and tx are same
pt is prone
talus (base of ankle) on edge of table
ipsilateral hand cups palm, fingers on calcaneous only
medial forarm along lateral side of 5th metacarpal
avoid inverting foot
use other hand to maximally plantarflex the foot
she puts fingers on sole and thumb on dorsum but either way OK
pull down on calc until slack is out of table cushion and soft tissue
pull around 45 degrees back, along angle of plantarflexed foot

BUNION CORRECTION/PREVENTION
if its not too late
wear good shoes, not: shoes too narrow, too much heel
silicon spacers between toes during day
halus valgus splint to wear at night
walking mechanics
stretching toes into abduction, actively abducting
"yoga toes"
stripping massage of muscle on dorsum btw 1st and 2nd metatarsals
strengthen adductor: standing with feet hipwidth and abduct big toe
strengthen toe flexors: picking things up, scrunching a towel, etc
6-8 weeks to measurable change

SHOES
too bad about fashion
shoes that separate toes for running will cause calf soreness the next day
cause eccentric contraction of gastroc/soleus, more microtears
Vibram FiveFingers KSO (Keep Stuff Out)
Price: $85. (800) 842-7267; www.vibramfivefingers.com
http://www.geekologie.com/2007/08/these_shoes_are_confused.php
http://www.runnersworld.com/article/0,7120,s6-240-400--12828-0,00.html

Ray McLanahan, ND podiatrist in PDX, offers preceptorships to NCNM students
spoke at Grand Rounds last term
http://nwfootankle.com/
actually recommends wearing crocs for running
http://www.crocs.com/home/homepage,default,pg.html
others concur
http://crocrunner.blogspot.com/2008/03/thanks-to-crocs-i-can-run-again.html

NORDSTROM will sell you two different sized shoes to make a pair

TO SEE IF SHOE FITS
take out inner sole and stand on it
if your foot hangs over the edges of the innersole anywhere, not a fit

FOR MY PRACTICE
check on local shoe stores
running stores
know where people can special order stuff
inner soles, orthotics, fabrication supplies for support
business networking to generate good referrals
find a local podiatrist, orthotist, physical therapist

PLANTAR FASCIITIS

CHARCOT FOOT
from uncontrolled diabetes-->nerve damage-->worse
navicular bone degeneration
transverse arch falls
http://www.doctorbret.com/charcot.htm

does this image still work?


SUPERIOR GLIDE OF THE TARSALS
pt prone, doc knee on table, pt talus on foot dorsum stable on doc thigh
navicular bone is prominent below medial malleolus
navicular articulates with all three cuneiform bones to digits 1, 2, 3
place thumb pad in arch on navic just off 2nd ray, and fingers across dorsum
rest talus on my leg
plantarflex foot
other hand knifeedges on thumbnail to drive

CUBOID BONE
more springy than navicular
artic with 4th and 5th digits
find just behind large styloid on 5th metatarsal
keep talus on thigh
place thumb on cuboid in artch btw 4th n 5th digits
plantarflex fully
drive with knife edge to assess and adjust

CUNEIFORMS
put navicular on thigh
1st off end of 1st ray
find on medial border of foot
same approach as above
2nd easier to find on dorsum first
3rd
don't invert foot!

INFERIOR GLIDE OF THE TARSALS
pt is supine
doc seated at end of table
driving dorsal to plantar
flex the foot
shove navicular, cuneiforms or cuboid toward arch
stack midfingers on each bone
whole finger on navic, fingerpads for the rest
for medial bones use medial mid finger first
lateral finger for cubiod, either for 3rd cuneiform
angle to face the bone (slight medial-lateral shift of doc position)
get pretty far back and use upper body not just arms

SHEARING OF THE METATARSALS
sup to inf or inf to sup
inf: stand over supine pt to dorsiflex foot and push each bone inferiorly
ok to stabilize cunieforms or cuboid to eval jts w/metatarsals
good for up to grade 2
for grade 3 and up superimpose midfingers on top, dorsiflex and pull
sup: for superior glide put pt in prone
push one bone at a time to assess
use same procedure as for tarsal glide to adjust
doc knee on table, pt ankle on leg, knifeedge on thumb to adjust

INTERPHALANGEAL GLIDE
medial and lateral
superior and inferior
assess joints with appropriate hold (sides for med-lat, top/bot for inf/sup)
one direction at a time
avoid varus and valgus stress

TAPING
next week she'll show us how to tape for ankle sprain, plantar fasciitis, and one other thing, and also edema

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