Looking down the middle of a road with cars pared on each side. The sky is blue with some white puff clouds.

Beautiful Vancouver, down in Kits.

This past weekend, I was lucky enough to help Christine teach the Level 2 Lower course in Vancouver.  We were not alone though, we had Tricia as a teaching assistant.  This was going to be a tough weekend of learning for the physiotherapists on the course as we were going to talk about the foot.  Yikes!

Most people think that the foot does not have much to it.  Well let me tell you that there are 26 bones in the foot which = 33 joints.  We were going to not only touch on the bones, but also the muscles (and how to test them) and ligaments.  

We started off this weekend with doing the last half of the case study.  The case study was a good one, made by Christine.  The class was broken up into 3 groups and we discussed the objective findings for this ‘client’.  There was a lot of good discussion in the group I was leading.  We talked about why we do a case study in that format.  

Years ago, when I was going through these courses, we did a test at the end of each course.  Much like this course.  There were two components to these exams, a written exam and a case study.  We never did a case study during the courses.  It was similar for the Level 2 Upper/Lower and Level 3 Upper/Lower exams.  You would get a pass or fail grade on the exam.  That would be your feedback, pass or fail.  Then if you chose to go on further with you education you would have to write you Intermediate exam, which comprised of a written and a case study.  Again, your feedback would be only ‘pass or fail’.  I know a number of really good physiotherapists that tried the exam and failed the case study portion 2-3 times!!  That was because they did not know what they were doing wrong.  There was no feedback.  After a few years, the orthopaedic division decided to add a case study done in class.  The younger physiotherapists seemed interested listening to my tale of times past.  

The physiotherapists in the class working on each other's ankle joint.

Friday night working away

I was up and presenting.  My goal this weekend was teach the inferior tibiofibular joint and the talocrural joint.  We started with simply reviewing the anatomy of the area.  Going over the bones and muscles and ligaments in the areas that we were going to getting our hands into.  Did you know that the ankle joint is made up of three bones, the tibia, fibula and talus?  We will talk about that in my next blog post.  

Then we did the surface anatomy.  The surface anatomy is where you put your anatomy knowledge to practical use.  It is one thing to look at anatomy in a book and a totally different thing to find and move all the bones, muscles and ligaments on your partner’s foot/ankle.  We always go through everything twice.  Why you ask?  So one partner is the model, the other is the therapist and the second time around we switch.  

After a quick break, we dove right into the biomechanics of the ankle joint.  How the bones move, or at least how we think (and feel) they move. The inferior tibiofibular joint is a syndesmosis joint, that means there is no joint fluid there and it is held together with fibrous components.  While the talocrural joint does have the synovial fluid in the joint to lubricate and glide easily.  

We chatted about how the different joints were classified and how they move, their osteokinematics (how the bones move without caring about the joint surfaces) and their arthrokinematics (how the joints glide without caring what the bones are doing).  

Physiotherapists assessing their partners ankle range of motion and strength.

The physiotherapists assessing each other.

Once that was mastered we went into actually assessing the ankle joint.  Looking at how clients move, which is the specialty of Physiotherapy.  Squats, standing on one leg, single leg squats…  All of these movements can tells us something about how the client is moving.  But of course, it should relate to why we are seeing the client in the first place.  We ended off the night with going over some different treatment techniques for the ankle.  Everybody seemed to be in a good spot when we ended Friday evening.

Saturday morning, Christine was up and did a lecture on manipulation.  A manipulation is defined as a high velocity low amplitude thrust.  Chiropractors call these adjustments.  This technique can be used all over the body to loosen up stiff joints.  When most people think of ‘adjustment’ they think of their spine.  We were going to teach these physiotherapists how to do that to the ankle joint but we needed to cover the theory behind it first.  

I was back on the podium, so to speak.  We covered three ankle manipulations; distraction, posterior thrust and a loose body manipulation.  The loose body manipulation is used when something gets into the joint, sometimes a bone fragment from a fracture.  I think I have only used it once in my 13, close to 14, year career.  

Onwards and upwards onto ankle pathology.  We discussed ankle sprains, Achilles tendinopathy, osteochondritis dessicans, shins splints and high ankle sprains.  Lots of knowledge being poured into the minds of the learners.  Then it was time for the morning coffee break.  Whoa!

The physiotherapists are sitting in their desks and listening to Christine lecture on the foot.

Learning the foot from Christine.

Christine took the reins and started on the rest of the foot.  We started off talking about the functional foot and different assessment techniques for the students to start to try to use on their clients.  A few of them asked where does this fit into their assessment of the foot.  These techniques were about trying to watch the foot move through motion and how the motions occur and if compensations occur.

Then we started into the other joints of the foot.  There are a lot of different bones in the foot, as I previously mentioned.  I thought Christine did a great job of breaking it down.  It is difficult as there are so many different joints and different directions the joints could glide for different movements.  I think I was quizzed at every pair of students that I stopped in to chat with.  “Which way does the posterior subtalar joint glide for supination”?  I think that was their favorite question.  🙂  That is considered the hind foot/heel.

There is a young female physiotherapist assessing the right ankle of a male colleague.

Now which movement goes with supination?

Then the midfoot.  The navicular.  The cuboid.  The cuneiforms.  How they all join together and work in harmony.  What are the joint shapes + which ligaments hold them together + how do they move = mind blown!  Yuppers, everybody left the second day with their brains full (if not overflowing) with new knowledge.  People sometimes ask if these Level 2 courses are worth it.  I always say yes, they are expensive but you gain so much knowledge.  Not only theoretical knowledge but real practical knowledge that when you get back to the clinic on Monday,  you can start to use your new found smarts.  

Sunday morning started off with Christine again.  She did a quick review and then onto the forefoot.  The metatarsals and the phalanges.  Did you know that you have phalanges in your hands and feet?  They are the bones that make up your toes and fingers.  

We chatted about how the metatarsals and phalanges move.  Looking at the AROM (active range of motion), testing the PROM (passive range of motion) and the different joint glides.  We then got into stability testing of this area of the foot.  It seemed like another brain full of material given to the students before the morning coffee break.  

A physiotherapist working on the right subtalar joint, medial side. The physiotherapist is applying a lateral glide to the subtalar joint.

Working on the subtalar joint.

After we got back to the classroom, we spoke about foot pathologies.  Metatarsalgia, pain on the bottom ball of the foot area, Morton’s neuroma and the BIG one, plantar fasciitis!  If you want to learn more about plantar fasciitis, you can read my previous blog post.  

Getting into treatment of the different areas of the foot.  How to mobilize the different joints and we even did a couple more manipulations, metatarsal phalangeal traction and a flick technique for the medial subtalar joint.  For the most part, the class really did well on these manipulations.  

This weekend was coming fast to a close after lunch on Sunday.  We  discussed exercises for some different foot pathologies and ways to strengthen the feet.  In my opinion, it is really rare for strengthening to make a client worse off.  Getting muscles working, firing, strengthening are all really good things.  

We ended off the afternoon with a short case study review to try and integrate a lot of what was learned this past weekend.  

I will be heading back to Vancouver in a few weeks time to help out with the knee.  Stay tuned…

If you have any comments or questions, please leave one below and we will get back to you. 🙂

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