<p>Last week we started to take a look at the feet and ankles, and if you haven't read that one, I suggest you start there, just click here to go back and read that one.  </p>
<h2><b>What </b><b><i>Can</i></b><b> We Do In Terms Of Exercise?</b>  </h2>
<p><span style="font-weight: 400;">So this is the really cool part, we are the exercise experts, right? </span></p>
<p><span style="font-weight: 400;">So some non-contraindicated simple lower limb/foot exercises could be a real help AND would mean we stand out and have an increased confidence when working with clients requiring foot attention… not THAT kind….c’mon stay with me….I mean pronation and supination exercises.</span>  </p>
<p><span style="font-weight: 400;">Firstly we need to assess the foot to check if it is loose at the MTJ and/or if they struggle to supinate by applying the Jacks Test.</span>   <span style="font-weight: 400;">There are 2 simple tests that can contribute to…</span>  </p>
<ol>
<li style="font-weight: 400;"><span style="font-weight: 400;">Our understanding of the foot function of our clients</span></li>
<li style="font-weight: 400;"><span style="font-weight: 400;">Our confidence in then prescribing exercises </span></li>
<li style="font-weight: 400;"><span style="font-weight: 400;">Our ability to communicate more effectively and confidently with foot specialists </span></li>
</ol>
<p>&nbsp;</p>
<h2><b>SubTalar Motion Test (Testing for Mobility of the STJ)</b></h2>
<p>[embed]https://youtu.be/19cTcHQp5hQ[/embed]</p>
<p>&nbsp;</p>
<ol>
<li style="font-weight: 400;"><span style="font-weight: 400;">Have your client lie prone (face down) on a massage table, bed or bench and with their ankles free of the edge of the surface. Encourage them to relax.</span></li>
<li style="font-weight: 400;"><span style="font-weight: 400;">Now facing their feet, place your right hand on top of the left calf to keep the leg still. </span></li>
<li style="font-weight: 400;"><span style="font-weight: 400;">Using your left thumb and forefinger to take hold of the ball of the 5th met (little toe).</span></li>
<li style="font-weight: 400;"><span style="font-weight: 400;">Push the 5th met towards the centre of the knee, into dorsi flexion, the ‘wiggle’ the foot from side to side to get a sense of its laxity. </span></li>
</ol>
<ul>
<li style="font-weight: 400;"><span style="font-weight: 400;">If it feels loose this foot/ankle has a propensity to pronate</span></li>
<li style="font-weight: 400;"><span style="font-weight: 400;">If it feels very stiff it might have a propensity to supination</span></li>
<li style="font-weight: 400;"><span style="font-weight: 400;">Somewhere in the middle is more or less neutral</span></li>
</ul>
<p>  <img class="aligncenter size-large wp-image-15788" src="https://biomechanicseducation.com/wp-content/uploads/2019/08/Subtalar-Motion-Test-1-1024x768.jpg" alt="" width="1024" height="768" />  </p>
<p>&nbsp;</p>
<p><span style="font-weight: 400;">This test can feel subjective until you have felt a few or been taught by someone more experienced at this particular test. </span> <span style="font-weight: 400;">It is probably best to start by comparing the left to the right to see if one feels looser or stiffer, then decide which feels more so to start your analysis and make a decision.</span>  </p>
<h3><b>If It Feels Loose… What Do You Do?</b></h3>
<p><strong>Result = Loose</strong></p>
<p><span style="font-weight: 400;">I</span><span style="font-weight: 400;">f the foot feels loose (that it has a propensity to pronate) then there is a chance it struggles with supination. So we might prescribe supination exercises.</span> <span style="font-weight: 400;">Using a resistance band, place it around the inside of your client's right foot (for example) also the inside of their big toe, then offer resistance from their right side.</span> <span style="font-weight: 400;">Now ask them to pull/turn the foot inwards, adducting it, inverting the heel and if possible adding some plantar flexion - remember that triplanar motion for pronation?</span></p>
<p><span style="font-weight: 400;">Reps and sets are just common sense and client dependant - 2 x 8 up to 3 x 15 for example. </span></p>
<p><span style="font-weight: 400;">Repeat on both feet if they are both loose of course.</span>  </p>
<h3><b>If The Joint Is Stiff - What Can You Do?</b></h3>
<p><strong>Result = Stiff</strong></p>
<p><span style="font-weight: 400;">However, if the foot feels stiff then we might consider prescribing pronation exercises along with mobility work.</span> <span style="font-weight: 400;">This time we would take the resistance band around the outside of the right foot for example, close to the outside of the toes, then offer resistance from the left side of the client. </span> <span style="font-weight: 400;">Now ask them to pull/turn the foot outwards, abducting it, everting the heel and if possible dorsi flexing to take into account the triplanar action of supination.</span> <span style="font-weight: 400;">Mobility for the ankle might include what you would expect, calf stretching, joint mobilising etc.</span> <span style="font-weight: 400;">Reps and sets as above.</span>  </p>
<p>&nbsp;</p>
<p><span style="font-weight: 400;">Now let’s have a look at the second screen we can do...</span>  </p>
<h3><b>Jack’s Test (To Understand Capacity to Re-Supinate)</b></h3>
<p><i><span style="font-weight: 400;">This is my favourite of all the tests I do because it shows very simply the nature of our body as an integrated system. Watch whats happens to the shoulders and upper body when you do it on someone who scores a 2-3.</span></i></p>
<p>&nbsp;</p>
<p>[embed]https://youtu.be/iW7uAzKJmgs[/embed]</p>
<p>&nbsp;</p>
<ol>
<li style="font-weight: 400;"><span style="font-weight: 400;">Have your clients stand upright and relaxed, looking straight ahead and ask them to take a couple of steps to allow their feet to land where they want to.</span></li>
<li style="font-weight: 400;"><span style="font-weight: 400;">While kneeling down in front of them, explain “</span><i><span style="font-weight: 400;">try not to help nor resist against this movement and keep looking straight ahead, not down, arms by your sides”</span></i></li>
<li style="font-weight: 400;"><span style="font-weight: 400;">Now place open hands onto the floor in front of their right foot, place both of your thumbs underneath their big toe, with the rest of your hands, fingers spread out on the floor. </span></li>
<li style="font-weight: 400;"><span style="font-weight: 400;">Push the big toe upwards about 45 degrees towards the middle shin with as much effort as is required to see how ‘heavy’ this feels. Watch for if the foot arches and assess how easy of difficult it is to do this.</span></li>
</ol>
<p><img class="aligncenter wp-image-15787 size-large" src="https://biomechanicseducation.com/wp-content/uploads/2019/08/Jacks-test-1-1024x768.jpg" alt="" width="1024" height="768" /> <span style="font-weight: 400;">This movement should functionally activate the </span><b>Windlass Mechanism</b><span style="font-weight: 400;">.</span> <span style="font-weight: 400;">The Windlass Mechanism is when the plantar fascia that is ‘wrapped’ around the head of the Hallux (big toe) pulls the foot into that arched, supinated, rigid foot for Toe Off. (Imagine walking over the foot, the point at which your big toe extends)</span> <span style="font-weight: 400;">However, when we score the effort it takes to do this we can get an impression of its influence on the gait cycle.</span>  </p>
<p><span style="font-weight: 400;">We have a scoring like this :</span>  </p>
<p><span style="font-weight: 400;">0-    Very Low Resistance</span></p>
<p><span style="font-weight: 400;">1 -</span> <span style="font-weight: 400;">Low Resistance</span></p>
<p><span style="font-weight: 400;">2 - </span> <span style="font-weight: 400;">Moderate Resistance</span></p>
<p><span style="font-weight: 400;">3 -</span> <span style="font-weight: 400;">High Resistance</span></p>
<p><span style="font-weight: 400;">4 - </span> <span style="font-weight: 400;">Very High Resistance</span></p>
<p><span style="font-weight: 400;">5 - </span> <span style="font-weight: 400;">Impossible to Move</span>  </p>
<p>&nbsp;</p>
<p><span style="font-weight: 400;">You are again subjectively (initially at least) measuring the amount of effort it takes to push the toe into extension. This ‘action’ is part of Toe Off during the gait cycle.</span> <span style="font-weight: 400;">If the toe lifts so easily, it almost flies off the floor with virtually no effort, that is a 0-1 score. </span> <span style="font-weight: 400;">If the toe is so heavy that no movement or arch happens, even when you apply a huge effort this is a 5.</span> <span style="font-weight: 400;">If it is really heavy but there is a small arching this is a 4.</span> <span style="font-weight: 400;">The effort should score around a 2-3. This indicates there is some rigidity but its not so easy that it becomes unstable.</span>  </p>
<p>&nbsp;</p>
<h3><b>Exercise Prescription After The Screen</b></h3>
<p>&nbsp;</p>
<h4><strong>Result = 4-5</strong></h4>
<p><span style="font-weight: 400;">If the score is heavy and 4-5 then this indicates the foot struggles with supination. So we might prescribe supination exercises.</span> <span style="font-weight: 400;">Using a resistance band, place it around the inside of your clients right foot (for example) also the inside of their big toe, then offer resistance from their right side.</span> <span style="font-weight: 400;">Now ask them to pull/turn the foot inwards, adducting it, inverting the heel and if possible adding some plantar flexion.</span> <span style="font-weight: 400;">Same as the previous test/exercise.</span>  </p>
<h4><strong>Result = 0-2</strong></h4>
<p><span style="font-weight: 400;">However, if the foot moves too easily into supination then we might consider prescribing pronation exercises.</span></p>
<p><span style="font-weight: 400;">This time we would take the resistance band around the outside of the right foot for example, close to the outside of the toes, then offer resistance from the left side of the client. </span></p>
<p><span style="font-weight: 400;">Now ask them to pull/turn the foot outwards, abducting it, everting the heel and if possible dorsi flexing.</span></p>
<p><span style="font-weight: 400;">Same as the previous test/exercise.</span></p>
<p>&nbsp;</p>
<h3><b>Summary </b></h3>
<p><span style="font-weight: 400;">Pronation and supination exercises (of which there are several by they way) as you can imagine, are not likely to be contraindicated on the kind of clients we are generally insured to work with.</span> <span style="font-weight: 400;">The really cool thing here is that we can use really simply to apply tests and exercises like these that offer us additional insights for improving our clients capacity for movement. </span> <span style="font-weight: 400;">We should also gain some degree of confidence to approach foot specialists and we are also in a great position to prepare the lower body system/s for pre-orthotic conditioning.</span> <span style="font-weight: 400;">Try them out and please let me know how you get on….</span>    </p>
<hr />
<h2> </h2>
<h2>Would You Like To Be Able To Reduce Your Clients Risk Of Injury &amp; Help Them Get Even Better Results?</h2>
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