Clinical Summary of Lower Extremity Protocols

Cavus Only (usually with lateral foot overload)
  • STJ eversion
  • Type 3 FootMIND inserts
  • If spraining often and recently: Bauerfind Malleoloc ankle stirrup
  • Intrinsic strengthening
Planus
  • See 2006, “Pes Planus Structured PT Protocol” paper by Alvarez and Saltzmann
  • Gastroc stretching
    • First priority
  • When close to neutral ADF, can start extrinsic “arch maintenance” strengthening
    • Tibialis posterior
      • Inversion against resistance bands
      • See other exercises in Alvarez/Saltzmann article
    • Peroneus Longus
      • Isometric 1st Metatarsal head depression exercises, can be done while sitting or standing
      • Other exercises that isolate this muscle, check with Dr. Hoopes
Gastroc (isolated)
  • No wall stretch (runner’s stretch) at all! This stretch does not work since the foot compensates by everting. Never waste time on this stretch.
  • Best: seated belt/towel/strap stretching
    • Have some kind of shoe on for a platform to pull on. That way they don’t dorsiflex through the midfoot
    • Proximal to ball of the foot if normal or subtle cavus foot
    • Around the arch (proximal) if pes planus since they will try to cheat out into eversion/abduction and having the force directed more proximally minimizes this.
  • Stair stretch
    • Place a rolled towel under medial forefoot to prevent compensatory foot eversion on this stretch.
    • The foot will try to cheat into eversion with all of these calf stretches, especially with pes planus, not as much with pes cavus (the foot has a hard time everting with cavus.)
  • Squat while keeping heels on the ground
    • This addresses ankle joint mobility and soleus/Achilles tightness, but these are almost always associated with gastroc equinus imbalance. It cannot stretch the gastroc, the gastroc can only be stretched with the knee in full extension.
Intrinsic Strengthening
  • To address distal/dorsal fat-pad migration
  • Towel grab/scrunch
    • MUST be done using the pads of the toes while keeping the IP joints in extension and only flexing the MTP joints. If the IP joints flex, then it is only working the extrinsics. This is a key point, contact Dr. Hoopes if this is not clear.
  • Marble transfer
    • Buy a bag of 50 and go from ground to bowel above, then from above to bowl on ground.
  • Isometrics
    • ABducting and Adducting the toes, any time, any place, any activity.
Peroneus longus
  • Isometric pressure of the 1st Met head on ground
  • Feel for feedback on lateral proximal leg using ipsilateral hand.
Tibialis posterior
  • Theraband exercises
  • See 2006 “Pes Planus Structured PT Protocol” paper by Alvarez and Saltzmann
    • They made a special device, but the same motion can be recreated using Therabands or other things PT already have access to
Natural Running

See “Running Injuries”