Clinical Summary of Lower Extremity Protocols
1. Cavus Only (usually with lateral foot overload)
a. STJ eversion
b. Type 3 FootMIND inserts
c. If spraining often and recently: Bauerfind Malleoloc Ankle stirrup
d. Intrinsic strengthening
a. See 2006 “Pes Planus Structured PT Protocol” paper by Alvarez and Saltzmann
b. Gastroc stretching
i. First priority
c. When close to neutral ADF can start extrinsic “arch maintenance” strengthening
i. Tibialis posterior
1. Inversion against resistance bands
2. See other exercises is Alvarez/Saltzmann article
ii. Peroneus Longus
1. Isometric 1st Metatarsal head depression exercises (ask me if this is not clear) These can be done while sitting or standing
2. If you can think of another exercise that isolates this muscle, let me know, since I think this is an underappreciated muscle that is truly the central and primary “arch elevating” muscle/tendon
3. Gastroc (Isolated)
a. No wall stretch (runner’s stretch) at all! This stretch does not work, since the foot just compensates by everting. Please never waste any time on this stretch with any of my patients.
b. Best: Seatted belt/towel/strap stretching
i. Have some kind of shoe on for a “platform” to pull on. That way they don’t just “dorsiflex” through the midfoot
ii. Just proximal to “ball of foot” if normal or subtle cavus foot
iii. Around the arch (more proximal) if pes planus since they will try to “cheat” out into eversion/abduction and having the force directed more proximally minimizes this
c. Stair stretch
i. Place rolled up towel under medial forefoot to prevent compensatory foot eversion on this stretch.
ii. Basically, the foot will try to “cheat” into eversion with all of these calf stretches. Especially with pes planus, and not so much with pes cavus (since the foot has a hard time everting with cavus).
d. Squat while keeping heels on the ground
i. This addresses ankle joint mobility and soleus/Achilles tightness, but these are almost always associated with gastroc equinus imbalance. It cannot stretch the gastroc, since the gastroc can only be stretched with the knee in full extension (as the gastroc crosses the knee joint). ii. http://youtu.be/46EDDftgFZI
4. Intrinsic strengthening
a. To address distal/dorsal fat-pad migration
b. Towel grab/scrunch
i. 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 me if this is not clear.
c. Marble transfer
i. buy bag of 50 and go from ground to bowl above, then from above to bowl on ground
i. ABducting and ADducting the toes, any time, any place, any activity.
5. Peroneus longus
a. Isometric pressure of 1st Met head on ground
b. Feel for feedback on lateral proximal leg using ipsilateral hand.
6. Tibialis posterior
a. Theraband exercises
b. See 2006 “Pes Planus Structured PT Protocol” paper by Alvarez and Saltzmann
i. They had a special device made for this, but I think the same motion can be re-created using Therabands or other things PTs already have access to
7. Natural Running
a. See “Running Injuries”