2.7.2. Physical Exam Foot and Ankle Flashcards
How many major bones of the foot?
26
Two arches of the foot that act as springs for energy absorption/dissipation. What are they and where are they?
Longitudinal arch - Runs from the heel to the metatarsal bones
Transverse arch - Medial to lateral across the foot
Elastic properties and tensile strength in the arches is maintained by elastic and static elements.
What are they?
Dynamic - Muscles
Static - Ligaments and fascial components, particularly the plantar fascia which creates the solid platform needed needed for ambulation and propulsion
What is plantar fasciitis and how common is it?
Plantar fasciitis - Degeneration of the plantar fascia where it attaches to the calcaneus (heel bone) and is one of the most common overuse injuries in the foot
Describe the bone anatomy of the ankle and what a “sprain” is
Ankle serves as a hinge joint with the tibia and fibula as forks surrounding it (called the plafond) with the dome of the talus fitting in this fork, allowing it to rock back and forth but not side to side, which would indicate a sprain.
Describe the most common ligament associated with a sprain and how it is affected
Most ankle sprains are lateral and involve the Anterior-Talo-Fibular Ligament (ATFL). This ligament, along with the other lateral ligaments, are thin, wispy ligaments that tear easily.
Besides the ATFL, what are the other lateral ligaments?
Other lateral ligaments are the Calcaneo-fibular ligament and the posterior Talo-fibular ligament (CFL and PTFL)
What ligament is locatd medially?
Medial ligament is called the deltoid ligament, a big, broad, multilayered ligament. Hard to tear this guy
Why does the ATFL tear first?
If 90 degrees or foot flat on the ground, the CFL should tear first, however, most tears occur when you are on your toes.
When this happens, the small part of the talus is between the fork of the tibia and fibula, making the ankle unstable, unlike with planted foot at 90, where the larger part of the talus is between the fork which is very stable.
Being on your toes thus puts the ATFL in its most vulnerable state
What do we ask for the history for the ankle exam? Anything new?
Mechanism of injury, acute or gradual onset of pain, pop or tearing sensation with injury, location of the pain, swelling, able to bear weight after injury, can you bear weight now, makes pain better or worse, what have you tried for it
Same as usual except the portion about bearing weight then vs. now, which is a new specified question, although this makes sense to ask for some of the other exams as well!
What do we inspect for the ankle/foot exam?
Gait
Arches
Swelling vs. Edema
Ecchymosis
Atrophy
What arch types do we have?
Arches - Normal, Pes Planus, Pes Cavus, too many toes vs. Normal heel motion
For the foot only, what do we palpate?
Metatarsal shafts and bases - 5th metatarsal base and 2 - 4 metatarsal bases
Anterior Navicular
Medial Tubercle of the Calcaneus - Plantar fascia
Achilles - Insertion on calcaneus and the mid-substance
What do we palpate for the ankle exam?
Lateral: Ligaments - ATFL, CFL, PTFL ; Lateral malleolus - Infero Posterior Aspect
Medial: Ligaments - Deltoid ; Medial Malleolus - Infero posterior aspect
Anterior Syndesmoses - Between the tibia and fibula
ROM for the foot and ankle exams
Plantar flexion - 40 - 50 degrees
Dorsiflexion - 15 - 20 degrees
For the strength, nerovascular exam what are we testing?
Strength - Plantar flexion, Dorsiflexion, Eversion, Inversion
Sensation - Dermatomes
Pulses - Dorsalis Pedis and Posterior Tibial
What are the special tests for the foot and ankle?
Thomason Squeeze
Ankle Anterior Drawer
Aleternate Ankle Drawer
Talar Tilt/Varus Stress Test - Tests CFL Integrity
What does the Thompson Squeeze test evaluate and how do we do it?
Thompson Squeeze test - Testing Achilles Rupture
Have patient up on their knees on the examiner table. Squeeze calf of injured leg up high, Do the same for the uninjured leg. If Achilles ruptured, there will be reduced (if Plantaris is still intact) or completely absent plantar flexion
What does the Ankle Anterior Drawer Test evaluate and how do we do it?
Ankle Anterior Drawer Test - Tests ATFL integrity
NOTE - Not usually done in acute setting as pain invalidates the test
Patient sits with knee flexed at 90. Stabilize tibia distally with one hand and pulls calcaneus anteriorly wit hthe other.Ankle should come forward a bit and stop. Laxity or difference between legs is a positive test of ATFL injury.
How do we do the alternate drawer and what does it do for us?
Patient sits on exam table with knee at 90 and foot planted just like with the drawer test for the knee. Examiner sits on foot as well just like with the knee except you push on the distal tibia posteriorly on the calcaneus. As before, laxity or difference is what you are looking for, not pain.
What does the Talar Tilt/Varus Stress Test evaluate and how do we do it?
Talar Tilt/Varus Stress Test - Tests CFL Integrity
Sit patient with knees dangling at 90. Stabilize distal tibia with one hand, all of this the same as the classic anterior ankle drawer. With other hand, invert the foot until CFL stops it. Laxity or difference between the ankles indicates a positive test.
