2.7.2. Physical Exam Foot and Ankle

Question 6

How many major bones of the foot?

Answer 6

26

Question 7

Two arches of the foot that act as springs for energy absorption/dissipation. What are they and where are they?

Answer 7

Longitudinal arch - Runs from the heel to the metatarsal bones

Transverse arch - Medial to lateral across the foot

Question 8

Elastic properties and tensile strength in the arches is maintained by elastic and static elements.

What are they?

Answer 8

Dynamic - Muscles

Static - Ligaments and fascial components, particularly the plantar fascia which creates the solid platform needed needed for ambulation and propulsion

Question 9

What is plantar fasciitis and how common is it?

Answer 9

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

Question 10

Describe the bone anatomy of the ankle and what a “sprain” is

Answer 10

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.

Question 11

Describe the most common ligament associated with a sprain and how it is affected

Answer 11

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.

Question 12

Besides the ATFL, what are the other lateral ligaments?

Answer 12

Other lateral ligaments are the Calcaneo-fibular ligament and the posterior Talo-fibular ligament (CFL and PTFL)

Question 13

What ligament is locatd medially?

Answer 13

Medial ligament is called the deltoid ligament, a big, broad, multilayered ligament. Hard to tear this guy

Question 14

Why does the ATFL tear first?

Answer 14

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

Question 15

What do we ask for the history for the ankle exam? Anything new?

Answer 15

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!

Question 16

What do we inspect for the ankle/foot exam?

Answer 16

Gait

Arches

Swelling vs. Edema

Ecchymosis

Atrophy

Question 17

What arch types do we have?

Answer 17

Arches - Normal, Pes Planus, Pes Cavus, too many toes vs. Normal heel motion

Question 18

For the foot only, what do we palpate?

Answer 18

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

Question 19

What do we palpate for the ankle exam?

Answer 19

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

Question 20

ROM for the foot and ankle exams

Answer 20

Plantar flexion - 40 - 50 degrees

Dorsiflexion - 15 - 20 degrees

Question 21

For the strength, nerovascular exam what are we testing?

Answer 21

Strength - Plantar flexion, Dorsiflexion, Eversion, Inversion

Sensation - Dermatomes

Pulses - Dorsalis Pedis and Posterior Tibial

Question 22

What are the special tests for the foot and ankle?

Answer 22

Thomason Squeeze

Ankle Anterior Drawer

Aleternate Ankle Drawer

Talar Tilt/Varus Stress Test - Tests CFL Integrity

Question 23

What does the Thompson Squeeze test evaluate and how do we do it?

Answer 23

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

Question 24

What does the Ankle Anterior Drawer Test evaluate and how do we do it?

Answer 24

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.

Question 25

How do we do the alternate drawer and what does it do for us?

Answer 25

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.

Question 26

What does the Talar Tilt/Varus Stress Test evaluate and how do we do it?

Answer 26

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.