ankle and foot evaluation Flashcards
week 2
When developing a hypthesis list consider:
- location of pain
- MOI
- age
- prevelance of the condition
What is capsular pattern
limitation of movement in a joint specific ratio
- usually present with arthritis, or following prolonged immobilization
What is non capsular pattern
limitation of a joint in any pattern other than a capsular one
- may indicate the presence of either a derangement, a restriction of one part of the joint capsule, or an extra-articular lesion, that obstructs joint motion
distal tibiofibular joint - capsular pattern
pain with full DF
talocrural joint limitation: capsular pattern
PF > DF
subtalar joint limitation: capsular pattern
supination > pronation; inversion > eversion
limitation of varus ROM
midtarsal joints limitation: capsular pattern
DF > PF > adduction
1st metatarsophalangeal (MTP) joint limitation: capsular pattern
extension > flexion
2-5 MTP joints: capsular pattern
none (variable)
interphalangeal joints: capsular pattern
flexion> extension
arthrokinematics
distal tibiofibular joint:
dorsiflexion
increased distance between malleoli
fibula glides posteriorly and superiorly on tibia
arthrokinematics
distal tibiofibular joint:
plantarflexion
decreased distance between malleoli
fibula glides anteriorly and inferiorly on tibia
arthrokinematics
metatarsophalangeal joint:
extension
OKC: concave on convex
dorsal glide and dorsal roll
dorsal = posterior
arthrokinematics
metatarsophalangeal joints
flexion
OKC: concave on convex
plantar glide and plantar roll
plantar = anterior roll and glide
ottawa foot/ankle rules
ankle x ray series is required only if there is pain in malleolar zone and any of these findings
- bone tenderness at posterior edge or tip of lateral malleolus
- bone tenderness at posterior edge or tip of meidal malleolus
- inability to bearwieght both immediately and in emergency department
foot x ray series only required if pain in midfoot zone and any of these findings:
- bone tenderness at base of 5th metatarsal
- bone tenderness at navicular
- in ability to bear weight both immediately and at doctors
eversion ankle spain/medial ankle sprain is a disruption of what ligament?
deltoid
eversion ankle sprain/medial ankle sprain
subjective exam:
acute injury:
ICF category?
subjective exam:
- medial ankle pain
- MOI: ankle eversion
acute injury:
- swelling
- ecchymosis
icf category: movement coordination
eversion ankle sprain
objective exam:
special tests:
OE:
- limited ankle ROM, especially eversion
- limited ankle strength especially inversion
- TTP to deltoid ligamnet
special tests:
- talar tilt: medial: SN/SP - not reported
- strucutre taht stops eversion from occuring is gone so limited eversion due to muscle gaurding/protection
with eversion ankle sprain there could be possible secondary injury to what other tissues?
- nerve injury: tibial
- syndesmosis injury
- fracuture/avulsion fracture
syndesmosis injury due to high pressure from talus
tendinopathy of medial ankle can include structures such as?
- tibialis posterior
- flexor digitorum longus
- flexor hallucis longus
posterior tibialis tendon dysfunction
subjective exam:
-Gradual onset
- May/may not visible swelling
- Pain w/ weight bearing activities (inversion)
- Condition progresses- onset of pain earlier
- typically pt will have had an increase in activity - pain is usually load related
posterior tibialis tendon dysfunction
objective exam:
- SL calf raise
- inversion strength tests
- subtalar joint mobility assessment
- midfoot mobility assessment
posterior ribialis tendon dysfunction
some ‘why’s’ that need to be assessed?
- talocrural joint restriction
- great toe joint restriction
- decreased strength of tibialis anterior, gastroc- soleus complex and or fibularis longus/brevis
more force through midfoot
posterior tibialis tendon dysfunction
what are the stages of progression
early stage
middle stage
late stage
what are you looking for with early stage posterior tibialis tendon dysfunction
- localized pain
- able to perofrm SL calf raise
- strong but painful inversion strength tests (and Plantarflexion)
What to look for in middle stage poterior tibialis tendon dysfunction
- pain along tendon
- rear foot valugs; forefoot abduction
- weak SL calf raise
- increased mobility of subtalar joint (flexible)
- weak inversion strength tests
what to look for in late stage posterior tibialis tendon dysfunction
- lateral ankle pain
- severe arch collapse
- unable to perform SL calf raise
- loss of subtalar mobility (fixed)
gastroc/soleus PF + supination –> can’t do this
load greater than capacity
syndesmotic injury (high ankle sprain)
subjective exam: MOI?
MOI: external rotation of the foot when dorsiflexed and pronated (head of talus pushes laterally on fibula)
- high pain levels
- difficulty weight bearing
- may report feelings of instability
- less swelling than other ankle sprains
remember fibula is non weightbearing so you can still walk = more pain
syndesmotic injury (high ankle sprain)
objective exam
- limited ankle palnatar flexion ROM
- pain with ankle ER ROM
- pain with force ddorsiflexion ROM (spreads apart tib, fib)
- inabiltyto perofrm a sinlge leg hop
- palpation SN: 92% (not painful = good confidence not a high ankle sprain)
Syndesmotic injury (high ankle sprain)
special tests
dorsiflexion-external rotation test (kleiger test) SN: 71%
squeeze test SP: 99-94%
sibular translation test: neg test: SN 82% SP 88%
the more proximal you go on a squeeze test with reproduction of pain symptoms the more concerning the sprain is (pain produced at distal tib/fib)
what are some secondary injuries to a syndesmotic injury? what is the prognosis of a syndesmotic injury?
determine if secondarily a fracture occurred especially to fibula, deltoid ligament injury
prognosis: worse than other ankle sprains
grade I: 4-8 weeks
grade II: 2+ months
grade II: 3-6 mohts (likely srugical intervetion)
inversion ankle sprain (lateral ankle sprain)
indications during examination:
- sudden onset with ankle inversion injury
- negative ottawa ankle rules
- positive special test
- TTP to ATFL
inversion ankle sprain (lateral ankle sprain)
due to possible secondary injury, need to determine if the following have also occurred:
- fracture: distal fibula, distal tibia, 5th metatarsal, navicular
- bone contusions
- epiphyseal plate injuries
- cuboid subluxation (sits plantarly and feels like walking on pebble)
- nerve injury (superficial/deep fibular N.)
what are some ‘why’s’ that need to be assessed for inversion ankle sprains (lateral ankle sprain)
talocrural joint restriction
hip abduction/external rotation strength
chronic ankle instability can come down to what factors?
- functional (sensorimotor)
- mechanical
- combo
motor control takes over for mechanical instability
chronic ankle instability:
indications during examination
- may or may not have pain
- report of instability or giving way
- history of at leat one significant ankle sprain
- episode of subsequent sprain or perception of ankle instability
- decreased performance on functional tests
- pt reported outcome measures (PROMS or PROs)
and identification of functional ankle instabilty score of 11+
or a cumberland ankle instability tool score of 25 or less
could lead us down to thinking?
possible chronic ankle instability
fibular tendons
predisposed to:
- tendinopahty
- tear
- subluxation
fibularis subluxation
indications during exam
” snapping” reported w/ ankle movements (e.g. circumduction) ankle DF and eversion
- may or may not have swelling
- history of traumatic nakle injury (like ankle inversion sprain)
- positive fibularis subluxation test (SN/SP not reported)
prognosis is poor
ankle/foot
impingement
indications:
- pain with activites that cause repeated compression or distraction forces to soft tissue surrounding talocrural joint
superficial ankle pain
classification of ankle impingement
Grade 0: normal joint space; possible subchondral sclerosis
Grade I: normal joint space; presence of bone spurs
Grade II: joint space narrowing
Grade III: total loss of joint space
ankle/foot
anterior impingement CPR:
6 things
- anterolateral joint tenderness
- anterolateral joint swelling
- pain w/ forced DF
- pain w/ SL squat
- pain w activity
- absense of ankle instability (the feel structuraly sound, absense of hypermobility)
if 5 out of 6 of these then (+) for anterior ankle impingment
SN: 94% (<5), SP: 75% (5 or 6)
possible hard end feel
osteoarthritis subjective exam
no MOI - gradual onset
morning pain stiffness that decreases after moving around for 30-60 minutes (if they sit fora while then will be stiff again)
deep joint pain
more often secondary due to previous injury
osteoathritis
objective exam:
- decreased ROM (capsular pattern)
- TTPalong joint line
posterior ankle impingment
indications:
- pain with plantarflexion activities
- pain w/weightbearing
- superficial ankle pain
- positive heel thrust test
due to possible secondary injury need to determine if FHL injury occurred
What are some differences between anterior/posterior ankle impingemet, difference between achilles tendinopahty and this?
os trigonum syndrome
posterior ankle impingment from accessory bone in posterior ankle. the accessory ossicle w/softtissue becomes wedged between the tibia, talus and calcaneus
- often symptoms are bilateral
top of a calf raise could be painful
achilles tendinopathy
subjective exam:
no MOI - gradual onset
- may or may not have visible sweeling (inflammatory type presentation)
- pain w/ first few steps in the morning ( if not reported consider ruling out SN 89%)
- as condition progresses, onset of pain occurs earlier in the activity (same as tibialis posterio tendinopathy)
how do the nuances of tendinopathies presesnt similarly? what are the main differences that set them apart? - really challening to memorize each individually. think big picture what would a tendinopahty present like? then what could lead you down the path to pin point what kind? for example how do you know its achillies instead of posterior tibialis?
think girl think!
achilles tendinopathy
objective exam:
- pain with palpation
positive test: SP 81%
test cluster: palpation, royal london hospital test, arc sign
What are some whys that need to be assessed with achilles tendinopathy
- rearfoot alignment (doesnt take horizontal force very well)
- gastroc-soleus, tibialis posterior, FDL/FHL strength
What are the 4 stages of achilles tendinopathy
- no pain during activity; soreness in AM; minimal crepitus
- pain during activity; no loss of function; TTP; grepitus present
- pain limitingfunction; soreness through the day; crepitus
- unable to function due to pain; soreness throughout day; crepitus
achilles rupture - most frequently rupture tendon
risk factors
- long term corticosteroid use (auto immune, asthma, other medical reasons)
- hypercholesterolemia
- gout
- RA, lupus
- long term dialysis (parathyroidism weakens tendons due to altered calcium and phosphorus lvls in the body associated w/ kidney disease)
- renal transplant
achilles rupture
subjective examination
- acute injury
- feelings of being kicked in posterior ankle
- felt a pop
- difficulty weight bearing
achilles rupture
objective exam
- thompson test
- matles test
- palpation of gap (3-6 cm above calcaneal insertion)
