ankle and foot examination part 2 Flashcards
what are some common sites for foot and ankle fractures?
calcaneous
5th metatarsal (jones fx)
stress fractures of metatarsals (march fx)
distal fibula avulsion fx (traumatic)
fibular stress fracture
what is a common MOI for foot and ankle fractures?
trauma vs repetitive stresses/overuse
what are some symptoms of a fracture in the foot and ankle?
swelling, tenderness, gait change, reproduction of CC by performing activity
what are some special tests for foot and ankle fractures?
ottawa foot and ankle rules
metatarsal compression test
tuning fork
what is the purpose of the ottawa foot and ankle rules?
to determine which patients who have experienced trauma may need radiographs
what are some benefits of the ottawa foot and ankle rules?
this may help to decrease unnecessary exposure to radiation and reduce costs
what are some limits to the ottawa foot and ankle rules?
can only be used in skeletally mature patients and only if within 10 days of traumatic event
according to the ottawa foot and ankle rules what is the criteria for an xray required for the ankle?
upon palpation pain in malleolar region
bone tenderness distal 6cm of post med/lat malleolus
inability to bear weight on limb
according to the ottawa foot and ankle rules what is the criteria for an xray required for the foot?
upon palpation pain in metatarsal region
bone tenderness at base of 5th metatarsal or navicular
inability to bear weight on the limb
what is the metatarsal compression test (Moton’s test)
pos test if pain with metatarsal fracture or neuromas
proactive test
88% sensitive
false positive in patients with metatarsalgia
unclear evidence to support this test
what is the tuning fork test for a fibular fracture?
patient lays supine, stethoscope is placed on fibular head, and a hit tuning fork on the lateral malleolus
pos test if there is a different sound in bilateral comparison
83% sensitive and 80-92% specific
minimal evidence to support this test
what is the MOI for an achilles tendon rupture?
trauma, often when jumping or landing, prolonged steroid of h/o certain antibiotic use
what are some symptoms of an achilles tendon rupture?
“hit” in the back of the ankle, report hearing a loud “pop”
what age and sex is typically affected by an achilles tendon rupture?
typically males >40 years old
what activities commonly cause achilles tendon ruptures?
“weekend warrior” explosive activities
what medications can cause achilles tendon ruptures?
fluoroquinolones (antibiotics), systemic corticosteroids
what can we as PTs look for when looking to determine an achilles tendon rupture?
palpable defect, severe loss of function
what is the thompson test?
pos test if nonresponsive ankle PF during the test
40% sensitivity
unclear evidence to support this test
recommend using concurrent patient history
what should you look for with the bilateral toe raise?
cant see the tendon connected on one side may see slight bulge
are all achilles tendon ruptures surgical?
no
what is the MOI for a DVT?
insidious onset, after recent surgery or immobilization, oral contraceptives
what are some signs and symptoms of a DVT?
calf pain, ankle swelling
antalgic gait
what are some special tests for a DVT?
Homan’s sign
Calf swelling
Well’s criteria for DVT
what is Homans sign?
a + test is popliteal and/or calf pain when squeezed
many presentations lead to false positives
minimal evidence to support this test
how is calf swelling used as a special test for DVT?
+ test if bilateral comparison reveals difference of 15 mm for men or 12 mm for women
90% sensitive, 92% specific
minimal evidence to support this test
what is well’s criteria for a DVT?
asking questions related to recent events
= test is related to score on test
78% sensitive, 98% specific
evidence strongly supports the use of this test
what is the common MOI for musculotendinous injuries?
poor footwear
tight musculature
overuse
muscle imbalance
what are some signs and symptoms for a musculotendinous injury?
pain with active contraction of muscle and passive lengthening of the muscle (STT testing)
+ Biomechanical examination (WBing and NWBing)
How should you inspect a musculotendinous injury when the patient is NWB?
Short sitting or prone
How should you inspect a musculotendinous injury when the patient is NWB short sitting?
Inspect the foot health
View transverse arch: most evident in this position
Measure tibial torsion
What would you inspect a musculotendinous injury when the patient is NWB prone?
Passive hip rotation
Subtalar joint neutral- measurement of forefoot and rear foot valgus/valgus
How would you inspect a musculotendinous injury when the patient is WB?
Anterior- proximal to distal observation and
Posterior
What would you inspect a musculotendinous injury when the patient is WB on the anterior side?
Inspection of how the arches change NWB to WB- medial longitudinal arch change usually most evident
What would you inspect a musculotendinous injury when the patient is WB on the posterior side?
Calf symmetry
Achilles shape
Haglunds deformity
Tibial garum
Rearfoot vargus/valgus
What are some musculotendinous that could be in the posterior leg?
Achilles tendonitis
Achilles tendon rupture
What are some musculotendinous that could be in the lateral leg?
Longitudinal fibularis tendonitis/subluxation
What are some musculotendinous that could be in the medial leg?
Posterior tibialis tendon insufficiency (PTTI)
What are some musculotendinous that could be in the heel?
Plantar fasciitis
What is the MOi for Achilles tendonitis?
Overuse, increased running frequency or distance, Change in shoewear
What are some signs and symptoms of Achilles tendonitis?
Symptoms improve with mild activity, mild ache in posterior leg after activity, more severe pain after prolonged activity, pain with stair climbing, tenderness or stiffness, especially in AM
What are the two types of Achilles tendonitis?
Insertional and noninsertional
Where is non insertional achilles tendonitis located?
Midsubstance of the tendon, 2-6 cm proximal to insertion, zone of decreased vascularity
What are some types of non-insertional Achilles tendonitis?
Paratendonitis- inflammation of the lining around the tendon
Tendonosis- noninflammatory, age related degeneration of the tendon itself
Paratendonitis with tendonosis- Paratendonitis inflammation with introtendinous degeneraton
What is a key point with non insertional Achilles tendinitis?
Bulbous area mid-tendon with or without pain
Where is non insertional achilles tendonitis located?
At Achilles distal insertion on calcaneous
What are some types of insertional Achilles tendonitis?
Haglunds deformity
Pretend on bursitis (“pump bump”)
Retrocalcaneal bursitis
What is a key point of insertional Achilles tendonitis?
Tenderness, swelling over insertion at calcaneous
What are some key things to look at when examinating for Achilles tendonitis?
History (SOH), observation
AROM/PROM
Resisted tests (MMT vs FTPO vs STT)
Palpación
what are some special tests for Achilles tendonitis?
SLS heel raises for PF strength and FTPO
Confirm Achilles tendon integrity (Thompson test)
Foot/ankle biomechanical exam
How many grades of Achilles tendonitis treatment are there?
3: grade a, grade b, grade c
What is grade a Achilles tendonitis treatment?
Eccentric exercise for the gastrocnemius and soleus helps reduce pain and restore function in patients with id-portion Achilles tendinosis
What is grade b Achilles tendonitis treatment?
Modalities (laser) and modified eccentric exercises for gastrocnemius and soleus may help reduce pain and restore function in patients with insertional Achilles tendinosis
What is grade c Achilles tendonitis treatment?
Gastroc/soleus stretching
Long sit- knee flex, knee ext
Standing- knee flex, knee ext
What is recommended for a midsubstance lesion?
Heavy load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Continued sports activities using a pain monitoring model during rehabilitation
How does eccentric calf training work for midsubstance lesions?
Increases collagen synthesis rate in those that are injured (but not healthy controls)
Normalize tendon size or thickness
Proposed that the forces generated during the eccentric loading destroy new blood vessel and nerve formation, leading to decreased pain
What is suggested for an insertional lesion of the Achilles tendonosis?
Patient stands on uninvolved leg and plantarflexes to elevate the body in order to avoid concentric plantarflexion on involved leg, next shift their weight to the involved right leg to begin eccentric lowering of the body only to the level of the floor surface
