Ankle Foot Complex Exam & Interventions Flashcards
What are some major ankle pathologies
- Lateral ankle sprain
- Plantar fasciitis (Heel pain)
- Osteoarthritis
- Achilles Tendinopathies
- Diabetic foot (Charcot)
What are the Ottawa ankle rules to obtain an x-ray
- Pain to palpation distal 6cm of the posterior aspect or tip of medial or lateral malleolus
- Pain to palpation of navicular
- Pain to palpation to base of the 5th metatarsal
Serious pathologies of the ankle-foot complex
- Foot/ankle fracture (OAR/OFR)
- DVT/Vascular
- Compartment syndrome
- Foot drop (lumbar HNP)
- Sensory lass (DM)
- Septic arthritis
- Gout
Describe a foot neuron-vascular screen
- Observe foot/toe deformities: 1st toe alignment
- General foot position: arch height
- Skin diseases/open wounds
- Sensory loss: 5.07 monofilament takes 10 grams of force
- Swelling
- Pulses/Stemmer sign
Lateral ankle-foot complex palpation
- Lateral malleolus
- Calcaneofibular Lig (CFL)
- Anterioralofibular Lig (ATFL)
- Posterior talofibular Lig (PTFL)
- Peroneus Longus & Brervis
- Cuboid
- 5th MT Head (insertion peroneus brevis)
Medial an ole-foot complex palpation
- Medial Malleolus
- Sustentaculum tali (calcaneus)
- Navicular tubercule
- Tibialis Anterior
- Tibialis Posterior
- Flexor Dig Longus
- Post. Tibial Art. & Nerve
- Flexor Hallucis Longus
What are the 3 functional divisions of the ankle-foot complex
- Hindfoot (Rearfoot): proximal/distal tip-fib, talocural (talus with fib-fib), and subtalar (talus with calcaneus)
- Midfoot: transverse tarsal joint (Chopart) and calcaneocuboid & talonovicular
- Foerfoot: tarsometatarsal (Lisfranc), MTP joints, and IP joints
Describe the Talocural joint
- 34-50º PF, 10-20º DF
- Closed packed: max DF
- Open packed: 5-10º PF
Describe the Subtalar joint
- 18-32º inversion + ADD, 4-12º eversion + ABD
- Closed packed: max supination
- Open packed: 0-5º pronation
Describe the Midtarsal joint
- 10º invasion/eversion, 10º ABD + DF, 20º ADD + PF
- Closed packed: ADD, Inversion of Subtalar
- Open packed: ABD, Eversion of Subtalar
Describe the 1st MTP joint
- 96º extension, 17-34º flexion, 15-19º ABD/ADD
- Closed packed: max extension
- Open packed: 10-20º extension
Where does Soleus pain refer to
- It refers to the ipsilateral SI joint
Quick standing movement screen for the ankle-foot complex
- Up on toes
- Up on heels
- Stand inside
- Stand outside
Describe a diabetic screen
- Sensation/dermatomes
- Sensory loss: Semmes-Weinstein 5.07 monofilament takes 10 grams of force
- Joint malalignments: Charcot foot, toe abnormalities
Vascular screen for the ankle-foot complex
- Swelling
- Pulses
- Stemmer sign
- Arterial/Venous/Lymphedema type ulcers
Describe the lateral step dow test
- 7 point scale: 0-1 = Good and 2+ = Moderate
- 15cm step: 60º knee flexion and relationship to DF
Is the ankle-foot complex in supination or pronation during each phase of stance
- Initial contact: supination
- Loading response: rapid conversion to pronation
- Terminal stance: return to supination (rigid lever) for propulsion at terminal stance
How to identify rear foot and forefoot positioning
- Measured in non-weight bearing and prone
- Establish subtalar joint neutral (STJN) position by palpation b/w thumb and index for when the talus is felt equally on both sides
- Measure calcanea inversion or eversion by a line that bisects the leg vs that of the calcaneus
- Calcaneal INV = rearfoot varus
- Calcaneal EV = rearfoot valgus
- Slight rearfoot varus of 2-4º is normal
What is forefoot varus
- In non-weight bearing think more of inversion & supination
Describe uncompensated versus compensated forefront varus
- Uncompensated: The rearfoot is rigid and cannot compensate. Instead of subtalar joint compensation, it will have to try to take place in the midtarsal joint
- Compensated: When the degree of forefoot varus is equal to or less than the degree of calcaneal eversion.
Conditions associated with a compensated forefoot varus
- Halux valgus
- Posterior tendon tendinitis
What is forefoot valgus
- Eversion position relative to the calcaneus
- Measure in STJN non-weight bearing prone position
Describe a flexible forefoot valgus
- There is sufficient flexibility in the midtarsal joint to allow the lateral column of the foot to reach the supportive surface during the stance phase of gait. The heel may function perpendicularly, but the amount of compensation that occurs leads to an unstable gait with late pronation through midstance into propulsion.
Describe a rigid forefoot valgus
- When the range of motion in the mid-tarsal joint is not enough to allow the lateral column of the foot to touch the ground, rearfoot supination/compensation is required. This is rarely seen clinically.
Describe the foot posture index (FPI-6)
- Talar head position: POS = palpate medial
- Curves above & below lateral malleoli: POS = concave curve
- Inversion/eversion of calcaneus: POS = more everted calcaneus
- Bulge in region of TNJ: POS = more bulge TNJ
- Congruence of medial longitudinal arch: POS = flat arch
- ABD/ADD of the forefoot on the rear foot: POS = more toes lateral
Measurements for determining if the calcaneus is supinated or pronated
- Normal foot: 0 to +5
- Pronated: +6 to +9
- Highly pronated: +10 or more
- Supinated: -1 to -4
- Highly supinated: -5 to -12
What are the 3 CPG’s for the ankle-foot complex
- Heel pain: Plantar Fasciitis
- Ankle stability and movement coordination impairments: ankle ligament sprains
- Achilles pain, stiffness, and muscle power deficits: midportion achilles tendinopathy revision
What is the CPG for lateral ankle sprain (prevention)
- History of prior ankle sprain: not participating in a balance/proprioceptive prevention
- Not using an external support
- Improper warm up with static stretching & dynamic movement before activity
- Lack normal ankle DF ROM
What is the CPG for chronic ankle instability (prevention)
- Increased taller curvature
- Not using an external support
- Not participating in a balance/proprioceptive prevention
Describe a physical exam for an ankle sprain
- Swelling
- Ankle ROM
- Talar translation & inversion
- Single leg balance
Grade A evidence for ankle sprain interventions in the acute protective phase
- Use of external support
- Protective AROM, stretching, neuromuscular training
- Manual therapy: Talus
- Manual therapy: lymph drainage
- Cryotherapy
- DON’T use ultrasound
Grade A evidence for ankle sprain interventions in the progressive loading phase
- Manual therapy: mobs and manips, MWM
- Proprioceptive and neuromuscular therapeutic exercise
CPR for a Thrust & Nonthrust Manipulation and Exercise in Patients Post Inversion Ankle Sprain
- Sx worse when standing
- Sx worse in evening
- Navicular drop >5.5 mm
- Distal tibiofibular joint hypomobility
- Thrust: rearfoot distraction and proximal tib-fib PA
- Non-thrust: talocural PA, subtalar lateral glide eversion, & distal tib-fib
CPG for heel pain/plantar fasciitis patient exam findings
- Plantar medial heel pain mot noticeable with initial steps after
- Period of inactivity but also worse following prolonged weight bearing
- Heel pain precipitated by a recent increase in weight bearing activity
- Reproduction of the reported heel pain with palpation/provocation of the proximal insertion of the plantar fascia
- Positive windlass test
- Negative tarsal tunnel tests
