Ankle & Foot Dx and Tx OSCE

Question 1

Ankle Dysfx

Answer 1

-Anterior and posterior glide of tiobotalar joint -Anterior tibia on talus (plantarflexed talus) -Posterior tibia on talus (dorsiflexed talus) -Anterior lateral malleolus -Posterior lateral malleolus

Question 2

Foot dysfx

Answer 2

Dorsiflexed talus dysfx Plantarflexed talus dysfx Inversion calcaneus dysfx Eversion calcaneus dysfx Tarsal bone dysfx Plantar navicular dysfx Plantar cuboid dysfx Plantar cuneiform dysfx Metatarsal dysfx MTP, PIP, DIP dysfx

Question 3

Anterior and posterior glide of the tibiotalar joint

Answer 3

Posterior glide is the minor motion w/ dorsiflexion Anterior glide is the minor motion w/ plantarflexion

Question 4

Anterior tibia on talus (plantarflexed talus)

Answer 4

FOM: Ankle likes plantarflexion and anterior glide R: tibia is restricted in gliding posteriorly on talus Due to changes in distal tibia mechanics

Question 5

Posterior tibia on talus (dorsiflexed talus)

Answer 5

FOM: Ankle prefers dorsiflexion and posterior glide R: Tibia can’t glide anterior on talus Due to changes in distal tibia mechanics

Question 6

Anterior lateral malleolus

Answer 6

FOM: lateral malleolus has free anterior glide Distal medial border of talus is more prominent R: lateral malleolus restricted in posterior glide

Question 7

Posterior lateral malleolus

Answer 7

FOM: lateral malleolus has free posterior glide relative to distal tibia ANterior portion of talus is displaced in lateral direction R: lateral malleolus restricted in anterior glide

Question 8

Dorsiflexed talus dysfx

Answer 8

Expected dorsiflexion: 15-20 FOM: Dorsiflexion R: Plantarflexion Due to changed in talus mechanics

Question 9

Plantarflexed talus dysfx

Answer 9

Expected plantarflexion: 50-65 FOM: Plantarflexion R: Dorsiflexion

Question 10

Inversion calcaneus dysfx

Answer 10

Expected inversion: 5 Physician grasps calcaneus in one hand and locks out motion of the talus with other hand. Note degrees of motion and compare bilaterally. Freedom of Motion: Inversion Restriction: Eversion Due to changes in subtalar mechanics

Question 11

Eversion calcaneus dysfx

Answer 11

Expected eversion: 5 Physician grasps calcaneus in one hand and locks out motion of the talus with other hand. Note degrees of motion and compare bilaterally. Freedom of Motion: Eversion Restriction: Inversion Due to changes in subtalar mechanics

Question 12

Tarsal bone dysfunctions

Answer 12

Evaluate plantar glide and dorsal glide of the tarsal bones and determine preference of motion. Induce plantar glide by pressing inferiorly on tarsal bone Induce dorsal glide by pressing superiorly on tarsal bone

Question 13

Plantar navicular dysfunction  Most common dysfunction of the navicular bone  Lateral navicular drops plantar

Answer 13

Physician locks out motion at the talus with one hand while grasping the Navicular bone between the thumb & first finger of other hand. Glide it dorsally and ventrally, noting any restriction to motion and comparing bilaterally. Freedom of motion: Plantar glide Restriction: Dorsal glide

Question 14

Plantar cuboid dysfunction  Most common dysfunction of the cuboid bone Medial cuboid drops plantar

Answer 14

Physician locks out motion of the calcaneus with one hand while grasping the Cuboid bone between thumb & first finger of other hand. Glide it dorsally and ventrally, noting any restriction to motion and comparing bilaterally. Freedom of motion: Plantar glide Restriction: Dorsal glide Note: Commonly associated with a posterior fibular head dysfunction

Question 15

Plantar cuneiform dysfunctions Most common dysfunction of cuneiform bones

Answer 15

Physician locks out motion at the navicular bone with one hand while grasping each cuneiform individually between thumb & first finger of other hand. Glide each cuneiform dorsally and ventrally, noting any restriction to motion and comparing bilaterally Freedom of motion: Plantar Glide Restriction: Dorsal Glide

Question 16

Metatarsal dysfunctions  Due to change in metatarsal head mechanics

Answer 16

Physician grasps the metatarsal head in question with one hand and the adjacent head with the other hand. Glide plantar and dorsal relative to each another, noting ease and restriction to motion. Motion: plantar and dorsal glide

Question 17

MTP, PIP, and DIP dysfunctions

Answer 17

Evaluate flexion/extension, adduction/abduction, internal rotation/external rotation

Question 18

Distal Fibula Anterior Articulatory Treatment

Answer 18

Patient: Supine Physician: Stand/Sit at the foot of the table  Stabilize patient’s foot, wrapping fingers around calcaneus and engage dorsiflexion restrictive barrier.  Thumb of lateral hand contacts the anterior aspect of the distal fibula with other thumb on top. Engage the restrictive barrier and using articulatory technique until motion improves. Reassess TART

Question 19

Distal Fibula Posterior Articulatory Treatment

Answer 19

Patient: Prone Physician: Stand/Sit at the foot of the table  Stabilize patient’s foot, wrapping fingers around calcaneus and engage plantarflexion restrictive barrier.  Thumb of lateral hand contacts the posterior aspect of the distal fibula with other thumb on top. Engage the restrictive barrier and using articulatory technique until motion improves. Reassess TART

Question 20

Dorsiflexed Talus Muscle Energy Treatment

Answer 20

Patient: supine Physician: Stand/Sit at the foot of the table  Grasp patient’s ankle with one hand at the level of the malleoli. Other hand is placed over the dorsum on the patient’s foot.  Bring the patient’s foot into the plantar flexion restrictive barrier Activating Force: Patient is instructed to bring their foot into dorsiflexion against isometric resistance for 3-5sec then isometric relaxation. Engage a new barrier & repeat until no new barriers are met. Reassess TART

Question 21

Plantarflexed Talus Muscle Energy Treatment

Answer 21

Patient: Supine Physician: Stand/Sit at the foot of the table  Grasp patient’s ankle with one hand at the level of the malleoli. Other hand is placed on the plantar surface of the patient’s foot.  Bring the patient’s foot into the dorsiflexion restrictive barrier. Activating Force: Patient is instructed to bring their foot into plantar flexion against isometric resistance for 3-5sec then isometric relaxation. Engage a new barrier & repeat until no new barrier are met. Reassess TART

Question 22

Talus Eversion with anteromedial glide Talus Inversion with posterolateral glide Articulatory Treatment (with traction)

Answer 22

Patient: Seated with leg hanging off table Physician: Sitting at the foot of the table  Grasp patient’s heel with one hand and grasp the talus & dorsum of the foot with the other. Maintain traction on calcaneus and articulate inversion and eversion with a “figure 8” maneuver until no new restrictive barriers are met or quality of ROM normalizes. Reassess TART

Question 23

Everted Cuboid with plantar glide Inverted Navicular with plantar glide Cuneiform plantar glide Muscle Energy Treatment

Answer 23

Patient: Supine/seated Physician: Sitting at the foot of the table  Grasp patient’s foot with both hands on dorsum of foot, lifting the foot off the table and dorsiflex to engage restrictive barrier. Adjust accordingly with inversion/eversion and dorsiflexion/plantarflexion.  Cross thumbs on plantar surface with one pad on cuboid & other on navicular with a separating force.  Instruct patient to “Push your foot into my thumbs” & maintain a counterforce for 3- 5 seconds until no new restrictive barriers are met. Reassess TART

Question 24

Dorsal or Plantar Glide Articulatory Treatment

Answer 24

Patient: Supine/seated Physician: Sitting at the foot of the table  Isolate joint between fingers. Engage barrier, alternating between restrictive barrier and ease of motion until normal physiologic motion is restored. Reassess TART

Question 25

Dorsal or Plantar Glide Articulatory Treatment

Answer 25

Patient: Supine/seated Physician: Sitting at the foot of the table  Isolate joint between fingers. Engage barrier, alternating between restrictive barrier and ease of motion until normal physiologic motion is restored. Reassess TART

Question 26

The most common somatic dysfunction associated with the Cuboid and Navicular bones are with ____

Answer 26

plantarflexion

Question 27

During plantarflexion, the lateral aspect of the navicular bone drops _____

Answer 27

plantar as well as the medial aspect of the cuboid bone dropping plantar

Question 28

Inversion/lateral ankle sprain

Answer 28

• Accounts for 80-85% of all ankle sprains - Mechanism of injury: ankle inversion with plantar flexion - Ligaments involved: - Anterior talofibular (ATF= “Always Tears First”) - Calaneofibular - Posterior talofibular - Swelling, tenderness and ecchymosis over involved area

Question 29

High ankle sprain

Answer 29

• Accounts for 10% of all ankle sprains - Mechanism of injury: ankle eversion and rotation (some dorsiflexion) - Ligaments involved: - Anterior inferior tibiofibular - Syndesmosis - Pain more common on medial aspect with minimal swelling - Pain worse with weight bearing

Question 30

Plantar fascitis

Answer 30

Inflammation of origin of plantar aponeurosis - Worse with first steps, improves through day - Point tenderness of calcaneus - Pain with passive dorsiflexion - Commonly associated with tight calves, repetitive impact activities, high arches, obesity, new/changes in activities Common cause of heel pain in adults

Question 31

Morton’s Neuroma

Answer 31

Inflammation and thickening of tissue that surrounds the nerve between toes. Most commonly between 3rd and 4th toes (third web space) - Patient reports feeling like they are walking on a marble - Palpable in web space, which will replicate burning pain - Can have radiation of pain and numbness of toes - Test: Mulder’s sign o Clicking sensation upon palpating with one hand the third web space and other hand compressing the transverse arch together.

Question 32

TUrf toe

Answer 32

Inflammation and pain at base of 1st MTP - Presents as pain and bruising at base of great toe - Caused by hyperextension of great toe causing damage to the joint capsule. Severe cases can damage sesamoids and flexor tendon - Commonly associated with activities performed on hard surface

Question 33

Achilles tendonitis

Answer 33

Inflammation at Achilles tendon - Presents as sharp heel pain and stiffness at mid-Achilles tendon to insertion. Pain is worse with strenuous exercising, better with walking - Micro tears in tendon causes swelling and thickening - Commonly associated with tight calf muscles, sudden change in activity, poorly fitting shoes, incorrect running technique

Question 34

Diabetic neuropathy

Answer 34

Complication of diabetes causing gradual loss of nerve fibers, presenting as loss of vibratory sensation along with impaired pain, light touch, and temperature sensations - Test pressure sensation using a Monofilament test, vibration sensation using a tuning force, and superficial pain using pinprick. o Monofilament test is performed on the plantar aspect of foot. Physician asks the patient to close their eyes. The monofilament is placed on the first and third pad of toes and at base of first, third and fifth plantar MTP joints. Use enough pressure to cause a slight bend of the monofilament. Test is positive if patient cannot feel the monofilament. - Complete diabetic foot exam includes examining pulses, checking for skin lesions (sores, ulcers, open wounds, etc)

Question 35

Gout

Answer 35

Precipitation of monosodium urate crystals in joint space causing an inflammatory response - Most commonly affects the first metatarsophalangeal joint but can also affect the mid-tarsal joints, ankles, knees, and/or fingers - Swollen, tender, erythematous, and painful joint upon presentation

Question 36

Osgood-Schlatter disease

Answer 36

Osteochondritis of tibial tubercle - Caused by repetitive strain and chronic avulsion of ossification center of tibial tubercle, leading to a separation of proximal patella tendon insertion from tibial tubercle - Frequently seen in children (10-15 yrs) who participate in active sports - Presents as swelling of tibial tubercle with anterior knee pain that increases gradually over time - Pain may be reproduced by extending knee against resistance

Question 37

Ottawa: when would you get an ankle series

Answer 37

●Have bone tenderness at the posterior edge or tip of the lateral or medial malleolus OR ●Are unable to bear weight both immediately after the injury and for four steps in the emergency department or doctor’s office

Question 38

Ottawa: when would you get a foot series

Answer 38

●Have bone tenderness at the base of the fifth metatarsal or at the navicular OR ●Are unable to bear weight both immediately after the injury and for four steps in the emergency department or doctor’s office.