Ankle/Foot Examination (Lecture 1) Flashcards
Do we have lots of mobility in the foot?
Yes
Which two parts of the foot go in the same direction (supination/pronation)
Reer foot and mid foot go in the same direction
While the forefoot goes in the opposite direction
What joint(s) make up the rearfoot?
Talocrural (talus + crual [fibula / tibia])
Subtalar (Talus + calcaneous)
Remember the talus sits ontop of the calcaneous so the joint under that would be denoted as “subtalar”
What bones make up the rearfoot?
Calcaneous + talus
What bones make up the midfoot?
Navicular / cuboid / cuniform 123
What does the cuboid articulate with posterily?
Calcaneous
What does the navicular articulate w/ posteriorly?
Talus
KNOW: The main two midfoot joints are the navicular + talus and cuboid + calcenous (midtarsal joint)
What bones make up the forefoot?
metatarsals / phalanges
If theres locking in the foot what 2 things am I thinking?
Loose body (rare)
Fracture
Get Ottawa ankle rules
pt presents w/ pain with walking what grade sprain is it?
Grade 2
Patient presents w/ pain w/ running but not walking. What grade sprain is it?
Grade 1
Two outcome measures to know:
* Foot and ankle measurements (FAAM): general leg, foot, and ankle-related disorders
* LEFS (not specific to ankle)
What 2 arteries do we check to see if theres a loss of pulse in the foot?
Dorsal pedal / posterior tibia arterys
Redflags of foot (not all of them) = fracture / blood flow loss / numbness (use filament for sensation loss - bend till it becomes a C) / cancer (think bottom of foot because nobody puts sunscreen there [basal cell carcinoma]) / DVT
* 5.07
Yellow flags = more psycological symptoms.
* fear avoidance patterns - think chronic ankle insatbility and scared to do something
* Tampa scale of kinesaphobia
* FABQ
* Fear of moving foot
What from the knee might refer to the foot?
Gastroc / soleus / fibularis longus / brevis / anterior tibia
Most of these actually connect in the foot which is why they refer there
What 2 muscles of the hip refer to the foot?
Glute med / glute min
NOTE: Glute min looks like an L5/S1 radiculopathy
How do you differeinate a L5/S1 radiculopathy from a glute min refferal?
Numbness tingling (muscle doesnt do this)
Mobilize the back and if that brings on symptoms im thinking radic (because you’re not touching glute min)
Poke on glute med/min and if that brings on lateral thigh pain = thinking glute med/min
DTR absense = radiculopthy (dont lose these w/ muscle pathologies)
Mytome weakness = radiculopthy
Dermatonal sensation loss = radic
KNOW: if pt has had chronic back problems and got lateral ankle pain out of the blue w/o an MOI im thinking its probs coming from the back (could easily be on final practical)
its for if pt needs x-rays
100% sensitivity (if you get a negative rule out fractures)
He’s going to have test questions on this for if they need plain film radiography (much like clin med)
How to do tuning fork test
* what does it test for?
stethascope on fibular head and tuning fork on latearl malleolus or like anywhere on there foot and see if the vibrations are bringing on pain
tests for fracture
lack of sound = fracture
So you tap the fibula then put the stethascope on it comparing the sound side to side
Wells criteria for DVT
need more than 3 to rule it in
Signs of DVT (4)
Pittingedema
Tight shiny skin
Bruising
Swelling
(often happens after recent surgery)
KNOW: differiniate compartment syndrome and DVT by injury
* they look the same but department syndrome is normally a crush style injury while DVT is not
* DVT = normally after surgeries
IR or ER of the hip elevates the medial longitudinal arch of the foot?
ER
IR or ER of the hip causes the medial longitudinal arch to flatten?
IR
KNOW: external rotation of the hip makes you hang out on the outside of your feet while internal rotation of the hip makes you hang out on the inside of your foot
What is pes caves? what makes you go into it?
Pes caves = increasing that medial longitudinal arch
ER of hip makes you go more into it
What is pes planis? What motion makes you do it?
Pes planes = flat foot = decreased medial longitudinal arch
IR of the hip makes you do it
Does bad posture = disfunction?
No
What causes pigeon toes?
Its toes in so IR of the hip causes this
To many toes sign tests for what?
* what motion being increased causes this?
Pt looks behind pt to see if to many toes are showing laterally
Checks for ER of the hip
KNOW: Where calluses are on the feet can indicate abulation abnormailties (and wear and tear on the shoes)
KNOW: Bad toe nails can indicate poor blood flow or infection “window to your health”
What does this indicate?
Venous insufficency
causes wheeping wounds. Such bad circulation that the skin gets so thin that the lymph / seris fluid starts seeping out
* very tender / easily brusied
KNOW: Ray = metatarsal
Elevated1st ray, hypermobile 1st ray and long second metatarsal have been linked with the development of what 3 things
1) 1st MTP joint OA
2) Hallux valgus
3) Midfoot OA
What does foot supination do to the medial longitudinal arch?
What about pronation?
Increases it
Pronation decreases it
Is pes planis pronation or supiantion?
* does what to medial longitudinal arch?
Pronation
Decreases medial longitudinal arch
If you decrease your medial longitudinal arch (think walking in more pronation / pes planis) which bone is required to have more movement and inturn more muscle work is required for stability (more bone movement = more muscle activation for proper stability)
Talus is hypermobile in pronation = more muscle activation required for stability
* Can lead to talus OA
What are exostoses?
External bone growth at the foot
* often causes by abnormal loading
* Think a bunion
tibial shape will affect joint mechnicaics
If the pts right tibia is shorter than the left what will they do at the right foot to try and make that limb longer (what will they do at the foot?)
Supination becaue it will make the foot seem taller (making that medial longitudinal arch bigger)
KNOW: Supination makes you seem taller on one side (more plantar flexion)
KNOW: Thicker achilies tendon indicates pathology
Measuring subtalar lets us diliniate between varus and valgus
If your foot is in supination are you in varus or valgus?
is most of your pressure lateral or medial?
Varus
lateral
If you’re in rear foot / midfoot supination whats happening at forefoot?
Pronation
if you see wear and tear on the lateral aspect of someones shoe are they in varus or valgus
Foot is in supination which means they’re in varus
If your in over pronation of the foot whats happening up the chain
tibial external rotation and femoral internal rotation
do it seated and see the movement
NOTE: this is a valgus moment at the knee
In valgus what happens to the tibia and femur?
Femur = IR
Tibia = ER
What motions happen at the femur / tibia in varus?
Femur = ER
Tibia = IR
If someone measures a average arch of 140 in non weight bearing. Then in weight bearing their foot becomes much more flat (the arch collapses). Would we expect that angle to increase or decrease with this lower arch? Why?
Decrease
Because that navicular tuberosity drops making it closer to a right angle than being completely horizontal
He said dont memorize:
* High arch = 150
* Medium arch = 130-150
* Low arch = <130
What 3 points is the medial longitudinal arch measured by?
1st metatarsal
medial malleolus
navicular tuberosity
What is medial / latearl longitudinal arch maintained by? (3)
Wedging of tarsal and metatarsals
Tightening of plantar ligaments (spring us back up)
Instrinisc and extrensic muscles of foot + their tendons
Diliniate between the intrinisc and extrinsic muscles of the foot
Intrinsic = start and end in the foot
Extreinsic = start outside the foot and end inside the foot
Would someone doing large motor motions at the foot / ankle be hitting more intrinsic foot muscles or extrinsic foot muscles? Why?
Extrinsic because those larger movements are hitting those attachment points that originate outside of the foot. Whereas the intrinsic ones are all within the foot
Would a foot pt benefit from intrinsic foot m EX or extrinsic?
Both - they both help to support those longitudinal arches
are fine motor motions or stabilizations motions at the foot more intrinsic or extrinsic foot muscles?
Intrinsic
think toe stretchs / marbel pick up (however this even hits some of the extrinsic muscles as well)
pes planis or pes cavis?
Pes cavis
Pes planis or pes cavis
Pes planis
What is a good break in schedule?
wearing the new shoes one hour a day and not all day (because this will cause pain)
Whats special about an earth shoe?
* what position does it put you in at the knee?
It has a negative heel
Puts you into hyperextension of knee
High heels put more pressure in what part of the foot (from squeezing it)?
* what 4 things does this positioning lead 2?
Puts more perssure on the forefoot
Leads 2:
1) Hallxus valgus
2) Bunions
3) March fracture
4) Morton’s metatarsalgia
What position does this person walk in?
Supination
Swelling on one side of the achilles tendon is intra or extracapsular?
Extra
moves all to one side
swelling on just one side
Swelling on both sides of the achilles is intra or extra capsular?
Intra
it just balloons out
left foot = intracapsular (swelling on both sides)
Capsular pattern for the talocrural joint (joint capsule tightness)
What would the benefit from?
PF > DF
Benefit from mobilization EX
What joint does the most PF/DF
Talocrural
1st MTP capsular pattern of resitrction
EXT > flexion
IP joints capsular pattern of restriction
Flexion > extension
(less worried about us knowing this one)
is soleus or gastroc a 2 joint muscle?
Gastroc
Make sure you touch up on thomas test
Which muscle is most likely to limit great toe extension (which affects push off and our ability to ambulate)
Flexor hallasos longus
Special test high ankle sprains:
* External rotation stress test (Kleiger)
* Squeeze Test
* Cross Leg test
Lateral ankle sprains
* Anterior drawer - ATFL
* Talar Tilt - CFL
Talocrural impingement (feels like a pincching sensation)
* Impingement sign + TIC
Achilles Rupture
* Thompson test (squeeze gastroc and if they plantar flex it isnt ruptured)
Plantar Fasciitis
* Windlass test
* However, the best test is subjective pain –> first few steps such –> palpate on medial calcaneoal tubericle and it ligths them up
Tarsal tunnel
* Tinel’s test (more medial)
Morton’s Neuroma / Stress Fracture
* Squeeze test
* You are squeezing the metatarsals togther and seeing if this recreautes your pain. Numbness / tingling = mortons neuroma. Sharp pain = fx
What two ligaments are most likely ruptured w/ lateral ankle sprains?
anteriortalofibular ligament
calcaneofibular ligament
How much extension at the MTP do you need for walking?
65 degrees
How much extension do you need at the MTP for running?
85 degrees (you’re now really loading into the MTP)
CT scan is used for what? (6)
Bone tumors
Fractures: acute and stress fractures
Non-unions or delayed unions
degrenative and rhematoid arthritits
Post op monitoring
avascular necrosis
MRI is used for what in the foot? (4)
Tendinopathies and tears (however ultrasound is better if a skilled pro is using it)
Show areas of subtle changes within the substance of the tendon
Ligament disruption
Osteochondral fractures of the talar dome
