Approach to Ankle and Foot Flashcards
What to palpate on the ankle?
Palpate anterior ankle joint Medial and lateral malleolus Achilles tendon Metatarsophalangeal joints and heads Heel (calcaneus, plantar fascia)
ROMs to check in the ankle?
Plantarflexion, dorsiflexion, ankle inversion, ankle eversion, metatarsophalangeal flexion, metatarsophalangeal extension
Pulses found in ankle?
Posterior tibialis and dorsalis pedis pulse
What are the 3 main ankle sprains
Lateral ankle sprain
Medial ankle sprain
Syndesmotic ankle sprain (aka high ankle sprain)
What is a lateral ankle sprain?
THE MOST COMMON Mechanism of injury Foot inversion and/or plantar flexion Most likely ligament(s) injured Anterior talofibular ligament*** Calcaneofibular ligament Associated positive special tests Talar tilt test (aka Inversion test) Anterior drawer
How and what is injured in a medial ankle sprain?
Mechanism of injury Forced eversion Most likely ligament involved Deltoid ligament Associated positive special tests Eversion test
How to grade a ankle sprain?
Grade 1:
No laxity in the joint = minimal ligament damage
Grade 2:
Mild to moderate laxity in the joint
Grade 3:
Complete disruption of the ligament
How and what is injured in a high ankle sprain?
Mechanism of injury Forced external rotation of a dorsiflexed ankle Most likely ligament(s) involved Tibiofibular syndesmosis Associated positive special test Squeeze test
What are Achilles Tendinopathys?
Common Achilles diagnoses:
Tendonitis
Achilles rupture
Sever’s Disease (calcaneal apophysitis)
What is Achilles Tendonitis
What is it?
Tendonitis: inflammation of a tendon
Specifically the Achilles tendon
Why does it happen?
Repetitive motions create microtears in the tendon resulting in inflammation
Most commonly associated with competitive/recreational athletes
Signs of Achilles tendonitis?
Pain/stiffness at tendon insertion (posterior calcaneus)
Recent increase in exercise/activity level
Pain is worse with activity and goes away with rest
NEGATIVE Thompson test
Signs of Achilles rupture?
Most commonly associated with competitive/recreational athletes
Signs and symptoms:
80% occur during high impact recreational sports
Patients report a popping sensation at their heel
+/- pain
Associated special tests
POSITIVE Thompson test
Signs of Severs Disease?
Chronic heel pain in growing children
Pain is related to increased activity
Pain is reproduced with direct palpation over the apophysis
What is Tibiotalar effusion?
Joint Effusion: An abnormal accumulation of fluid in or around a joint
What is Pes Planus?
A loss of the longitudinal arch of the foot
“flat feet”
What is Pes Cavus?
An exaggeration of the longitudinal arch of the foot
What is Hammer toe
PIP flexion and DIP extension
What is Claw toe
PIP and DIP flexion
What is a Hallux Valgus (Bunion)
Defined by the lateral deviation of the great toe
Progressively leads to the development of a prominence on the medial aspect of the metatarsophalangeal joint (commonly known as a bunion)
Presence of hallux valgus can lead to inflammation and irritation at the first metatarsophalangeal joint
What are signs of plantar Fasciitis?
Pain is worse with first few steps in the morning and improves
Sharp stabbing plantar/heel pain
Pain is made worse by prolonged standing
Pain reproduced with forced dorsiflexion
What is Morton’s Neuroma?
Inflammation and thickening of tissue that surrounds the nerve between toes
Signs of Morton’s Neuroma?
Patient reports feeling like they are walking on a marble
Palpable in web space, which will replicate burning pain
Mulder’s Sign
A palpable clicking sensation between the third web space as the transverse arch is compressed
Signs of Fibular Nerve Compression?
The nerve most commonly gets compressed at the point it wraps around the lateral aspect of the fibular head
Weakness of dorsiflexion and eversion
“Steppage” gate
Sensory loss over dorsal foot/lateral shin
What is Charcot foot?
A consequence of chronic foot inflammation that ultimately results in mid foot deformities and a collapse of the longitudinal arch
Signs of Charcot foot?
Always associated with neuropathy of the foot
Diabetic neuropathy
Signs and symptoms:
Visible collapse of the longitudinal arch
Warmth, redness and edema over the joint
History of minor trauma
Long term history of peripheral neuropathy
What is Diabetic Neuropathy?
Diabetic neuropathy is a common complication of uncontrolled diabetes
When the patient’s blood sugar remains elevated for a prolonged period of time peripheral nerves become damaged
The damaged nerves no longer function as well and patients will lose sensation (most commonly in the feet)
What causes Gout?
An inflammatory arthropathy caused by the deposition of MONOSODIUM URATE crystals in joints
Signs of Gout
Joint aspiration reveals NEGATIVELY BIREFRINGENT NEEDLE SHAPED CRYSTALS
Most commonly occurs in the first MTP joint
Fibular head glides…. with foot pronation
anteriorly
Fibular had glides…. with foot supination
posterioly
What is plantar glide?
A sliding motion (along an axis) of a tarsal bone toward the plantar surface in relation to surrounding bones
What is Dorsal Glide?
A sliding motion (along an axis) of tarsal bones toward the dorsum of the foot in relation to surrounding bones
Cuboid two movements together
Eversion with plantar glide
Navicular two movements together?
Inversion with plantar glide
Ottawa Rules for malleolar zone?
Must have at least one of the following:
Bone tenderness at the posterior tip of the medial or lateral malleolus
Unable to bear weight immediately after injury AND unable to walk 4 steps in the doctor’s office/ER
Ottawa Rules for midfoot region?
Must have at least one of the following:
Bone tenderness at the FIFTH metatarsal or the NAVICULAR
Unable to bear weight immediately after injury AND unable to walk 4 steps in the doctor’s office/ER
ROM of Dorsiflexion:
15-20°
ROM of Plantarflexion:
55-65°
ROM of Ankle inversion (no locking out
20°
ROM of Ankle eversion (no locking out):
10-20
ROM of Subtalar inversion (lock out talus)
5°
ROM of Subtalar eversion (lock out talus):
5°
ROM of Forefoot adduction:
20°
ROM of Forefoot abduction:
10°
ROM of 1st Metatarsophalangeal flexion:
45°
ROM of 1st Metatarsophalangeal extension:
70-90°
Nerve root for Achilles tendon reflex
S1
Reflex documentation scale
4+/4: Very brisk, hyperactive, with clonus (rhythmic
oscillation between flexion and extension)
3+/4: Brisker than average, possibly but not necessarily indicative of disease
2+/4: Average, normal
1+/4: Somewhat diminished, low normal
0/4: No response
Muscular documentation scale
+0/5: No muscular contraction detected
+1/5: Barely detectable flicker/trace of contraction
+2/5: Active movement with gravity eliminated
+3/5: Active movement against gravity
+4/5: Active movement against gravity and some resistance
+5/5: Active movement against full resistance without evidence of fatigue (normal muscle strength)
Pulse documentation?
+3/3: Bounding
+2/3: Average intensity, expected, normal
+1/3: Diminished, barely palpable
0/3: Absent, not palpable
Edema checked on the foot where?
Dorsum of foot and behind medial malleolus
Edema documentation
0: Absent
1+: Barely detectable, slight pitting (2mm);
disappears rapidly
2+: Slight indentation (4mm); 10-15 sec
3+: Deeper indentation (6mm); >1 min
4+: Very marked indentation (8mm); 2-5 min
How to do Talar Tilt Test
Grasp distal tibia/fibula with one hand and inferior calcaneus
with the other, blocking motion of the calcaneus on the talus.
Invert the talus to evaluate ROM
Indications of Talar Tilt Test
(+) Test: Laxity, increased ROM, or pain
Indication: Calcaneofibular ligament pathology/tear, also
tests some ATF (lateral ankle sprain)
How to do Eversion Test
Grasp distal tibia/fibula with one hand and plantar surface of the
mid-foot with the other hand. Evert the foot to evaluate ROM.
Indications of Eversion Test
(+) Test: Laxity, increased ROM or pair
Indication: Deltoid ligament pathology (medial ankle sprain)
How to do Thompson Test
Patient prone with foot off the table. Squeeze the patient’s calf.
Observe for plantarflexion.
Indications of Thompson Test
(+) Test: Absence of plantar flexion
Indication: Achilles tendon rupture
How to do ankle Anterior Drawer Test
Grasp posterior calcaneus with one hand and distal tibia/fibula
with the other hand, monitoring anteriorly at the anterior talus.
Provide anterior force on calcaneus while stabilizing the distal
tibia/fibula. Normal springing of calcaneus back to neutral
should occur.
Indications of Anterior Drawer Test
(+) Test = pain, no springing, excessive motion/laxity
Indication: ATF ligament pathology/tear (lateral ankle
sprain)
How to do Homan’s Sign test?
Patient laying or seating with knee extended. Dorsiflex the
patient’s foot. Can apply lateral compression to calf
Indications of Homans sign?
(+) Test: Pain with dorsiflexion
Indication: thrombophlebitis or acute deep vein thrombosis
(DVT)
Can also observe accompanying signs of edema, erythema, and
warmth of lower leg. Would need to order a Venous Doppler to
rule out clot
What is Mulder’s Sign
Tests for Morton Neuroma. Clicking sensation upon palpating with one hand
the third web space and other hand compressing
the transverse arch together.
How to treat Plantar Fascia Hypertonicity ST?
Longitudinal Stretch with the closed fist rolled along plantar aponeurosis. Do this on each metatarsal.
Medial Longitudinal arch. The two hands twist in opposite directions with a “wringing” motion to reestablish the arch. This rolling, stretching motion is repeated until the desired effect is achieved or to patient tolerance.
How to treat Plantar Fasciitis with MFR?
The physician’s thumbs are crossed, making anX, with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia.
The thumbs impart an inward force is vectored distal and lateral. This pressure is continued until the restrictive (bind) barrier is met.
How to treat interosseous membrane?
The physician places the thumbs over the anterior dysfunctional aspect of the interosseous membrane with the palm and fingers encircling the leg.
The physician monitors cephalad and caudad, left and right rotation, and clockwise and counterclockwise motion availability for ease-bind asymmetry.
After determining the presence of an ease-bind asymmetry, the physician will either indirectly or directly meet the ease-bind barrier.
The force is applied in a very gentle to moderate manner.
This force is held for 20 to 60 seconds or until a release is palpated. The physician may continue this and follow any additional release until it does not recur.
How to treat Gastrocnemius Hypertonicity
The physician places both hands side by side under the gastrocnemius muscle. The physician’s fingers should be slightly bent, and the weight of the leg should rest on the physician’s fingertips.
The physician’s fingers apply an upward/anterior force into the muscle and then pull inferiorly, using the weight of the leg to compress the area.
What are the hind foot SDs?
Tibotalar Joint: Plantarflexed/ Dorsiflexed Talus MET
Subtalar: Grasp heel and do a figure 8.
Calcaneal Eversion/Inversion SD. Do opposite movem.
What are the midfoot SDs?
Tarsals Bones with Dorsal or plantar glide. (Cuboid does eversion too and Nanvicular does inversion).
Find bone and hold while doing ART
Plantar Glide SD MET for Tarsals. Do the x and have them adjust inversion/ eversion and dorsiflexion and plantarflexion
What are the forefoot MET joints?
MTP, PIP, and DIP Flexion/extension. Adduction/abduction. IR/ER
