Examination Flashcards
When is there generally a need to refer out?
if the injury is acute (after determining seriousness of injury)
When may a full biomechanical exam NOT be necessary?
post surgery or post injury
What are Dutton’s key points on history taking?
- Mechanism of injury
- severity of condition
- when symptoms began
- location, nature and behavior of symptoms
- structure at fault
- other systemic conditions (collagen disease, neuropathy, vascular, radiculopathy, other pathology)
Immediate and continuous inability to bear weight may indicate what?
Fracture
Nocturnal pain may indicate what?
Malignancy
Hemarthrosis
Fracture
Infection
Gross pain with ankle valgus stress and tenderness with pressure on the distal fibula may indicate what?
Fractured fibula
Pain and weakness during resisted eversion may indicate what?
Fracture of the 5th metatarsal base
Calf pain and/or tenderness, swelling with pitting edema, increased skin temperature, superficial vein dialation, or cyanosis may indicate what?
Deep vein thrombosis
REQUIRES IMMEDIATE MEDICAL!
An abnormally warm foot may indicate what?
Local inflammation, but can also originate from a tumor in the pelvic or lumbar region.
An abnormally cold foot may indicate what?
Vascular problem
What are the 8 special questions?
1) Do symptoms change with movements of LOW BACK? Do you have BACK PAIN if you feel it is unrelated?
2) Does your foot ankle PAIN EXTEND up into your knee, thigh, hip or back? Do you experience NUMBNESS OR TINGLING into the hip, thigh, leg, or ankle?
3) Have you INCREASED your PHYSICAL ACTIVITY, especially running?
4) Do you have ankle pain or STIFFNESS that EASES AFTER A FEW HOURS in the MORNING?
5) Do you have pain in the bottom of your foot that is WORSE when you INITIALLY BEAR WEIGHT (especially in the AM) and WORSENS with INCREASED TIME ON YOUR FEET?
6) Is your leg/ankle or foot pain a RESULT OF TRAUMA, such as injury with JUMPING, LANDING, TWISTING, etc?
7) Have you ever had or do you have ACTIVE CANCER, PARALYSIS, PLASTER IMMOBILIZATION, RECENT PERIOD OF BED REST, LOWER LEG SWELLING, PITTING EDEMA?
8) Do you or have you had sudden episodes of REDNESS, HEAT, SWELLING, and PAIN? Have you recently consumed GREATER THAN NORMAL PORTIONS OF MEATS, SEAFOODS, BEANS, or other foods high in PURINES? INCREASED intake of ALCOHOL?
What do you do if pt has symptoms that change with movements of low back / low back pain.
Examine lumbopelvic region and back.
What do you do if pt has ankle pain extending up into knee/thigh/back and experiences numbness/tingling into hip/thigh/leg/ankle?
Neurological exam
Low back exam
What do you do if pt has pain in posterior calf and/thigh but no numbness?
Consider:
Hamstring strain
Ischial bursitis
Piriformis syndrome
What do you do if pt has recently increased physical activity, especially running.
Be suspicious of a stress fracture.
What do you do if pt has ankle pain of stiffness that eases after a few hours in the morning?
Be suspicious of osteoarthritis .
What do you do if pt has pain in the bottom of foot that is worse when initially bearing weight (especially in the AM) and worsens with increased time on his feet?
Be suspicious of plantar fascitis?
What do you do if pt’s leg/ankle/foot pain is a result of trauma (i.e. jumping, landing, twisting, etc.)?
Be suspicious of: Ligamentous injury talar dome osteochondral defect fracture ankle sprain sydesmosis injury
What do you do if pt has/had paralysis, plaster immobilization or recent period of bed rest?
Be suspicious of DVT.
What do you do if pt has/had sudden episodes of redness, heat, swelling, and pain?
Be suspicious of gout.
What do you do if pt recently consumed a greater than normal portion of meat, seafood, beans, or other foods high in purines?
Be suspicious of gout.
What do you do if pt had increased intake of alcohol?
Be suspicious of gout.
What do you do if pt has/had active cancer?
Be suspicious of DVT.
What do you do if pt has/had lower leg swelling or pitting edema?
Be suspicious of DVT.
What is a biomechanical exam used for?
To determine if there is a deviation from optimal position (where there is no increase in pronation/supination throughout the gait cycle)
Navicular drop is a risk factor for what?
Patellaemoral pain syndrome
Most asymptomatic individuals exhibit typical or prolonged inversion or eversion during stance?
Eversion
There is a significant relationship between navicular drop and what?
Medial tibial stress syndrome (MTSS) aka shin splints
Abnormal pronation is postulated to increase ________ tibial rotation and related events.
Internal
What are the Ottawa ankle rules?
X ray only required if:
(Can’t bear with for 4 steps) AND
tenderness at
(posterior edge/tip of the lateral malleolus)OR
(base of the 5th metatarsal) OR
(posterior edge/tip of medial malleolus)OR
(navicular)
Name 5 important components of foot/ankle exam
1) occupation
2) mechanism of injury
3) symptom progression
4) functional limitations
5) show ware
Name 8 causes of overuse.
1) prolonged training, changes in training, mileage
2) impact force of activity
3) surface of training for competition
4) downhill running
5) lack of flexibility, technique
6) poor posture
7) anatomic factors
Now do you quantify navicular drop?
Determine change of arch height from STJ neutral/ NWB to weight bearin- relaxed calcaneal stance.
Normal is <10mm navicular drop
What is Fick Angle?
Angle between direction gait direction and axis for foot.
Normal= 5-18 degrees.
Children begin with about 5 degrees.
Related to ER of tibia
Excessive lateral rotation of tibia is usually correlated with pronation/ supination of foot?
pronation
What is morton’s toe and how does it affect foot?
2nd metatarsal is longer than the 1st metatarsal.
Can cause weight bearing on 2nd metatarsal rather than first and—> pain
Name 3 Foot types in population and rank from most to least common.
Egyptian > Morton/Greek > Squared
Egyptian foot (great toe is longer than 2nd toe)
Mortons/Greek (2nd toe is longer than great toe)
Squared foot (great toe is same length as 2nd toe)
What is Haglund’s deformity and who is more prone to it?
“pump bump” bony enlargement on back of heel that can irritate achilles tendon/surrounding tissue
symptoms = bump on back of heel pain at achilles insertion swelling in back of heel redness near inflamed tissue
prone if= high-arched foot tight achilles tendon tendency to walk on outside of heel (can also be hereditary)
True/False? Plantar contact areas predict arch height during walking.
False.
Foot Posture Index Items and Reference Values
Rearfoot: 1) Talar head palpation 2) curves above and below the lateral malleolus 3) inversion/eversion of the calcaneus Forefoot: 4) prominance in the region of the TNJ 5) Congruence of the medial longitudinal arch 6) abd/adduction forefoot on rearfoot
score out of -12 to +12
Reference Values Normal = 0 to +5 Pronated =+6 to +9 Highly pronated = 10+ Supinated =-1 to -4 Highly supinated = -5 to -12
Foot Mobility Magnitude
Measure midfoot width while standing
“ “ non-WB
Measure dorsal arch height while standing
“ “ non-WB
Modified Foot Posture Index (FPI-6) interrater reliabilty
moderate with adult assessment
hight with pediatric assessment
Pediatric flatfoot... found to be associated with \_\_\_\_\_\_\_\_\_\_\_. is inversely proportional to \_\_\_\_\_\_\_. is more prevalent in girls/boys? correlates directly with \_\_\_\_\_\_ and \_\_\_\_\_\_.
reduced ankle joint ROM
age
boys
joint hypermobility; being overweight/obese
Q angle
measured as angle between line from ASIS to central patella & line from central patella to tibial tuberosity
Normal values = 10 degrees for men
15 degrees for women
Structural Test: Tibial Torsion
> 15 to 18 deg = + for excessive external tibial torsion
Pt sitting with knee in 90 deg flexion. measure angle between like through femoral condyles and line through medial and lateral malleoli
normal value is about 15 to 18 degrees
How to examine ankle after Inversion Sprain
Palpate medial and lateral ligaments Palpate deltoid ligament Palpate syndesmosis ER stress test for syndesmosis injury. Palpate base of 5th met. to rule out fx anterior drawer test motor testing of peroneal and post tib tendons ottawa ankle rules
Special Test: Peroneal Dislocation
+ finding = subluxation of peroneal tendons
Pt prone with knee 90 deg flexed.
Inspect posterolateral region of the ankle and inspect for swellng.
Have Pt DF/PF along with EV against your hand. Look for tendon subluxation
Special Test: Kleiger’s (External Rotation Stress Test)
+ finding for syndesmosis injury if pain over anterior/posterior tib fib ligament and interosseous membrane.
OR
indicates tear of deltoid ligament if pain medially and examiner feels talus displace from medial malleolus
Pt sitting with leg 90 deg flexion.
Stabilize leg with one hand.
With other hand, hold the foot in plantigrade (90 deg) and apply lateral rotation stress to foot and ankle.
Special Test: Dorsiflexion Maneuver
+ finding for syndesmotic injury, anterior ankle impingement
Pt sitting, examiner stabilizes the leg with one hand. Passively move foot toward DF with other hand using forearm.
Structural Test: Feiss Line
Pes planus (flatfoot) degree = distance to floor In standing, navicular drop: 1/3 of distance to floor = 1st degree flat foot 2/3 of distance to floor= 2nd degree flat foot Rests on floor = 3rd degree flatfoot
Mark the apex of the medial malleous and the plantar aspect of the MTP joint when pt not WB. Note location of navicular tuberosity in relation to line between those points. Pt standing, recheck location of dots and check level of navicular.
Structural Test: STJ neutral
forefoot varus, forefoot valgus, PF 1st ray, rearfoot varus, rearfoot valgus
Special Test: Anterior Drawer
+ finding for injury to ATFL, CFL, Deltoid Lig
if pain, dimple/suction.
Pt lies supine with foot relaxed. Stabilize tibia and fibula. Hold foot in 20 deg plantarflexion and draw talus forward in ankle mortise.
DF/neutral to bias CF
Special Test: Homans Sign
+ finding for DVT
Pain, tenderness to palpation, pallor and swelling in leg, loss of dorsalis pedis pulse.
Pt supine. passively DF with knee extended.
Special Test: Tinel’s
+ finding for injury to tibial nerve and peroneal nerve
precuss the nerves. look for tingling/paresthesia
Special Test: Morton’s Test
+ finding for metatarsal stress fx
OR
morton’s neuroma (irritation between 3rd and 4th toe)
Pt supine. Squeeze foot around metatarsal heads.
Special Test: Talar Tilt
+ finding for injury to lateral ligaments OR deltoid ligament
Pt sidelying with knee flexed.
Inversion stress:
PF foot for ATFL
Foot in 90 deg to bias CF
Abduct:
Deltoid ligament
Test STJN standing
check: forefoot varus forefoot valgus PF 1st ray rearfoot varus rearfoot valgus
Navicular Drop test standing
> 10mm difference = abnormal midfoot mobility
STJ neutral vs Relaxed calcaneal stance
Thompson’s test
+ test for achilles tendon rupture
if ankle does not PF upon squeezing of gastrocnemius.
