Examination of the Ankle and Foot Flashcards
Define a dor no pé/tornozelo.
Foot pain is an unpleasant sensory and emotional experience following perceived damage to any tissue distal to the tibia or fibula; including bones, joints, ligaments, muscles, tendons, apophyses, retinacula, fascia, bursae, nerves, skin, nails and vascular structures.
Quais as funções do tornozelo e pé?
- Mobility
- Allows shock absorption
- Allows loose adaptation during stance
- Acts as directional torque transmitter during stance
- Stability
- Acts as a rigid lever during push-off
- Dynamic support of the foot, evenly distribute weight.
Quais os 5 mecanismos envolvidos na função do tornozelo/pé?
- The lower leg
- Talocrural mechanism
- Subtalar joint
- Midtarsal complex
- Metatarsophalangeal mechanism.
A articulação tibiofibular superior pertence ao joelho ou ao tornozelo?
- Anatomically belongs to the knee but functionally belongs to the ankle/foot
- Oval synovial joint
- Joint moves in response to movement in the talocrural joint and limitations here can create end-range limitations and possible pain in the anterior ankle with weightbearing.
Qual a função da membrana interóssea da perna?
- Spans between tibia and fibula
- Functions as a divider of the lower leg compartments with only 2 openings for the passage of nerves and vessels
- Transfers up to 30% of weightbearing load from tibia to fibula
- Mortise is stabilized at end-range dorsiflexion.
Quais as propriedades da articulação talocrural?
- Consists of the talar dome resting within the rigid roof of the mortise or distal tibiofemoral joint
- Allows tibia to move over the foot
- Primary constraint is the architecture followed by ligamentous stability
- Provides 30 degrees of DF and 50 PF passively.
Explica o mecanismo da articulação subtalar.
- Primarily adds stability but also for shock absorption
- Talus functions as a torque converter between the internally rotating tibia and the everting calcaneus
- Anterior and posterior STJ covered by fibrous capsule and synovial membrane
- Triplanar joint
- Predominant source of inversion/eversion and abduction/adduction in the entire ankle/foot region.
Resume o Midtarsal Complex.
- 3 joint compartments – Calcaneocuboid joint, Talonavicular joint, Cubonaviculocuneiform joint.
- Functionally the 3 compartments are seen as a single ball and socket joint
- Accounts for 25% of dorsiflexion of the ankle/foot complex
- 45% of total plantarflexion
- MTJ is locked with inversion, mobile with eversion.
Além das estruturas musculotendinosas e articulares, que outras estruturas compõem o calcanhar?
- Plantar surface of the heel is covered by skin and a subcutaneous fat pad
- Fat pad consists of a meshwork of fibroelastic septae whereby imposed loads are distributed over the entire region of contact
- The septal chambers consist of a significant blood and nerve supply
- Thickness of the pad is paramount to compressive load tolerance and reduced fat pad height is consistent with increased incidence of heel pain
- Shock absorbing capacity of the fat pad decreases with age.
O que é a fáscia plantar?
- Dense fibrous connective tissue originating from the calcaneal tuberosity
- Tissue fans and thins out attaching to the plantar fibrous digital sheaths of thelateral four toes and the sesamoids of the great toe
- Serves as a functional windlass in the foot complex helping support the foot’s longitudinal arch contributing as much as 25% to the stiffness of the foot and carrying as much as 14% of the total load imposed on the foot during weightbearing.
Lateral ankle sprains account for up to what percentage of all injuries in sports?
Lateral ankle sprains account for up to 38-45% of all injuries in sports.
Which structure is responsible for transferring up to 30% of weightbearing load from the tibia to fibula?
The interosseous membrane transfers up to 30% of weightbearing load from tibia to fibular.
The subtalar joint is primarily responsible for which movements of the ankle/foot?
The subtalar mechanism is the predominant source of inversion/eversion and abduction/adduction in the entire ankle/foot region.
Which of the following structures serves as the main eccentric stabilizer of the subtalar complex during pronation in weightbearing?
The tibialis posterior serves as the main eccentric stabilizer of the subtalar complex during pronation in weightbearing.
Como podemos avaliar a irritabilidade dos sintomas?
Aggravating and relieving factors:
– What activities make your symptoms worse? (Running, shoes, hopping, walking);
– What is the pain level during these activities?
– Does it worsen immediately or over time?
– After stopping the activity, how long before your pain level returns to normal?
How can we get the history of the present illness?
- When and how did this start? – Mechanism of injury may assist in determining presence of a fracture
- How long have you been suffering from these symptoms?
- Do you have a previous history of these symptoms?
- Have you undergone any imaging?
- Course of symptoms – Are you better, worse, or the same?
- Have you undergone any previous treatment? – Was it effective?
O que é importante perceber a nível social?
• Are you currently working? – What are your occupational demands?
• Look for yellow (Factors that may affect treatment plan), blue (Features of work generally associated with
increased rate of symptoms), and black flags (Established policy concerning work conditions)!
• What is your current living situation? – Do you have stairs in your home, rugs?
• Do you have family support? – How much help does this patient have in the home?
Que questões especiais poderão ajudar a identificar um problema de origem não mecânica?
- Do you notice any feelings of numbness or pins and needles bilaterally?
- Have you suffered any recent weight loss?
- Do you ever feel as though you are stumbling while walking?
- Have you suffered any recent bowel/bladder changes?
- Do you suffer from any pins/needle like feelings in the inner groin area?
Qual o outcome measure mais apropriado para avaliar as disfunções funcionais em casos com instabilidade do tornozelo?
The FOOT AND ANKLE DISABILITY INDEX (FADI) can be considered as the most appropriate, patient assessed tool to quantify functional disabilities in patients with chronic ankle instability.
Nomeia alguns instrumentos com evidência para o seu uso relativo.
- Sports Ankle Rating System QOL measure;
- FAAM;
- FFI;
- FHSQ;
- LEFS.
Refere algumas das fraquezas da utilização de medidas de resultados de auto-preenchimento.
- Do not always differentiate between whether or why a specific task is not done or can’t be done
- Do not accurately characterize or quantify the impact of the health condition nor a change in that impact
- Errors in memory or judgment, impaired cognition, willingness and ability to answer accurately
- Poor correlation between self-report and PPM
- Appear to be highly reflective of changes in pain (and what the patient is experiencing) and less reflective of changes in function.
Porquê administrar self-reported e physical performance measures para ajudar a compreender a condição clínica?
- Because assessment of function is multidimensional, indexes of functional disability have been considered misleading without considering the patients’ values and preferences, thus reflecting the important role of self-report measures
- The patient’s subjective evaluation serves to represent patient perception, an essential aspect to consider when determining functional change
- Self-report used in isolation may overestimate patients’ functional status due to the high correlations with pain.
Exemplifica uma questão que nos permita avaliar a taxa de recuperação do paciente na altura da alta de fisioterapia.
• “Taking into account all the activities you have during your daily life, your level of pain, and your functional impairment, do you consider that your current state is
satisfactory?”
• Basically, this helps to identify whether the patient is good versus are they better
• Better does not always equal satisfied
Jeff Grant is a 20 year old male who presented to physical therapy with complaint of left ankle pain and requesting crutches. The patient was an intercollegiate football player who had sustained a combination forced-dorsiflexion and external rotation injury to his left ankle, getting tackled while returning a punt during a game on the previous Saturday evening. He stated that he heard an audible “pop” but was able to limp off the field and did not return to the game. He was treated with ice and elevation that evening and the next day he iced his ankle several times and was able to walk to the dining facility several times. Given what we know about Mr. Grant’s history, which could be considered as potential outcome measures to distribute?
Both the foot and ankle ability measure and the foot and ankle disability index would be good options as they are both validated, reliable, and have sport specific subscales which would be important in this patient.
Which of the following statements is FALSE with regards to self-report measures?
• There is a poor correlation between self-report and physical performance measures of function
• There is a strong correlation between self-report measures of function and performance measures of function
• Self report measures of function appear to be highly reflective of changes in pain and less reflective of changes in function
There is a strong correlation between self-report measures of function and performance measures of function - Several studies have shown low correlations between self-report measures of function and performance measures given self-report tends to be highly dependent upon pain and patient perceived ability.
The minimal clinically important difference (MCID) is the same as the minimal detectable change?
False. The minimal clinically important difference is determined by the patient whereas the minimal detectable change is based upon statistics and sample distribution.
The MCID is dependent upon which factors?
The MCID is not a fixed attribute and will vary based upon the patient’s age, acuity of symptoms, disease specific state, and other.
Quais os três critérios a avaliar durante a observação do pé e tornozelo?
- Inspection of the foot and ankle during standing
- Gait evaluation
- Skin and Nail Inspection.
Define algumas informações chave que devemos ter em consideração na inspeção da posição do pé e tornozelo.
- Abnormal alignment of the forefoot and hindfoot that is associated with a concordant pain during stance may require specific intervention such as orthotics or stabilization
- Fallen longitudinal arch increases pronation during static stance; also known as “too many toes”
- A greater risk for stress fractures in the tibia, fibula, and foot has been associated with high longitudinal arch and excessive forefoot varus in runners.
- Elevated first ray, hypermobile first ray and long second metatarsal have been linked with the development of first metatarsophalangeal joint OA, hallux valgus, and midfoot OA, respectively.
Quais os valores de referência para o ângulo do arco longitudinal do pé? Como podemos medir?
- High arch = or sup 150 degrees
- Medium arch = 130-150
- Low arch =or inf 130 degrees.
Pode ser medido com um goniómetro. A tuberosidade navicular é o eixo; e o maléolo medial e a cabeça do primeiro metatarso são os braços do goniómetro.
Para que serve o naviculum drop test? E quais os valores representativos de um teste positivo?
• Naviculum drop test for hyperpronation
– Normal drop test less than 3-5mm
– Positive test sup 10mm
What do we assess during gait?
- Footwear Assessment
- Forward/backward walking
- Walk on toes/heels
- Look for stride length
- Stance phase – Shortened?
- Foot rotation – Externally rotated?
- Often, a gait evaluation will identify a concordant abnormality in the ankle/foot complex.
What should we look in footwear assessment?
- Length/width
- Heel cup?
- Arch support?
- Torsional/Toebreak flexibility
- Patterns of wear
O que devemos verificar na inspeção da pele e unhas?
- Trophic changes may be indicative of peripheral vascular disease
- Pigmentation may be associated with venous insufficiency
- Significant callus formation may be a consequence of abnormal gait or increased pressure during WB
- Toenail disorders may be a result of psoriasis, poor blood flow, and/or infection
- Edema.
Que tipo de movimentos dinâmicos podemos solicitar? E o que devemos procurar?
- Deep Squat – Point of pain or weight shift; Heel rising from floor earlier than opposite side leads to suspicion of TCJ hypomobility.
- Unilateral squat
- Single leg hop – Pain reproduction
- Ascend/Descend Stairs – Which foot do they lead with; Pain reproduction.
How to perform o navicular drop test?
The patient stands and places the patient in subtalar neutral. Subtalar neutral is found by palpation of the patient’s tali in which both the medial and lateral aspects are felt equally by the examiner. The most prominent aspect of the navicular bone is palpated and marked with a pen. The examiner marks the height of the “neutral” position on a 3x5 note card. The patient is then instructed to stand normally. A repeat measure of the navicular height is again measured. A difference of greater than 10mm is considered a positive finding.
Upon physical examination, a patient was antalgic gait with his left lower extremity externally rotated. Left leg stance time and stride length was decreased approximately 50%. The left ankle demonstrated moderate edema laterally and medially, and ecchymosis present laterally. When testing the longitudinal arch angle, the arch height was recorded at 145 degrees. This would place the patient in which category?
Medium arch height (between 130 and 150 degrees).
The “too many toes” signs refer to what?
A fallen longitudinal arch or increased pronation.
What type of questions could be done to screen any patient?
- Medical history
- Surgical history
- Weight loss
- Medications
- Other tests (radiographs, blood work, etc)
- Stress
Quais as red flags específicas para o tornozelo e pé?
- Foot and Ankle Fractures
- Stress fracture
- Morton’s Neuroma
- DVT (deep vain trombosis)
- Peripheral Neuropathy
- Lumbar radiculopathy
- Lumbar myelopathy.
Quais os critérios das Ottawa ankle rules para presença de fratura no tornozelo?
History of trauma or fall.
A series of ankle x ray films is required only if there is
any pain in malleolar zone and any of these findings:
• Bone tenderness at posterior edge or tip of lateral malleolus - 6 cm
• Bone tenderness at medial edge or tip of lateral malleolus - 6 cm
• Inability to bear weight both immediately and in emergency dept.
(Sn 100 ; Sp 62)
Quais os critérios das Ottawa ankle rules para presença de fratura no pé?
History of trauma or fall.
A series of x ray films is required only if there is any
pain in mid-foot zone and any of these findings:
• Bone tenderness at base of fifth metatarsal
• Bone tenderness at navicular
• Inability to bear weight both immediately and in emergency department.
(Sn 100 ; Sp 62)
Explain the tuning fork test for stress fracture.
The patient lies supine. The examiner places a stethoscope on the fibular head and the tuning fork on the lateral malleolus. A positive test is a change in “tone” (sound) during the assessment.
(Sn 83; Sp 80)
