Lower Limb Assessment Flashcards
What kinds of things should you ask in a history intake in regards to the lower limb?
a.MOI: insidious vs. traumatic
Traumatic: sprains, strains, breaks
Insidious onset: tendinopathies, plantar fasciitis
- b.Initial swelling/bruising*
- More bruising the higher degree of muscle tearing.
- c.Numbness and tingling?*
- Numbness and tingling: could also be coming from the back. Needs to make sense with what you are thinking of in terms of diagnosis.
- d.Shoes? Type. Wear pattern.*
What are we looking for in terms of observation of the lower limb?
a) Swelling, bruising, pitting edema
b) Posture of the foot in weight bearing, arches
c) Ability to weight bear
d) Effects of movement on foot posture (twisting, squatting)
e) Shoes - type, wear pattern
Compare Pes cavus to Pes planus
Pes cavus – foot with an unusually high plantar longitudinal arch
Pes planus - flat foot, fallen arch
Compensatory pronation associated with pes planus is one of the most common lower extremity disorders seen currently by physical therapists working in sports medicine
Pes cavus, typically a stiffer foot, less able to accommodate to issues, more susceptible to plantar fasciitis as it cannot accommodate like a pronated foot
What would an examination of the lower limb involve?
a.Active Range of Motion
i. Plantar flexion (50 degrees)
ii. Dorsifexion (20 degrees)
iii. Inversion (35-40degrees)
iv. Eversion (15 degrees)
v. Midtarsal glides (folding/fanning)
vi. Toe extension/flexion (especially D1)
b. Passive Range of Motion (end feel)
i. Plantar flexion (tissue stretch)
ii. Dorsifexion (tissue stretch)
iii. Inversion (tissue stretch)
iv. Eversion (tissue stretch)
v. Midtarsal glides
vi. Toe extension/flexion (especially D1) (tissue stretch)
* vii. Bent Knee Dorsiflexion Test*
What is the bent knee dorsiflexion test?
Good for the person to use to go home and work on their range, keep an eye on it. Measure toe to the wall when bending knee against a wall but keeping the heel flat on the ground (bend knee as much as possible).
What will the end feel be for a subluxed talus?
Blocked end feel
What isometric testing could you do for the ankle?
Isometric Testing
i. Plantar flexion
ii. Dorsifexion
iii. Inversion
iv. Eversion
v. Toe extension/flexion
What are three special tests for ligament stabilty of the syndesmosis joint of the ankle?
- Syndesmosis Squeeze test
- External rotation test
- Anterior Drawer Test
What are the lateral ankle ligament stress tests?
- ATFL test (anterior talofibular ligament)
- CFL (calcaneofibular ligament)
- PTFL test (posterior talofibular ligament)
What are the tests for fracture or interdigital neuroma?
- Morton’s test (squeeze test)
- Plantar percussion test
What is the Thompson test? What does it test for?
- Patient lies prone with shin on a bolster or on examiner’s knee.
- Examiner applies a squeeze to the calf of the patient’s affected leg
- A positive test is a non-response during the squeeze test
This test for an Achilles tendon rupture
What is Homan’s sign? What does it test for?
- Patient lies in a supine position with knee slightly flexed
- Examiner applies a forceful dorsiflexion maneuver
- Positive test is popliteal pain and calf pain
This test for a deep vein thrombosis (DVT)
What are the Ottawa rules for determining whether an ankle x-ray is required? (know these for test!)
Ankle X-ray is only required if there is any pain in the malleolar zone and/or talar dome and any one of the following:
A.Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus, OR
B.Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, OR
An inability to bear weight both immediately and in the emergency department for four steps
What are the Ottawa rules to determine whether a foot x-ray is required? (know these for test!)
A foot x-ray series is required if there is any pain in the dorsal medial and lateral aspect of the mid-foot and any of the following findings…
- Bone tenderness at the base of the fifth metatarsal
- Bone tenderness at the navicular bone
- Inability to weight bear immediately after the injury and in the emergency room
What sinew channel would you look to for Achilles tendinopathy?
Bladder sinew channel
What sinew channel would you look to for peroneal neuropathy (foot drop)?
Gallbladder
What sinew channel would you look to for shin splints?
Stomach
What sinew channel would you look to for tibialis posterior tendonitis/tendonopathies?
Kidney predominantly
also Liver
What sinew channel would you look to for plantar fascitis?
Kidney
What ligaments are sprained in a lateral (inversion) ankle sprain?
- ATFL anterior talofibular
- CFL - calcaneofibular
- PTFL - posterior talofibular
Inversion (lateral) ankle sprains account for what percentage of ankle sprains?
70-85%
What is the mechanism of injury for an inversion ankle sprain?
Excessive plantar flexion and supination
What ligaments/structures are involved in a medial (eversion) ankle sprain?
Medial or deltoid ligaments
Often involves a fracture of the lateral malleolus as well!
Why does an eversion (medial) ankle sprain often involve a fracture of the lateral malleolus?
- Lateral malleolus projects further inferiorly
- Deltoid ligament stronger than lateral ligaments
What is the MOI for eversion ankle sprains?
Eversion of the ankle, most often with dorsiflexion
What ligaments are involved in a high ankle (syndesmotic) sprain?
Sprain of any or all of the five syndesmotic ligaments: the anterior tibiofibular ligament, the posterior tibiofibular ligament, the transverse ligament, the interosseous ligament, and the interosseous membrane.
What is the MOI for a high ankle sprain?
Commonly occur from a sudden and forceful outward twisting of the foot which occurs in contact and cutting sports
Are x-rays required for syndesmotic (high ankle) sprains?
Yes. X-ray required to rule out talar dome fractures or splaying of the ankle mortis. High ankle sprains associated with widening between the tibia and fibular usually require surgery.
Which type of ankle sprain takes longest to heal?
Both eversion and syndesmotic ankle sprians generally take twice as long to heal as inversion sprains.
What happens if a high ankle sprain is not properly managed and the tibia and fibula splay?
If it is not addressed with circumferential taping or pinned there can be a subluxation of the talus. The talus gets jammed forward in the mortis because there is too much room in the joint.
What is a grade 1 ankle sprain? Symptoms? Recovery time?
- Mild damage to a ligament or ligaments without instability of the affected joint. No ligament laxity.
- Symptoms: Minimal swelling, point tenderness, no limp or difficulty hopping.
- Typically recovery: 2-10 days.
What is a grade 2 ankle sprain? Symptoms? Recovery time?
A partial tear to the ligament resulting in mild to moderate instability of the joint.
- Symptoms: more swelling specific to the ankle, bruising most likely present, patient presents with a limp, inability to heel raise, hop, or run.
- Typical recovery: 10-30 days.
What is a grade 3 ankle sprain? Symptoms? Recover time?
A complete tear of a ligament, causing gross instability in the joint.
- Significant swelling and bruising, tenderness on both the inside and outside of the ankle, inability to weight bear.
- Typical recovery: 30-90 days or more.
What is non-insertional Achilles tendonitis? What demographic do we see with this?
Tendonitis of the mid-substance of the tendon. Nodules may build up here. More common in younger population.
What is insertional Achilles tendonitis? What demographic do we usually see with this?
Tendonitis of the Achilles tendon where it inserts into the calcaneus. More common in non-active and older patients. Often associated with bone spurs.
What is the cause and etiology of Achilles tendonitis?
Cause: overuse
Etiology: Degeneration of collagen tissue of the Achilles tendon
What are risk factors for Achilles tendonitis?
- Poor blood supply to the Achilles tendon (due to surrounding synovial sheath)
- Tightness in the calf muscles
- Sudden increase in activity level (weekend warrior)
- Sports or activities that involve repetitive use and quick contraction of the gastroc/soleus complex such as running, jumping, change of speed, fast stops and starts
- Individuals 30-40
- Excessive inversion of the subtalar joint (greater than 5 degrees)
What are the symptoms of Achilles tendonitis?
- Pain can vary from a local ache to a burning sensation surrounding the entire tendon.
- Pain is worse during and after activity
- Achilles tendon and ankle can become stiff the following day due to swelling.
- Local swelling around the Achilles.
- Possible bone spur formation or calcification in the tendon.
Compare tendonitis, tendinosis and tendinopathy
Tendonitis - acute tendon injury accompanied by inflammation
Tendinosis - chronic tendon injury with degeneration at the cellular level and no inflammation
Tendinopathy - chronic tendon injury with no implication about etiology
Describe the tibialis posterior tendon
The tibialis posterior muscle has a tendon that runs down the inside of your lower leg and behind your ankle bone (medial malleolus) and joins on to your midfoot. Its job is to help support our foot arch and to support your ankle. It is the main long tendon dynamic foot stabilizer.
What is the etiology of tibialis posterior tendinopathy? What are the symptoms?
Etiology: Begins with inflammation due to some irritant and progresses to histological degradation of the tendon if irritation is not rectified.
Symptoms:
- Pain under medial malleolus and up medial aspect of the shin
- Pain with activity, especially running
What are some causes of tibialis posterior tendinopathy?
- Friction between the tendon and muscle fascicles within the sheath (repetitive overuse)
- Adipose tissue within the muscle
- Ischemia
- Neural sprouting
- Tensile overlaod (tight muscles/high impact)
What are some contributing factors to tibialis posterior tendinopathy?
- Anteriorly rotated pelvis
- Dropped navicular
- Inadequate support for medial arch
- Overweight
- Pronated feet (decreased medial arch)
- Sudden increase/change in activity
- Tight deep posterior compartment
- Valgus knee angle increased
What is the chain of problems that starts with an anteriorly rotated pelvis?
- Pelvis tilts foward
- Hip internally rotates
- Knee moves inward
- Leg internally rotates
- Overpronation of foot
What is compartment syndrome?
Excessive pressure builds up inside a compartment in the lower leg, impeding the flow of blood to and from the affected tissues
What is acute compartment syndrome? What are some causes?
An acute medical emergency resulting from some type of trauma, such as crush injuries, overly tight bandages/casts, blood clots, burns or envenomation. Without treatment it can lead to permanent muscle damage.
What are symptoms of compartment syndrome?
- Swelling, tightness, shiny skin, possible bruising
- Persistent deep ache, numbness, pins and needles, electricity-like pain
- Pain with minimal ROM of joint
What other pathologies should you look at in a differential diagnosis for compartment syndrome?
- Cellulitis (bacterial infection involving inner layers of the skin and below, dermis and subcutaneous tissue)
- Deep Vein Thrombosis
- Necrotizing fasciitis
- Peripheral vascular injuries
What is chronic or exertional compartment syndrome?
Not typically a medical emergency. Most often caused by athletic exertion or anabolic steroid use.
What are the symptoms of chronic or exertional compartment syndrome?
- Worsening aching or cramping and possible numbness with exercise. Typically begins soon after exercise start, progressively worsens and stops within 30 minutes of finishing
- Tight, red, shiny and swollen in area
- Weakness of affected limb
- Foot drop in severe case
What other pathologies would one need to look at in a differential diagnosis for chronic or exertional compartment syndrome?
- Shin splints/periostitis
- Stress fractures
- Tendinopathy
What is plantar fasciitis?
Inflammation of the broad band of connective tissue called the plantar fascia that extends from the medial calcaneal tubercle to the base of the toes and helps support the medial arch of the foot.
What is the etiology of plantar fasciitis?
Microscopic anatomical changes indicate that plantar fasciitis is actually due to non-inflammatory structural breakdown rather than an inflammatory process, therefore more properly termed planta fasciosis. This breakdown is believed to be the result of repetitive micro-trauma. Microscopic examination of the plantar fascia often shows degeneration, connective tissue calcium deposits, disorganized collagen fibers.
What are the risk factors of plantar fasciitis?
- Calcaneal spurs: unclear if they have a causative role but highly correlated
- Dorsiflexion limited: due to subluxed talocrule joint or tight Achilles
- Hypermobile subtalar joint (most commonly due to repetitive or severe ankle sprains)
- Inactivity
- Obesity
- Overpronation of foot
- Overuse: longe periods of standing or significant, sudden increase in exercise
What are possible underlying causes of plantar fasciitis?
- Hypomobile Talocrural joint
- Hypermobile Subtalar Joint
- Excessive tone in tricep surae (gastroc/soleus and plantaris)
- Dropping of the medial arch
Problem with Hypomobile Talocrural joint
Problematic due to the decreased dorsiflexion and thus forward tibial excursion during the gait cycle, Flexor Hallucis Longus (FHL) will work harder for push off. This increased activity of FHL can potentially cause FHL tendonitis thus predisposing the foot to plantar fasciitis.
Problem with Hypermobile Subtalar joint?
Excessive movement in the subtalar joint (most often due to a cervical or interosseous ligament sprain with multiple or really bad inversion ankle sprains) can cause excessive shimmy in the heel at heel strike. This causes the intrinsic muscles of the foot to work harder to try to stabilize the subtalar joint predisposing it to plantar fasciitis.
Problem with excessive tone in tricep surae?
Tight gastroc and soleus muscles (and to some extent plantaris) can cause excessive pull on the achilles tendon. In younger individuals, the Achilles has a fascial connection to the plantar fascia and can transfer it’s load to it, therefore putting it at risk of plantar fasciitis.
Problem with dropping of medial arch?
In older individuals or in some cases of trauma, the tarsals can start to drop medially thus decreasing the medial arch and putting more stress on the plantar fascia.
What are the symptoms of plantar fasciitis?
- Stabbing pain in the heel that usually occurs after any period of significant rest (eg. first thing in the morning or after sitting for a while)
- Point tenderness that starts at the medial calcaneal tubercle and along the medial arch
- Pain typically dissipates with walking because the plantar fascia stretches, but it may return after long periods of standing or inactivity
