Special Test For Ankle And Foot 3rd year Final Exam Flashcards
- How is Homan’s Sign performed and what does a positive finding suggest?
- Why wouldn’t they just do plantar flexion for DVT?
Homan’s Sign
- Patient is supine with knee extended, forcibly dorsiflex patient’s ankle
Indicates: Deep Vein Thrombosis (DVT)
Positive: pain in calf region
**Not a highly specific test, but can be used in conjunction with other physical signs of DVT to help with recommendations for more specific blood/imaging tests
More information:
Why Homan’s Test Causes Pain
In the presence of a DVT, there is a thrombus (blood clot) in a deep vein, commonly in the calf veins.
Dorsiflexion of the foot stretches the calf muscles and deep veins, increasing pressure on the vein walls and thrombus.
This stretching can irritate the inflamed vein wall (thrombophlebitis) and stimulate nearby pain receptors.
The squeezing of the calf muscle further compresses the vein, exacerbating the pain in the presence of a clot.
Why Pain Suggests DVT
Inflammation and Vessel Wall Damage:
A thrombus in a vein causes inflammation of the vein lining (venous endothelium).
This inflammation sensitizes pain receptors in the surrounding tissues.
When the calf is stretched or compressed during Homan’s test, the irritated vein triggers a pain response.
Obstruction and Increased Pressure:
A DVT partially or completely obstructs blood flow in the vein.
The mechanical pressure during the test increases venous pressure, amplifying the discomfort caused by the clot.
Limitations of Homan’s Test
Although Homan’s test may cause pain and is suggestive of DVT, it is not highly reliable:
Low Sensitivity and Specificity:
Many patients with DVT do not have a positive Homan’s sign, and many with a positive test do not have DVT.
Other Causes of Pain:
Calf pain during the test can also result from conditions like a muscle strain, Baker’s cyst, or superficial thrombophlebitis.
Modern Diagnostic Tools:
Doppler ultrasound and D-dimer testing are now preferred for diagnosing DVT because they are far more accurate and non-invasive.
Key Takeaway
Homan’s test causes pain in DVT because the thrombus and surrounding vein inflammation are aggravated by dorsiflexion and compression of the calf. However, due to its limitations, the test is no longer considered definitive or highly reliable for diagnosing DVT.
- Dorsiflexion Stretches the Calf Muscles and Veins
Homan’s test uses dorsiflexion because it stretches the calf muscles, particularly the gastrocnemius and soleus muscles, and places tension on the deep veins within these muscles.
If a thrombus (blood clot) is present in these veins, this stretch can irritate the inflamed vein wall or thrombus and provoke pain.
Plantar flexion, on the other hand, shortens the calf muscles and decreases tension on the veins, so it is unlikely to cause irritation or pain related to a clot. - Lack of Diagnostic Value with Plantar Flexion
Plantar flexion would not sufficiently stress the vein where the clot is likely located. This makes it an ineffective maneuver to provoke symptoms of DVT.
By shortening the muscle, plantar flexion reduces compression on the veins, decreasing the likelihood of triggering pain in a patient with DVT. - Direction of Blood Flow Obstruction
Dorsiflexion increases the stretch in the veins, momentarily altering blood flow dynamics, especially in the presence of a thrombus, which can cause pain.
Plantar flexion does not create the same dynamic change in the veins, so it cannot effectively reveal a DVT. - Mechanical Principles
Dorsiflexion is used because it stresses the tissues where most DVTs occur—the deep veins of the lower leg, particularly the posterior tibial vein and peroneal vein.
Plantar flexion predominantly activates the anterior muscles of the lower leg (e.g., tibialis anterior) and does not sufficiently involve the deep venous system of the calf.
Key Takeaway
Plantar flexion is not used in DVT testing because it does not stretch or compress the structures associated with deep vein thrombosis, such as the deep veins in the calf. Dorsiflexion is better suited to elicit symptoms because it effectively stresses the veins and surrounding tissues, helping reveal the presence of a thrombus.
Which of the following best describes the purpose of eccentric control heel raises?
A) To strengthen the quadriceps muscle.
B) To increase flexibility of the gastrocnemius/soleus complex and Achilles tendon.
C) To improve ankle joint stability through concentric strengthening.
D) To rehabilitate the iliotibial (IT) band.
Correct Answer: B) To increase flexibility of the gastrocnemius/soleus complex and Achilles tendon.
Explanation: The purpose of eccentric control heel raises is to strengthen the gastrocnemius and soleus muscles, focusing on the Achilles tendon complex. This exercise involves both concentric (lifting) and eccentric (lowering) movements, targeting flexibility and strength.
A) Incorrect: The quadriceps muscle is not the target of this exercise; it focuses on the calf muscles.
C) Incorrect: The exercise involves both concentric and eccentric strengthening, not just concentric strengthening.
D) Incorrect: The iliotibial (IT) band is not involved in this exercise; it targets the Achilles tendon and calf muscles.
When performing the gastrocnemius/soleus stretch, what is the correct position for the back leg?
A) The back knee should be bent.
B) The back knee should be straight.
C) The foot should be flexed.
D) The back foot should be elevated on a wedge.
Correct Answer: B) The back knee should be straight.
Explanation: To effectively stretch the gastrocnemius muscle, the back knee must remain straight. A bent knee would target the soleus muscle instead.
A) Incorrect: If the back knee is bent, the focus will shift from the gastrocnemius to the soleus.
C) Incorrect: The foot should be flat on the ground, not flexed, to maintain the proper stretch alignment.
D) Incorrect: Elevating the back foot on a wedge is not the recommended position for this stretch, though it can be used to modify other exercises.
Purpose
Gastrocnemius/soleus stretch
- Increase flexibility of gastrocnemius, soleus, and Achilles
tendon complex
Position
* Standing, split stance with the involved lower extremity (back leg) straight, front knee flexed in a semi-lunge position
* Weight is on the back foot.
* Subtalar joint neutral; a small pad can be placed under the arch, if needed, to prevent excessive pronation and angulation of the muscle complex.
* Hands supported on counter, table, or wall
Action
1. Maintaining the alignment and weight on the back foot, the patient leans forward keeping the back heel on floor and the knee extended to stretch the gastrocnemius.
2. Maintaining the weight on the back foot, flex the knee while still leaning forward, to stretch the soleus.
What is the primary purpose of the iliotibial (IT) band stretch?
A) To improve flexibility in the gastrocnemius muscle.
B) To increase flexibility of the tensor fascia latae (TFL) and IT band.
C) To improve knee stability.
D) To rehabilitate the Achilles tendon.
Correct Answer: B) To increase flexibility of the tensor fascia latae (TFL) and IT band.
Explanation: The iliotibial (IT) band stretch specifically targets the TFL and IT band to improve flexibility and mobility along the side of the leg.
A) Incorrect: The gastrocnemius muscle is not the focus of the IT band stretch; it targets the TFL and IT band.
C) Incorrect: Knee stability may improve indirectly by stretching the IT band, but that’s not the primary purpose of the exercise.
D) Incorrect: The Achilles tendon is not involved in the IT band stretch; it targets the IT band and TFL.
What is the most appropriate modification for a patient who has difficulty balancing during eccentric control heel raises?
A) Increase the speed of the eccentric descent.
B) Perform the exercise seated.
C) Use a small wedge under the heel or perform the exercise with hand support.
D) Limit the range of motion in the ankle.
Correct Answer: C) Use a small wedge under the heel or perform the exercise with hand support.
Explanation: To help patients with balance issues, modifications like a small wedge under the heel or using hand support (such as parallel bars or a counter) can provide more stability.
A) Incorrect: Increasing the speed of the eccentric descent would make the exercise more difficult and could worsen balance issues.
B) Incorrect: Performing the exercise seated doesn’t engage the ankle and foot stability as much, which is the focus of this exercise.
D) Incorrect: Limiting the range of motion would reduce the effectiveness of the exercise, especially in terms of strengthening and flexibility.
In the iliotibial (IT) band stretch, what is a common error that should be corrected?
A) Allowing the pelvis to roll toward the involved leg.
B) Keeping the back foot flat on the ground.
C) Lifting the front knee off the ground.
D) Using a long duration of the stretch.
Correct Answer: A) Allowing the pelvis to roll toward the involved leg.
Explanation: A common error is allowing the pelvis to roll or tilt towards the involved leg, which can reduce the stretch’s effectiveness. Proper positioning of the pelvis is essential for an effective IT band stretch.
B) Incorrect: Keeping the back foot flat on the ground is generally correct during the stretch.
C) Incorrect: Lifting the front knee is not part of this stretch and would make it less effective.
D) Incorrect: A long duration of the stretch is not an error, but rather part of the progression for flexibility.
What is the purpose of the Thompson test in ankle and foot assessment?
A) To test for plantar fasciitis.
B) To assess the stability of the ankle joint.
C) To evaluate the integrity of the Achilles tendon.
D) To determine the range of motion in the ankle.
Correct Answer: C) To evaluate the integrity of the Achilles tendon.
Explanation: The Thompson test is specifically designed to assess the integrity of the Achilles tendon by squeezing the calf and observing for plantar flexion. Lack of movement indicates a potential Achilles tendon rupture.
A) Incorrect: The Thompson test is not used to diagnose plantar fasciitis.
B) Incorrect: This test doesn’t assess ankle joint stability but focuses on the Achilles tendon.
D) Incorrect: The Thompson test doesn’t measure range of motion; it assesses tendon integrity.
What is the role of the Windlass test in assessing foot and ankle conditions?
A) To check for tibial torsion.
B) To assess the function of the iliotibial band.
C) To diagnose plantar fasciitis.
D) To test the flexibility of the Achilles tendon.
Correct Answer: C) To diagnose plantar fasciitis.
Explanation: The Windlass test is used to diagnose plantar fasciitis by testing for pain in the plantar fascia when the big toe is dorsiflexed. Pain during this maneuver is indicative of plantar fasciitis.
A) Incorrect: The Windlass test doesn’t assess tibial torsion; it tests the plantar fascia.
B) Incorrect: The test does not assess the iliotibial band; it’s focused on the plantar fascia.
D) Incorrect: The test does not directly assess the Achilles tendon but is specific to the plantar fascia.
Which of the following exercises is designed to challenge ankle and foot stability using multidirectional movement?
A) Eccentric control heel raises.
B) Multidirectional ankle isometrics against elastic resistance.
C) Gastrocnemius/soleus stretch.
D) Iliotibial (IT) band stretch.
Correct Answer: B) Multidirectional ankle isometrics against elastic resistance.
Explanation: This exercise involves multidirectional resistance, which challenges ankle and foot stability through various movements, helping improve overall strength and stability.
A) Incorrect: Eccentric control heel raises focus on strengthening the calf muscles and Achilles tendon, not multidirectional stability.
C) Incorrect: The gastrocnemius/soleus stretch focuses on increasing flexibility, not on stability.
D) Incorrect: The IT band stretch does not involve ankle or foot stability; it targets the side of the leg.
What is the primary purpose of the neural mobility exercise in the slump position?
A) To improve cardiovascular endurance
B) To increase the gliding of neural structures between surrounding tissues
C) To strengthen the calf muscles
D) To improve spinal flexibility
Correct Answer: B) To increase the gliding of neural structures between surrounding tissues
Explanation:
The primary purpose of neural mobility exercises in the slump position is to increase the gliding of neural structures (like the sciatic nerve) between surrounding tissues, helping to address issues with nerve tension or mobility. This can help improve overall neural function and flexibility.
Position
* Sitting, knees flexed with legs off the edge of the treatment table
Precaution
* This exercise requires caution if there is any neural irritability, and range is adjusted (or holds) to avoid exacerbating symptoms excessively.
Action
Neural mobility (slump position)
Flex the spine forward, and then extend the knee on the involved side to the point of, or slightly
before, reproduction of symptoms (referred pain, tingling, hot/cold sensations) .
2. Dorsiflex and plantarflex the ankle.
3. Release the cervical spine flexion or slump position if the symptoms are too severe. The sequence of the movements can be changed by using proximal (cervical/ trunk) movement and prepositioning the lower extremity just short of the symptomatic range or alternatively prepositioning the trunk and moving the lower extremity.
4. Monitor the type and region of symptoms and use the information from the selective tissue tension and neural mobility tests to select the appropriate position and choice of mobility exercise. Hamstring stretching and neural glides in supine are preferred if there are excessive neural symptoms
Teaching tips
* Instruction examples:
* “Keep your knee straight and look down while you bring your foot and toes up and then point the foot and toes down. You should feel a gentle stretch, but not pain, on the back of your leg. If it hurts, then make the movements smaller.”
Neural mobility (slump position)
Specific parameters for neural mobility
* Range and sequence can be adjusted to target symptom avoidance or reproduction:
* “Flossing,” moving through range without reaching the end range to promote movement
* Move to end range, or the point of symptom reproduction, and then reverse the movement without holding.
* Holding the end range
* The parameters are selected based on SINS, especially irritability. Peripheral nerve sensitization can result in increased symptoms during or after the movement; therefore, it is very important to monitor the degree of irritability and responses.
Alternatives
* Supine or side-lying
* Start without cervical motion or slump
* See Chapter 11 Section 4 (Exercise 11.51) for further alternatives for neural mobility.
Progression
* Increase range by increasing motion at the ankle, knee, hip, or spine.
* Increase repetitions.
* Increase frequency.
* Add cervical flexion or generalized slump.
What position should the patient be in for the neural mobility slump exercise?
A) Lying prone with legs straight
B) Sitting with knees flexed and legs off the edge of the treatment table
C) Lying supine with legs extended
D) Standing with knees locked and legs straight
Correct Answer: B) Sitting with knees flexed and legs off the edge of the treatment table
Explanation:
For the neural mobility slump exercise, the patient should sit with knees flexed and legs off the edge of the treatment table. This position allows for effective stretching and movement of the neural structures while controlling the range of motion.
What should be done if symptoms become too severe during the neural mobility slump exercise?
A) Continue without changing anything
B) Release the cervical spine flexion or slump position
C) Perform the exercise faster to reduce symptoms
D) Increase the range of motion aggressively
Correct Answer: B) Release the cervical spine flexion or slump position
Explanation:
If symptoms such as pain or discomfort become too severe during the neural mobility slump exercise, the cervical spine flexion or slump position should be released. This reduces the pressure on the nervous system and prevents exacerbating symptoms.
What is the purpose of multidirectional ankle isometrics against elastic resistance?
A) To increase flexibility of the ankle joint
B) To develop neuromuscular coordination and reaction time
C) To increase muscle endurance and strength while improving circulation
D) To reduce swelling in the ankle joint
Correct Answer: C) To increase muscle endurance and strength while improving circulation
Explanation:
Multidirectional ankle isometrics against elastic resistance are aimed at increasing muscle endurance, strength, and improving circulation. This exercise is used during the early phases of rehabilitation, especially for reducing effusion and edema.
Purpose
* Multidirectional isometric activation
* Increase muscle endurance
* Increase strength
* Improve circulation to resolve effusion and edema during early Phase I
Precautions
* Specific direction(s) may be contraindicated in the presence of unstable fractures.
Position
* Long sitting with the talocrural joint in the neutral position (or resting position if effusion is present); the ankle
can be off the table or supported
* Elastic resistance band is wrapped around patient’s midfoot.
Action
1. Therapist provides resistance in a variety of directions.
2. The patient resists tension from elastic resistance band without ankle motion.
Which of the following is a key precaution when performing multidirectional ankle isometrics?
A) The ankle should be in a plantarflexed position
B) Avoid any movement in the ankle joint
C) Specific direction(s) of resistance may be contraindicated in the presence of unstable fractures
D) The exercise should be performed only in a supine position
Correct Answer: C) Specific direction(s) of resistance may be contraindicated in the presence of unstable fractures
Explanation:
The exercise involves resistance in various directions, but in the presence of unstable fractures, certain directions of resistance may be contraindicated. Careful attention should be paid to the patient’s specific condition to prevent further injury.
What is the primary goal of perturbation training?
A) To improve range of motion in the ankle
B) To develop neuromuscular and proprioceptive control
C) To increase cardiovascular fitness
D) To strengthen the quadriceps
Correct Answer: B) To develop neuromuscular and proprioceptive control
Explanation:
The goal of perturbation training is to develop neuromuscular control, improve stability, and enhance proprioception, particularly for the lower extremities. This exercise is designed to help improve reaction times and balance in response to external forces.
Which of the following is an appropriate alternative for perturbation training?
A) Using a stationary treadmill
B) Performing upper extremity movements in various planes outside the base of support
C) Engaging in sprinting exercises
D) Using a stationary bike for cardiovascular training
Correct Answer: B) Performing upper extremity movements in various planes outside the base of support
Explanation:
An alternative for perturbation training involves performing upper extremity movements in various planes, which challenges the patient’s balance responses. This alternative allows for progression when the basic perturbation exercise is mastered or needs to be modified.
Correct Answer: B) Performing upper extremity movements in various planes outside the base of support
Explanation:
An alternative for perturbation training involves performing upper extremity movements in various planes, which challenges the patient’s balance responses. This alternative allows for progression when the basic perturbation exercise is mastered or needs to be modified.
What is the correct action during perturbation training?
A) Hold the position and do not move
B) Respond to push and pull forces to maintain balance
C) Focus only on upper body movements
D) Sit on a stability ball for support
orrect Answer: B) Respond to push and pull forces to maintain balance
Explanation:
During perturbation training, the patient is asked to maintain balance while responding to push and pull forces provided by the therapist. This helps improve their ability to stabilize in response to external challenges, which is key for rehabilitation and functional recovery.
Purpose
* Develop neuromuscular and proprioceptive control
* Improve lower extremity stability
* Improve reaction time to changes in direction
* Improve standing balance
Position
* Standing on a rocker board or unstable surface, in double-leg stance hip distance apart with weight distributed equally on both legs
* Knees and hips slightly flexed
* Chest aligned over the forefoot
Action
1. Therapist provides push and pull forces to the rocker board to challenge the patient’s balance reactions
2. Patient maintains static standing position while responding to perturbation.
Which of the following is NOT a goal of the single-leg standing balance exercise?
A) Improve reaction time
B) Improve proprioception
C) Improve cardiovascular endurance
D) Improve single-leg stability
Correct Answer: C) Improve cardiovascular endurance
Explanation:
The single-leg standing balance exercise is intended to improve reaction time, proprioception, and single-leg stability, especially for neuromuscular coordination and muscle activation. It does not directly target cardiovascular endurance.
Purpose
Single-leg standing balance
- Improve generalized force closure and muscle activation (particularly frontal plane hip and ankle stabilizers) using balance challenges
- Improve single-leg stability and neuromuscular coordination after weight bearing precautions or injury
- Challenge ankle and foot stability on unstable surfaces (foam)
- Improve standing balance
- Improve response time
Precautions
* Use upper extremity support if difficulty standing on one leg without loss of balance (Fig. 9.24B).
* Test single-leg balance with guarding before starting the exercise or progressing to more unstable options
Position
* Standing on the involved leg with the knee slightly flexed
* Chest over forefoot
* Subtalar joint neutral, natural bony alignment
* Center of mass is over the midfoot
Action
* Patient shifts weight to the involved leg and lifts the uninvolved leg from floor, maintaining initial alignment on
stance leg with or without arm support.
Which of the following best describes the primary goal of rocker board motion exercises?
a) Improving knee hyperextension for injury recovery
b) Improving standing balance and neuromuscular coordination
c) Increasing hamstring activation and flexibility
d) Enhancing explosive jumping power
✅ Correct Answer: b) Improving standing balance and neuromuscular coordination
Explanation:
(a) Incorrect: Rocker board exercises do not focus on knee hyperextension, but rather on controlled weight shifts and joint stability.
(b) Correct: Rocker board training challenges balance and neuromuscular coordination by requiring active stabilization of the lower limb during movement.
(c) Incorrect: While lower limb muscles like the hamstrings are engaged, flexibility is not the primary focus of rocker board exercises.
(d) Incorrect: Explosive jumping power training is typically done through plyometric exercises, not rocker board work.
Which precaution should be taken before starting rocker board motion exercises?
a) Providing appropriate guarding and support
b) Performing exercises barefoot to increase difficulty
c) Keeping the rocker board tilted to increase instability
d) Avoiding any arm support during early stages
✅ Correct Answer: a) Providing appropriate guarding and support
Explanation:
(a) Correct: Proper guarding and support should be provided to prevent falls and ensure safe execution, especially for patients recovering from injury.
(b) Incorrect: While barefoot training can improve proprioception, it is not always safe, particularly for beginners or individuals with balance deficits.
(c) Incorrect: Keeping the rocker board tilted excessively before the patient develops control can increase fall risk.
(d) Incorrect: Some individuals require arm support early on. Gradual reduction of arm support should be part of the progression.
Which of the following special tests is used to assess an Achilles tendon rupture?
a) Thompson Test
b) Ankle Anterior Drawer Test
c) Windlass Test
d) Calcaneal Squeeze Test
Which of the following is the most common symptom of plantar fasciitis?
a) Dull aching pain at the lateral side of the foot
b) Sharp heel pain, worse with the first few steps in the morning
c) Pain at the Achilles tendon insertion aggravated by dorsiflexion
d) Immediate swelling and bruising after a traumatic injury
