The Foot and Ankle The Foot and Ankle EvaluationEvaluation

HistoryPastPast• Has this ever happened BeforeHas this ever happened Before

MechanismMechanism• What happenedWhat happened• How did it happenHow did it happen• When did it happenWhen did it happen• What specific mvmt caused the injury?What specific mvmt caused the injury?• Did you fall? How did you land?Did you fall? How did you land?• Which direction did the body part move?Which direction did the body part move?

Changes in symptomsChanges in symptoms• Symptoms incr. or decr. since injurySymptoms incr. or decr. since injury• Taking any meds?Taking any meds?• Treating it on your own at allTreating it on your own at all

History

Sounds or Sensations– Did you feel any unusual

sensations when it occurred?

– Did you hear any unusual sounds when it occurred?

PainPain• Where does it hurt?Where does it hurt?

Point with ONE fingerPoint with ONE finger

• Rate the painRate the painScale of 1-10Scale of 1-10

• What makes it hurt?What makes it hurt?Specific movements?Specific movements?

positioningpositioning• When does it hurt? When does it hurt? • Can you describe the Can you describe the

pain?pain?

Observation/InspectionMovement– How do they move?– How did he walk in?– What mannerisms did he use during the history?– Facial expressions

Asymmetries/ Deformity– Do both sides look the same?

Obvious deformity– Swelling - Lumps– Markings - Redness/ Discoloration

Sounds

Pes Planus or Cavus

• Structural Deformities

• Pes Planus = flat footed/ no arch

• Pes Cavus = high arch

ObservationStructural Deformities– Valgus or varus

Gait (walking pattern)Shoe Wear

Worn down on the heel = walks mostly on heelsWorn only on ball of foot = walks flat footed or only on toesEtc.

The Gait Cycle

Heel Strike – shock absorptionHeel Strike – shock absorptionToe-off – propel forwardToe-off – propel forward

The Gait Cycle

Have you ever watched people walk?

What do you notice?

Do you think that this can leave people at risk to injuries?

PalpationUsed to confirm or deny assessments.

Start away from the injury and move toward the site of pain (about 2-3 inches when appropriate)

Palpate Bilaterally (both sides)

Start w/ light pressure then move to deeper palpation

PalpationNotice–Point Tenderness

Specific site of pain

–Trigger Points

–CrepitusGrinding, crunching, or crackling sensation with the rubbing of tissues

Tissue Density

Increased Spasm

Scarring

Decreased

Swelling

Hemorrhage

SymmetryAre both sides equal

Temperature

Special Tests

1st Special Tests– Fracture Tests

____________

____________

____________

– ________ ___ ________________________

____________ or ____________

Range of motion

Passive Resistive

LeverBump

Compression

Active

Types of Injuries• Sprain • – tear of a ligament• Strain • – tear/ pull of a muscle• “-itis” • – irritation of

• Tendonitis – irritation of a tendon (joins muscle to bone)• Bursitis – irritation of a bursae (fluid filled sac under tendons)

• Fracture • – break of a bone (complete or incomplete• Dislocation • – Joint pops out and stays out• Subluxation • – joint pops out and goes back in

Ankle InjuriesGrade 1– Stretching or slight tear – Mild pain

Little to no disability

Grade 2– Moderate tear

Moderate pain and disabilityTrouble weight bearing (PWB)Swelling and Bruising may occur

Grade 3– Severe/Total tear of the ligament– Often causes ankle to subluxate

DisablingCannot weight-bear (NWB) – put weight/ pressure on it.

• Fracture (fx)– Avulsion fx

– Piece of bone broken off

– Transverse fx“crack” Straight across

- Evaluation:- Pain with pressure

- Specific site (over bone)- High on the pain scale

- Immediate swelling (tell tale sign IF it happens) - Bump, lever, or compression painful

Ankle Injuries

Fracture Tests• Bump – bump/ tap the end of the bone AWAY

from the site of pain

• Lever – (can only be used with long bones or 2 parallel bones) – a- squeeze both bones AWAY from the site of

pain– b- apply a bending force to the long bones at

each end if pain is in the middle of the bone

• Compression – apply pressure at both ends of the bone simultaneously

Achilles InjuriesTendonitis – irritation of the tendon

Initially slight painOnly hurts after practice/ activity

As it progresses pain lasts longer and gets irritated with even regular walkingHurts to dorsiflex (stretch/ lengthen the tendon)Painful to the touch

Achilles Tendon Rupture (complete tear)– *Common w/ athletes 30+– Cannot “see” the tendon– Gastroc/ Soleus recoil (ball up) towards knee– Athlete cannot plantarflex the foot/ push off

Special Test – Achilles RuptureThompson Test– Positioning

Athlete prone with leg off the tableBoth hands on the calf

– TestSqueeze calf at proximal 1/3

of lower leg– Positive

Foot does not plantarflex

TRY IT!! Have your partner lie on your desk

http://www.youtube.com/watch?v=HPkaNdG2uus

Ankle InjuriesInversion Sprain– PF and inversion

Tears Anterior Talofibular– Pure Inversion

Tears Calcaneofibular

Eversion Sprain– Deltoid ligament

Syndesmotic Sprain (“high” ankle sprain)– Tear anterior and posterior tib-fib– External rotational or forced df

Anterior tibiofibular

ligament

Calcaneofibular ligament

Anterior talofibular

ligament

Ankle Sprains• The only difference between a sprain of the talofibular,

tibiofibular, and calcaneofibular ligaments are the location of pain when it comes to the H.O.and P…..

– History• Lateral ankle pain after “rolling” or “twisting” it• Pain scale depends on the severity and the person• If treating with ice, it helps• May hear a “pop”, but not common

– Observation and Palpation• May see/ feel swelling• Possible limp• Possible bruising (if it has been a couple days)• Specific site of pain

Anterior Talo-fibular sprain

• Pain location

Anterior Drawer– ATaloFib

Positioning– Have the athlete sit with their leg off the table .– Grasp calcaneus w/ one hand– Let foot lie on your forearm– Other hand on tibia

Test– Dorsiflex foot slightly– Pull Calcaneus forward while push tibia backward

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Special Tests

Anterior Drawer cont

•Positive Test–Foot slides forward (laxity)–Makes a clunking sound/ sensation–Pain

Grades of Sprains

• Grade 1 = mild pain, no laxity (movement/ looseness)

• Grade 2 = moderate pain, some laxity

• Grade 3 = severe pain and a lot of laxity

• **If no pain, but is lax (loose) then that is a negative test

Pain Locations

• Deltoid sprain

• Anterior Tibio-fibular sprain (syndesmotic/ high)

Special Tests – Deltoid Lig.Kleiger’s Test– Positioning

Patient seated w/ ankle over the tableStabilize the lower legHold the medial aspect of the foot and evert the foot

– Testrotate the foot laterally

– PositivePain over the deltoid ligament Pain over the lateral malleolus (indicates a syndesmotic sprain)

http://www.youtube.com/watch?v=eDeQcAs9A5M

Tendinitis sites

Foot InjuriesCalcaneus– Heel Spurs– Bursitis– Contusion

Plantar Fasciitis– Common

problem Pain in the proximal arch and heel

Foot Injuries

Morton’s toe– Short Great Toe

Usually benign, may cause probs w/ running

Jones Fracture– Fracture of 5th metatarsal

Foot Injuries

Bunion– Caused by poorly fitting shoes

Hammertoe– Flexion contracture of toes

Turf Toe– Hyperextension

Other Conditions/ Injuries

Tibial Contusion - bruise

Muscle Cramps

Muscle Strain

Other Conditions/ Injuries

Shin splints– Catch-all term for anterior pain

Stress fractures, muscle strains and chronic compartment syndrome

Medial Tibial Stress Syndrome– Due to repetitive microtrauma– Weak muscles - Poor shoes– Overtraining -Running surface– Malalignment

Grades of MTSSGrade 1 – pain after activity

Grade 2 – pain during and after activity – No performance affects

Grade 3– Before during and after– Affects performance

Grade 4– Activity impossible/ too painful

Compartment Syndrome– Acute – secondary to

trauma– Exertional – activity

related– Symptoms

Deep Aching Pain

Tightness and Swelling

Pain w/ stretching

Reduced circulation and sensation

Management of Ankle InjuriesSwelling Management

- RICE – Rest Ice Compression Elevation

- METH – Mobility Elevation Traction Heat

Inversion Ankle Sprains– Light Compression with Horseshoe– Massage– Begin ROM exercises

Syndesmotic Sprain– Takes MUCH longer to heal– Rest/ Immobilize for at least 6-10 days before beginning

ROM exercises

Management of Ankle Injuries

Achilles Tendon Rupture– Surgical Repair or– Cast for 6-8 weeks

Contusion– Doughnut pad to reduce risk of repeated force– Light ROM– Light stretching

Management of Ankle Injuries

Cramps/ Spasms– Massage– Overpressure (trigger point)– Stretching– Monitor hydration and electrolytes if this

becomes chronic

ManagementMedial Tibial Stress Syndrome (MTSS)– Modification of activity– Gait analysis– massage– Stretching– Arch taping – Compression

http://www.youtube.com/watch?v=ea4cInVmIv4

Achilles TendinitisDecrease intensity of activity/ what is aggravating it

Stretching of calf and foot muscles

Look at foot alignment

Recent change in running surface, distance, form, or intensity

Heat

Massage

Heel Lifts

Plantar Fascitis

Comfortable movements (ROM)

Stretch foot and lower leg

Add tennis ball stretch

Strengthen lower leg and foot

Check foot alignment

Tape arches

Night Splint

In-Grown Toe Nail

Soak in hot water for 10-15 minutes

Lift edge of nail and put small piece of cotton under to elevate the nail

Apply antiseptic and cover with a sterile dressing

Or cut a “v” into middle of nail (grows and pulls toward center)

If pus present, refer to MD for antibiotics

Management of Ingrown Toe Nail