Assessment of Lower Leg, Ankle, and Foot PDF

ASSESSMENT OF LOWER LEG, ANKLE, AND FOOT CHAPTER 13 MAGEE - About 80% of the population has foot problems - This will alter the mechanics of gait resulting in movement impairments - Causes stress on lower limb joints - May end up leading to pathology in these joints - Thr...

ASSESSMENT OF LOWER LEG, ANKLE, AND FOOT CHAPTER 13 MAGEE - About 80% of the population has foot problems - This will alter the mechanics of gait resulting in movement impairments - Causes stress on lower limb joints - May end up leading to pathology in these joints - Three principle functions of the lower leg, ankle, and foot - Impact absorption and adaptation to uneven surfaces - Propulsion - Support - In the foot, movement occurring in each joint is minimal, but when they are combined there is normally sufficient range of motion - **FOOT** is divided into 3 sections - [Hindfoot (rearfoot)] - Distal tibiofibular joint - Anterior tibiofibular, posterior tibiofibular, and inferior transverse ligaments - Interosseous ligaments - Minimal movement but allows dorsiflexion - Also allows fibula to move up and down during dorsiflexion and plantar flexion - Talocrural (ankle) joint - Little or no inversion occurs here while in dorsiflexion - Responsible for plantar and dorsiflexion - Medial Ls - Deltoid/medial collateral ligament - Tibionavicular - Tibiocalcaneal - posterior tibiotalar - These 3 resist talar abduction - Anterior tibiotalar - Resists lateral translation and lateral rotation of the talus - Lateral Ls - Anterior talofibular ligament - Resists excessive inversion of talus - Posterior talofibular ligament - Resists dorsiflexion, adduction, medial rotation, and medial translation of talus - Calcaneofibular ligament - Stability against maximum inversion at the ankle and subtalar joints - Subtalar joint - 3 degrees of freedom - Inversion/eversion - Gliding - rotation - Lateral talocalcaneal ligament - Medial talocalcaneal ligament - Interosseous talocalcaneal ligament - Cervical ligament - Medial rotation of leg = valgus (outward) movement of the calcaneus - Lateral rotation of the leg = varus (inward) movement of the calcaneus **TIBIOFIBULAR JOINT** --------------------------- -------------------------------------------------------- Resting position Plantar flexion Close packed position Maximum dorsiflexion Capsular pattern Pain when joint is stressed **TALOCRURAL JOINT** Resting position 10° plantar flexion, midway b/t inversion and eversion Close packed position\*\* Maximum dorsiflexion Capsular pattern Plantar flexion, dorsiflexion **SUBTALAR JOINT** Resting position Midway b/t extremes of ROM Close packed Supination Capsular pattern Limited ROM (varus, valgus) - [Midfoot (midtarsal joints)] - Enable the foot to adapt to many positions - Chopart joint = the midtarsal joints b/t the talus-calcaneus and the navicular-cuboid - Talocalcaneonavicular joint - Cuneonavicular joint - Cuboideonavicular joint - Intercuneiform joints - Cuneocuboid joint - Calcaneocuboid joint **JOINTS OF THE MIDFOOT (MIDTARSAL JOINTS)** ---------------------------------------------- -------------------------------------------- Resting position Midway b/t extremes of ROM Close packed Supination Capsular pattern Dorsi, plantar, adduction, medial rotation - [Forefoot] - Tarsometatarsal joints (all these joints together = Lisfranc joint) - gliding - Intermetatarsal Joints - gliding - Metatarsophalangeal joints - Condyloid (flexion, extension, adduction, abduction) - Interphalangeal joints - Hinge +-----------------------------------+-----------------------------------+ | **TARSOMETATARSAL JOINTS** | | +===================================+===================================+ | RP | Midway between extremes of ROM | +-----------------------------------+-----------------------------------+ | CPP | Supination | +-----------------------------------+-----------------------------------+ | CP | None | +-----------------------------------+-----------------------------------+ | **METATARSOPHALANGEAL JOINTS** | | +-----------------------------------+-----------------------------------+ | RP | 10° extension | +-----------------------------------+-----------------------------------+ | CPP | Full extension | +-----------------------------------+-----------------------------------+ | CP | Big toe: extension, flexion | | | | | | Toes 2-5: variable | +-----------------------------------+-----------------------------------+ | **INTERPHALANGEAL JOINTS** | | +-----------------------------------+-----------------------------------+ | RP | Slight flexion | +-----------------------------------+-----------------------------------+ | CPP | Full extension | +-----------------------------------+-----------------------------------+ | CP | Flexion, extension | +-----------------------------------+-----------------------------------+ What are some causes of overuse injuries in the lower limb?? - See page 996 Magee -- table S/S and risk factors for DVT - Table on page 998 **OBSERVATION P. 999** - Should compare weight-bearing (closed chain) to non-weight bearing (open chain) - Open chain - Talus is fixed - Shows functional and structural abnormalities without compensation - Closed chain - Talus moves to help foot and leg adapt to terrain - Shows how the body compensates for structural abnormalities - Observe from the front, side, and back - Note bony and soft-tissue contour deviations, including callouses - Weight-bearing Anterior view - Note the position of the hips and trunk -- rotation could result in elevation of medial longitudinal arch (fig 13.8), pigeon toes, IT band can cause eversion and lateral rotation of the foot - Tibia -- bowed? Torsion? Can also lead to pigeon toes (toe-in deformity) - Medial malleolus is normally anterior to lateral malleolus - Also look down on feet (anterosuperior view) - Any asymmetry, malalignment - Note where the foot is bearing weight - Just about evenly distributed at heel and metatarsal heads (bit more in heel) - Fick angle -- normal amount of toe-out is 12°-18°, starts at 5° as a child (fig 13-13) - Normal is the following - Forefoot and hindfoot are parallel to one another and the floor - Midtarsal joints are in maximum pronation - Subtalar joint is neutral, parallel to the floor - Talocrural parallel to floor - Looks for bumps, scars, circulatory impairments, swelling, edema - Weight-bearing Posterior View - Compare bulk of calf muscles - Observe achilles tendons - If it curves out, may indicate a fallen medial arch (flatfoot) fig 13-17 - Observe calcaneus - Bumps (pump bump -- from pressure on heels) fig 13-18 - Compare malleoli - Lateral extends more distal than medial - Weight-bearing Lateral View - Primarily looking at the arches - Maintained by 3 mechanisms - Wedging of the interlocking tarsals and metatarsals - Tightening of ligaments on plantar surface of the foot - Intrinsic and extrinsic muscles of the foot and their tensons - Longitudinal (medial and lateral) - Medial = calcaneal tuberosity, talus, navicular, 3 cuneiforms, metatarsals 1-3 - Maintained by tib ant and post, flx dig long, flx hal long, ab dhal, flx dig brev, plantar aponeurosis, plantar calcaneonaviular ligament - Lateral = calcaneus, cuboid, metatarsals 4 and 5 - More stable, less adjustable - Maintained by peronus long, brev, and tertius, abd dig min, flx dig brev, plantar fascia, long plantar lig, short plantar lig - Transverse arch - Navicular, cuneiforms, cuboid, metatarsal bones - Maintained by tib post and ant, per long, plantar fascia - Is medial arch higher than lateral arch (this is normal) fig 13-19, fig 13-20 - Non-weight bearing Position - Supine - Observe the soles of the feet - Shape of metatarsal arch fig 13-27 - 'fall' of arch can be due to equinus forefoot, pes cavus, RA, short heel cord, or hammertoes - SHOES p. 1018 - Normal wear = beneath ball of foot, slightly to t he lateral and posterolateral side of the heel - If too small or narrow may cause deformities - Worn out offer little support - Too stiff limit proper foot movement - Excessive bulging on medial side of shoe = valgus or everted foot - Excessive bulging on later side = inverted foot - Scuffs on toe of shoe, could be from drop foot - Oblique forefoot creases = possible hallux rigidus - No forefoot creaes = no toe-off during gait - Platform of high heels - Knees - Pain from shoes causing you to walk with flexed knees - Calf muscles are contracted, can lead to knee pain - Back - L spine goes into an increased lordotic posture, can lead to pain - Increased risk for sprains and fractures - High heels and pointed shoes - Contribute to hallux valgus, bunions, march fractures, morton's metatarsalgia - Negative heel - Lead to hyperextension of knees and patellofemoral syndrome **COMMON DIFFORMITIES P. 1008** Bunionette (tailor's bunion) fig 13-30 - Prominence of the lateral aspect of the fifth toe metatarsal head - Associated with pronated foot Claw Toes (fig 13-31A) - Hyperextension of the metatarsophalangeal joints - Flexion of the proximal and distal interphalangeal joints - Usually from defective lumbrical and interosseus muscles - Unilateral or bilateral - Associated with pes cavus, fallen metatarsal arch, spina bifida, or neurological problems Clubfoot (fig 13-29) - Congenital deformity - Many forms - Some can be treated without surgery - ROM is limited Crossover Toe (fig 13-35B) - Medial deviation of the toe, usually the second or third - Associated with hallux valgus - Results from weakening ligaments of the MTP joint and pull of extrinsic muscles Curly Toe - Flexion of proximal and distal IP joints, MCP is neutral or flexed, often combined with rotation - Results from contracture of flx dig brev and long tendons - Mostly seen in 5^th^ toe of children Equinus Deformity (Talipes Equinus) - Limited dorsiflexion (less than 10°) at talocrural joint - Usually from contracture of gastroc, soleus, or achille's tendon - Could also be from structural bone deformity, trauma, or inflammatory disease - Stresses forefoot, may lead to rocker-bottom foot and excessive pronation at subtalar joint - Can contribute to plantar fasciitis, metatarsalgia, heel spurs, talonavicular pain Exostosis (Bony spur) fig 13-32 - Abnormal bony growth extending from surface of a bone - In response to irritation from overuse, trauma, or excessive pressure - Common areas - Dorsal TMT joint - Head of 5^th^ metatarsal - Calcaneus (pump bump, runner's bump) - Insertion of plantar fascia - Superior aspect of navicular bone - Often from poorly fitting footwear Forefoot valgus (fig 13-33b) - Structural midtarsal deviation - Eversion of forefoot on hindfoot, prolonged supination of midtarsal joint - Decrease in medial longitudinal arch - Can contribute to lateral ankle sprains, IT band syndrome, plantar fasciitis, anterior tarsal tunnel syndrome, toe deformities, sesamoiditis, leg and thigh pain Forefoot Varus (fig 13-33a) - Structural midtarsal deviation - Inversion of forefoot on the hindfoot, prolonged pronation of midtarsal joint - Decrease in medical longitudinal arch - Can contribute to tibialis posterior paratenonitis, patellofemoral syndrome, toe deformities, ligamentous stress (medially), shin splints, plantar fasciitis, postural fatigue, Morton's neuroma Hallux Rigidus (fig 13-34) - Extension of the big toe is limited because of OA of the 1^st^ MTP joint - May also be caused by an anatomical abnormality - There is an acute type that occurs in adolescence - Chronic type is more common, occurs in adults, men \> women, frequently bilateral - Toe stiffens, pain (especially at the base of the bog toe on walking) Hallux Valgus (fig 13-35)=, 36, 37) - Medial deviation of the head of the first metatarsal, lateral deflection of the phalanx - Women \> men, footwear, genetics - Callus forms, bursa becomes thickened and inflamed, excessive bone forms = bunion Hammer Toe (fig 13-31b) - Extension contracture at the MTP joint and flexion contracture at the PIP joint - DIP may be flexed, straight, or hyperextended - Due to interosseus muscles losing their effect causing an imbalance - Hereditary, mechanical - Usually in 2^nd^ toe, callus or corn over dorsum of flexed joint - Often asymptomatic Hindfoot Valgus (subtalar or rearfoot valgus) fig 13-39b - Structural, eversion of calcaneus - May result from genu valgum - Decreased medial arch, pes planus Hindfoot Varus (subtalar or rearfoot varus) fig 13-39a - Structural, inversion of calcaneus - Medial arch may seem accentuated - May be result of genu varum - May contribute to pump bumps, shin splints, plantar fasciitis, hamstring strains, knee and ankle pathologies Mallet Toe (fig 13-31c) - Flexion deformity of the DIP joint - Can occur on any 4 of the lateral toes - Corn or callus over dorsum - Usually asymptomatic Morton's (Atavistic or Grecian) Foot - Second toe is longer than the first - Metatarsal length makes the difference - Increased stress on longer toe, first toe tends to be hypomobile Morton's Metatarsalgia (interdigital neuroma) fig 13-40 - Aka Morton's neuroma - Interdigital neuroma as a result of injury to one of the digital nerves - Usually between 3^rd^ and 4^th^ toes - Need to differentiate between neuroma and stress fracture of a metatarsal (march fracture) - Fracture is more painful when palpated - Sudden agonizing pain on outer border of the forefoot during walking or running - Intermittent - Squeezing the metatarsals together elicits pain Pes Cavus (hollow foot of rigid foot) fig 13-41, 42) - May be congenital, caused by a neurological problem, or from muscle imbalance - Longitudinal arches are accentuated bilaterally - Metatarsal heads are lower in relation to the hindfoot at the TMT joints - Soft tissues of sole are shortened - If persists, bones may change shape - Claw toes are often associated, may not tough the ground even with AROM and PROM - Pain - Beneath metatarsal heads - Along deformed toes - Tarsal region due to OA changes - Rigid foot - Difficulty with repetitive stress activity - Require a cushioning shoe Pes Planus (flatfoot or mobile foot) fig 13-42, 43 - May be congenital, from trauma, muscle weakness, ligament laxity, dropping of the talar head, paralysis, a pronated foot, postural deformity (medial rotation of hip or tibia) - Common, can cause little to no problem - All infants have flat feet until about 2 years of age - Medial longitudinal arch is reduced, becomes close to or in contact with the ground Plantar Flexed First Ray - Big toe lies lower than the other four metatarsal bones Polydactyl (fig 13-45) - Extra digit or toe - Can be seen with syndactyly (webbing) of the toes or hands fig 13-45 Rocker-bottom Foot - Forefoot is dorsiflexed on the hindfoot - Arches are absent - Foot appears to be bent the wrong way Splay foot - Broadening of the forefoot - Caused by weakness of the intrinsic muscles and intermetatarsal ligament - Dropping of the anterior metatarsal arch Turf Toe - Hyperextension injury (sprain) combined with compressive loading to the MTP joint of the hallux - Related to flexible footwear and artificial turf **EXAMINATION -- RANGE OF MOTION p. 1019** [ACTIVE RANGE OF MOTION --] measure degrees when non-weight bearing Plantar flexion 50° ----------------------------------------- ------------------------------------------- Dorsiflexion 20° Supination 45-60° Pronation 15-30° Toe extension (2-5)/great toe extension MTP 40°, PIP 0°, DIP 30°/MTP 70°, IP 0° Toe flexion(2-5)/great toe flexion MTP 40°, PIP 35°, DIP 60°/MTP 45°, IP 90° Toe abduction ? Toe adduction ? Plantar Flexion - If standing, heel inversion should occur with plantar flexion, if it does not the foot is unstable or there is tibialis posterior weakness or tightness (recall that this muscle supports the medial arch) - Fig 13.53A Dorsiflexion - Ankle lunge test -- standing, place one foot perpendicular to the wall and bend he same knee toward the wall, progressively move the move away from the wall until knee barely touches; measure the distance from wall to big toe, compare sides; differences may be due to tight achille's or talocrural restriction (fig 13.54) Supination and pronation - Important to compare sides since there is a large range that is normal - These movements are a combination of other movements - Supination inversion, adduction, plantar flexion - Pronation eversion, abduction, and dorsiflexion Toe abduction and adduction - Compare sides [PASSIVE RANGE OF MOTION] - End feel is tissue stretch for all ranges - Plantar and dorsiflexion at talocrural joint - Inversion and eversion at subtalar joint - Adduction/abduction at midtarsal joints - Flexion/extension/adduction/abduction of toes - Test dorsiflexion with knee bent (to test soleus) and straight (to test gastroc) - Fig 13.59 [ACTIVE RESISTED RANGE OF MOTION] - Sitting or supine - Knee flexion - Plantar and dorsiflexion - Supination - Pronation - Toe extension and flexion - Foot in anatomical position - Table 13.10 shows all the muscles that act on the lower leg, ankle, and foot - Fig 13.61 -- photos of resisted action, note dorsiflexion (stronger this way) - Include knee flexion (due to tricep surae) [FUNCTIONAL TESTING] - Page 1029 functional activities for lower leg, ankle, and foot & ROM needed for selected activities - Table 13-11 for functional testing of foot and ankle - Allows repetitive movements that mimic activities that cause pain, this will bring about symptoms that take a while to build (compartment syndrome for example); test balance as well **SPECIAL TESTS p. 1035** **TESTS FOR NEUTRAL POSITION OF THE TALUS** - Important to asses the neutral position of the talus in both weight-bearing and on-weight bearing situations - This will help to differentiate between functional and structural deformities - Serves as a reference point - Used to determine foot and leg deviations - If a functional asymmetry occurs on both weight bearing and non-weight bearing, it is structural and functional, if only in weight bearing it is functional only - This position is often called the neutral or balanced position of the foot, it is an ideal position - The foot is neither pronated or supinated - There is 2x more inversion than eversion at the calcaneus - Not commonly found in people in normal weight-bearing (usually subtalar joint is in slight valgus with the forefoot in slight varus and calcaneus in slight valgus) +-----------------+-----------------+-----------------+-----------------+ | TEST | STRUCTURE | CLIENT | RMT | +=================+=================+=================+=================+ | Neutral | Subtalar joint | \- prone | \- grasp foot | | Position of the | | | over 4^th^ and | | Talus (Prone; | | \- foot off the | 5^th^ metaT | | non weight | | end of the | heads with | | bearing) | | table | index finger | | | | | and thumb | | Yellow | | | | | | | | \- with other | | p\. 1035 | | | hand, palpate | | | | | talus on dorsum | | fig 13.68/13.69 | | | of foot on both | | | | | sides | | | | | | | | | | \- then | | | | | passively | | | | | dorsiflex the | | | | | foot until | | | | | resistance is | | | | | felt | | | | | | | | | | \- then move | | | | | foot through | | | | | the arc of | | | | | supination | | | | | (talus bulges | | | | | laterally) and | | | | | pronation | | | | | (talus bulges | | | | | medially) | | | | | | | | | | \- throughout | | | | | this arc, there | | | | | is point where | | | | | the foot | | | | | appears to fall | | | | | more easily to | | | | | one side or the | | | | | other | | | | | | | | | | \- this is the | | | | | neutral | | | | | non-weight | | | | | bearing | | | | | position of the | | | | | subtalar joint | | | | | | | | | | \- best for | | | | | determining | | | | | relation of the | | | | | hindfoot to the | | | | | leg | +-----------------+-----------------+-----------------+-----------------+ | Neutral | Subtalar joint | \- supine | \- grasp metaTs | | Position of the | | | the same way as | | Talus (Supine; | | \- foot off end | above | | non weight | | of table | | | bearing) | | | \- palpate | | | | | talus in the | | Yellow | | | same way as | | | | | above | | p\. 1035 | | | | | | | | \- dorsiflex is | | fig 13.70 | | | the same way as | | | | | above | | | | | | | | | | \- take foot | | | | | through | | | | | supination/pron | | | | | ation | | | | | arc | | | | | | | | | | \- looking for | | | | | the position in | | | | | which the talus | | | | | doesn't appear | | | | | to bulge to | | | | | either side | | | | | | | | | | \- this is the | | | | | neutral | | | | | non-weight | | | | | bearing | | | | | position of the | | | | | subtalar joint | | | | | | | | | | \- best for | | | | | determining | | | | | relation of the | | | | | forefoot on the | | | | | hindfoot | +-----------------+-----------------+-----------------+-----------------+ | Neutral | Subtalar joint | \- standing | \- palpate head | | Position of the | | | of talus on | | Talus | | \- feet in | dorsal aspect | | (weight-bearing | | relaxed | of the foot | | ) | | position | with thumb and | | | | | forefinger | | Yellow | | \- one foot at | | | | | a time | \- client | | p\. 1036 | | | slowly rotates | | | | | trunk to left | | fig 13.71 | | | and then right | | | | | (causes tibia | | | | | to medially and | | | | | laterally | | | | | rotate so the | | | | | talus pronates | | | | | and supinates) | | | | | | | | | | \- no bulge to | | | | | either side = | | | | | neutral weight | | | | | bearing | | | | | position | +-----------------+-----------------+-----------------+-----------------+ | Navicular Drop | Quantify | \- standing | \- use a small | | Test | mobility in | | ruler | | | foot | | | | (variation/exte | | | \- measure the | | nsion | Medial | | height of the | | of neutral | longitudinal | | navicular from | | weight bearing | arch | | the floor in | | test) | | | the neutral | | | | | talus position | | Red | | | (so they need | | | | | to hold trunk | | p\. 1036 | | | rotation) | | | | | | | fig 13.72 | | | \- then measure | | | | | during their | | | | | relaxed | | | | | standing | | | | | | | | | | \- the | | | | | difference is | | | | | called THE | | | | | NAVICULR DROP; | | | | | indicates the | | | | | amount of foot | | | | | pronation or | | | | | flattening of | | | | | the med long | | | | | arch during | | | | | standing | | | | | | | | | | \- 10mm+ = | | | | | ABNORMAL | | | | | (therefore | | | | | positive)\*\* | +-----------------+-----------------+-----------------+-----------------+ **TESTS FOR ALIGNMENT** - Determine the relation of the leg to the hindfoot and the hindfoot to the forefoot - Used to differentiate functional from anatomical/structural deformities or asymmetries +-------------+-------------+-------------+-------------+-------------+ | TEST | STRUCTURE | CLIENT | RMT | POSITIVE/OU | | | | | | TCOME | +=============+=============+=============+=============+=============+ | Coleman | Hindfoot | \- standing | \- place | \- varus | | Block Test | varus | | small block | goes away = | | | | | under | due to | | (se this if | \- due to | | lateral | valgus | | see | forefoot | | side of the | forefoot or | | hindfoot | valgus or | | heel and | plantar | | varus in | is it from | | lateral | flexed | | standing) | a tight | | border of | first ray | | | tibialis | | foot | | | Red | posterior | | | \- varus | | | | | | stays = | | p\. 1037 | | | | tight | | | | | | tibialis | | fig 13.73 | | | | posterior | +-------------+-------------+-------------+-------------+-------------+ | Forefoot- | \- | \- supine | \- position | \- normal = | | Heel | determine | | foot in | plane | | Alignment | if forefoot | \- foot | supine | perpendicul | | | varus or | over end of | neutral | ar | | Yellow | valgus | table | talus | to vertical | | | | | position | axis | | p\. 1037 | | | | | | | | | \- pronate | \- medial | | fig 13.74 | | | the | side of | | | | | midtarsal | foot is | | | | | joints | raised = | | | | | maximally | forefoot | | | | | | varus | | | | | \- observe | | | | | | relation | \- lateral | | | | | between | side is | | | | | vertical | raised = | | | | | axis of the | forefoot | | | | | feel and | valgus | | | | | plane of | | | | | | 2^nd^ thru | | | | | | 4^th^ metaT | | | | | | heads | | +-------------+-------------+-------------+-------------+-------------+ | Leg-Heel | \- hindfoot | \- prone | \- place a | \- if lines | | Alignment | varus or | | mark over | are | | | valgus | \- feet | the midline | parallel or | | Yellow | | over end of | of | in slight | | | | table | calcaneus | varus = | | p\. 1038 | | | at the | normal | | | | | insertion | | | fig 13.75 | | | of the | \- if heel | | | | | achilles | is inverted | | | | | | = hindfoot | | | | | \- second | varus | | | | | mark | | | | | | approx. 1cm | \- if heel | | | | | distal to | is everted | | | | | the first | = hindfoot | | | | | mark | valgus | | | | | | | | | | | \- joins | | | | | | these dots | | | | | | to create | | | | | | calcaneal | | | | | | line | | | | | | | | | | | | \- make 2 | | | | | | more marks | | | | | | on the | | | | | | lower 1/3 | | | | | | of the leg | | | | | | in midline; | | | | | | join them = | | | | | | tibial line | | | | | | (long axis | | | | | | of tibia) | | | | | | | | | | | | \- then | | | | | | place foot | | | | | | in prone | | | | | | neutral | | | | | | position | | +-------------+-------------+-------------+-------------+-------------+ **TESTS FOR TIBIAL TORSION** - Some lateral tibial torsion is normal (13°-18°) - More than 18° = 'toe-out position' - Less than 13° = 'toe-in position' (also called pigeon toes, may be caused by medial tibial torsion, medial femoral torsion, or excessive femoral anteversion) +-------------+-------------+-------------+-------------+-------------+ | TEST | STRUCTURE | CLIENT | RMT | POSITIVE/OU | | | | | | TCOME | +=============+=============+=============+=============+=============+ | Tibial | \- tibia | Prone | \- place | \- see | | Torsion | | | subtalar jt | bullets | | (prone) | | \- knee | in neutral | above about | | | | flexed to | position | degrees | | Yellow | | 90° | | | | | | | \- view the | | | p\. 1038 | | | angle | | | | | | formed by | | | fig 13.76 | | | the foot | | | | | | and thigh, | | | | | | from above | | | | | | | | | | | | \- note the | | | | | | angle the | | | | | | foot makes | | | | | | with the | | | | | | tibia | | +-------------+-------------+-------------+-------------+-------------+ | Tibial | \- tibia | Sitting on | \- place | \- normal | | Torsion | | table | index | angle is | | | | | fingers | 12° to 18° | | (sitting) | | \- knees | over apex | | | | | flexed to | of medial | | | Yellow | | 90° | and lateral | | | | | | malleoli | | | p\. 1039 | | | | | | | | | \- | | | fig 13.77 | | | visualize | | | | | | the axes of | | | | | | the knee | | | | | | and of the | | | | | | ankle | | +-------------+-------------+-------------+-------------+-------------+ | Tibial | \- tibia | \- supine | \- palpate | \- see | | Torsion | | | both | bullets | | | | \- patella | malleoli at | | | (supine) | | straight up | their apex | | | | | | | | | Yellow | | | \- draw a | | | | | | line on the | | | p\. 1039 | | | plantar | | | | | | heel | | | no fig | | | representin | | | | | | g | | | | | | a line | | | | | | joining the | | | | | | two apices | | | | | | | | | | | | \- second | | | | | | line is | | | | | | drawn on | | | | | | the heel | | | | | | parallel to | | | | | | the floor | | | | | | | | | | | | \- the | | | | | | angle | | | | | | formed | | | | | | where these | | | | | | two lines | | | | | | intersect | | | | | | is the | | | | | | amount of | | | | | | lateral | | | | | | tibial | | | | | | torsion | | +-------------+-------------+-------------+-------------+-------------+ | A"Too Many | \- tibial | \- standing | \- view | \- heel | | Toes" Sign | rotation vs | | feet from | valgus, | | | forefoot | | behind | forefoot | | Yellow | | | | ABD, or | | | | | | tibia lat | | p\. 1039 | | | | rot; you'll | | | | | | see more | | fig 13.78 | | | | toes on the | | | | | | affected | | | | | | side than | | | | | | the normal | | | | | | side | | | | | | (lateral | | | | | | torsion of | | | | | | femur could | | | | | | cause this | | | | | | too) | +-------------+-------------+-------------+-------------+-------------+ **TESTS FOR LIGAMENT STABILITY** +-------------+-------------+-------------+-------------+-------------+ | TEST | STRUCTURE | CLIENT | RMT | OUTCOME/POS | | | | | | ITIVE | +=============+=============+=============+=============+=============+ | Anterior | \- anterior | \- supine | \- | \- there is | | Drawer Test | talofibular | | stabilize | sometimes a | | of the | ligament | \- knee at | tibia and | dimple over | | Ankle | primarily | 90° | fibula | the ant | | | | | | talofib L | | Green | (most | | \- hold | (dimple or | | | frequently | | foot in 20° | suction | | p\. 1039 | injured) | | plantar | sign) | | | | | flexion and | | | fig | | | repeat in | \- straight | | 13.79/13.80 | | | dorsiflexio | anterior | | | | | n | translation | | | | | | indicates | | | | | \- draw | both medial | | | | | talus | and lateral | | | | | anteriorly | lig | | | | | OR push leg | insufficien | | | | | posteriorly | cies | | | | | | | | | | | \- can add | \- if tear | | | | | inversion | is only on | | | | | to further | one side, | | | | | stress the | just that | | | | | ligament as | side would | | | | | well as the | translate | | | | | calcaneofib | forward | | | | | ular | while | | | | | lig | causing | | | | | | rotation | +-------------+-------------+-------------+-------------+-------------+ | Prone | Same | \- prone | \- push | \- too much | | Anterior | | | heel | anterior | | Drawer Test | | \- feet | forward | movement | | | | over edge | | and a | | Green | | of table | | sucking in | | | | | | of the skin | | p\. 1042 | | | | on both | | | | | | sides of | | fig 13.88 | | | | the | | | | | | Achilles) | +-------------+-------------+-------------+-------------+-------------+ | Cotton Test | \- | \- seated | -Stabilize | \- lateral | | (lateral | syndesmosis | | tibia and | translation | | stress | instability | \- supine | fibula | of more | | test) | caused by | | | than 3 to | | | separation | \- prone | \- use | 5mm | | Yellow | of the | | other hand | | | | tibia and | ??? | to apply a | \- or a | | p\. 1040 | fibula | | lateral | clunk | | | | | translation | | | fig n/a | \- normally | | force to | | | | held | | the foot | | | | together by | | (not | | | | 4 ligs | | eversion) | | +-------------+-------------+-------------+-------------+-------------+ | Medial | Same as | Same | Same but | Same | | Subtalar | above | | apply | | | Glide Test | | | medial | | | | | | translation | | | | | | force | | +-------------+-------------+-------------+-------------+-------------+ | Dorsiflexio | \- | \- seated | \- | \- pain | | n | syndesmosis | | stabilize | | | Maneuver | of tibia | | leg with | | | | and fibula | | one hand | | | Red | | | | | | | | | \- use | | | p\. 1041 | | | other hand | | | | | | to force | | | fig 13.83 | | | foot into | | | | | | dorsiflexio | | | | | | n | | | | | | | | | | | | \- use hand | | | | | | on heel and | | | | | | forearm on | | | | | | sole of | | | | | | foot | | +-------------+-------------+-------------+-------------+-------------+ | External | \- | \- seated, | \- | \- pain | | (Lateral) | syndesmosis | leg hanging | stabilize | over | | Rotation | injury | | leg with | anterior or | | Stress | | \- knee at | one hand | posterior | | Test/Kleige | \- deltoid | 90° | | tibiofibula | | r | L tear | | \- hold | r | | Test | | | foot in | Ls and | | | | | plantigrade | interosseus | | Green | | | (90°) as if | membrane = | | | | | foot is on | syndesmosis | | p\. 1041 | | | ground | injury | | | | | | | | fig 13.84 | | | \- apply | \- pain | | | | | passive | medially | | | | | lateral | with talus | | | | | rotation | displacemen | | | | | stress to | t | | | | | foot and | from medial | | | | | ankle | malleolus = | | | | | | tear of | | | | | | deltoid | | | | | | ligament | +-------------+-------------+-------------+-------------+-------------+ | Talar Tilt | \- | \- supine | \- hold | \- pain, | | | calcaneofib | or | foot in | hypermobili | | Yellow | ular | sidelying | anatomical | ty | | | lig tear | | position | | | p\. 1044 | | \- knee at | (can put | \- with | | | \- anterior | 90° | into | inversion = | | fig 13.91 | talofibular | | plantar | calcaneofib | | | lig (ATL) | \- test | flex to | ular | | | | bilaterally | stress ATL) | and ATL | | | \- deltoid | | | | | | ligament | | \- tilt | \- with | | | | | talus into | eversion = | | | | | eversion | deltoid L | | | | | and | | | | | | inversion | | +-------------+-------------+-------------+-------------+-------------+ **OTHER TESTS** +-------------+-------------+-------------+-------------+-------------+ | TEST | STRUCTURE | CLIENT | RMT | POSITIVE/OU | | | | | | TCOME | +=============+=============+=============+=============+=============+ | Buerger's | \- arterial | \- supine | \- ask | \- foot | | Test | blood | | client to | blanches or | | | supply to | \- examiner | sit after | prominent | | Red | lower limb | to 45° for | the 3 | veins | | | | at least 3 | minutes so | collapse | | p\. 1044 | | minutes | legs dangle | quickly = | | | | | | positive | | no fig | | | | | | | | | | \- once | | | | | | legs are | | | | | | dangling, | | | | | | it takes | | | | | | 1-2 minutes | | | | | | for colour | | | | | | to be | | | | | | restored = | | | | | | confirmed | | | | | | positive | +-------------+-------------+-------------+-------------+-------------+ | Functional | \- leg | \- standing | \- palpate | \- if | | Leg Length | length | | ASIS and | previous | | | discrepancy | | PSIS (note | differences | | Yellow | | | any | remain, | | | | | difference) | further | | p\. 1046 | | | | examine | | | | | \- then | pelvis and | | fig 13.99 | | | position | SI joints | | | | | client so | | | | | | that | \- if they | | | | | subtalar | go away = | | | | | joints are | functional | | | | | in neutral | leg length | | | | | position | difference | | | | | while | resulting | | | | | weight | from hip, | | | | | bearing | knee, or | | | | | | ankle | +-------------+-------------+-------------+-------------+-------------+ | Homans Sign | \- deep | \- non | \- | \- pain in | | | vein | weight | passively | calf | | Red | thrombophle | bearing | dorsiflex | | | | bitis | | the ankle | (calf will | | p\. 1046 | | | with knee | also be | | | | | extended | tender on | | fig 13-93 | | | | palpation; | | | | | | might be | | | | | | pallor or | | | | | | swelling in | | | | | | leg; loss | | | | | | of dorsal | | | | | | pedal | | | | | | pulse) | +-------------+-------------+-------------+-------------+-------------+ | Matles | \- 3° | \- prone | \- watch | \- should | | Test/Knee | strain | | foot | stay | | Flexion | (rupture) | \- actively | | slightly | | Test | of | flex knee | | plantar | | | Achille's | to 90° | | flexed | | Yellow | tendon | | | | | | | | | \- positive | | p\. 1047 | | | | = foot | | | | | | falls into | | fig 13.100 | | | | neutral or | | | | | | slight | | | | | | dorsiflexio | | | | | | n | +-------------+-------------+-------------+-------------+-------------+ | Morton's | \- stress | \- supine | \- use | \- pain | | (Squeeze) | fracture or | | thumb and | | | Test | neuroma | | index | | | | | | finger of | | | Yellow | | | one hand to | | | | | | squeeze | | | p\. 1047 | | | around the | | | | | | dorsal and | | | | | | plantar | | | | | | aspect of | | | | | | each | | | | | | intermetars | | | | | | al | | | | | | space | | | | | | | | | | | | \- then use | | | | | | the other | | | | | | hand to | | | | | | grasp and | | | | | | squeeze all | | | | | | metatarsal | | | | | | heads | | | | | | together | | +-------------+-------------+-------------+-------------+-------------+ | Swing Test | \- | \- seated | \- hands | \- | | for | posterior | | around | resistance | | Posterior | tibiotalar | \- feet | dorsum of | to normal | | Tibiotalar | subluxation | over the | the using | dorsiflexio | | Subluxation | | edge | fingers to | n | | | | | keep feet | = positive | | Red | | | parallel to | | | | | | the floor | | | p\. 1048 | | | | | | | | | \- use | | | fig 13.102 | | | thumbs to | | | | | | palpate | | | | | | anterior | | | | | | talus | | | | | | | | | | | | \- | | | | | | passively | | | | | | plantar and | | | | | | dorsiflex | | | | | | foot | | | | | | | | | | | | \- compare | | | | | | quality of | | | | | | movement | | +-------------+-------------+-------------+-------------+-------------+ | Thompson's | \- achilles | \- prone or | \- squeeze | \- absence | | (Simmonds') | tendon | kneels on | the calf | of plantar | | Test (sign | rupture | chair | muscles | flexion = | | for | (3-degree | | | positive | | achilles | strain) | | | | | tendon | | | | | | rupture) | | | | | | | | | | | | Yellow | | | | | | | | | | | | p\. 1048 | | | | | | | | | | | | fig 13.105 | | | | | +-------------+-------------+-------------+-------------+-------------+ | Tinel's | \- nerve | n/a | \- tap | \- tingling | | Sign at the | pathology | | along nerve | or | | Ankle | | | distributio | paraesthesi | | (Percussion | | | n | a | | Sign) | | | | distal to | | | | | \- in ankle | where you | | Green | | | can do deep | are tapping | | | | | peroneal N | | | p\. 1049 | | | (in front | \- wed | | | | | of ankle) | space | | fig 13.106 | | | and | tenderness | | | | | posterior | for neuroma | | | | | tibial | | | | | | nerve | | | | | | (behind | | | | | | medial | | | | | | malleolus) | | | | | | and over a | | | | | | suspected | | | | | | Morton's | | | | | | neuroma | | | | | | (extend | | | | | | toes, then | | | | | | tap space) | | +-------------+-------------+-------------+-------------+-------------+ | Windlass | \- plantar | \- stand on | \- | \- pain or | | Test (Great | fasciitis | stool with | passively | increased | | Toe | | metatarsal | dorsiflex | pain at the | | Extension | \- hallux | heads | the great | insertion | | Test, First | rigidus | resting on | toe | of the | | Metatarsal | | the edge of | | plantar | | Rise Test) | | the stool | | fascia | | | | | | | | Yellow | | | | \- lack of | | | | | | extension = | | p\. 1050; | | | | hallux | | fig | | | | rigidus | | 13.108 | | | | | +-------------+-------------+-------------+-------------+-------------+ **REFLEXES AND CUTANEOUS DISTRIBUTION p. 1050** - Fig 13.109 = peripheral nerve distribution - Fig 13.110 = dermatomes of lower leg - This section has a great description of how to complete a sensory. It is what I have already lectured, but it is written down in this section - Also great info on different types of injuries - Reflexes - Achilles tendon (S1-S2) fig 13-103 p. 614 for details - Prone, sitting, or kneeling - Ankle in anatomical or slightly dorsiflexed - Directly with hammer - Reflex is plantar flexion - Posterior tibial (L4-L5) fig 13-104 - Prone - Hit thumb while it is over the tendon (p. 613) - Reflex is plantar flexion with inversion (p. 58) - REVIEW THE MUSCLES/TENDONS THAT PASS BEHIND THE MEDIAL MALLEOLUS (tom dick and harry) - Fig 13.114 = areas of referral pain due to joint issues - Table 13.13 = muscles' referral pain - Table 13.14 = peripheral nerve injury's effects - \*\* what could cause achilles tendonitis? improper warm up/cool down, overuse, improper footwear, improper surfaces for walking/exercise