Ortho - Foot and Ankle Exam Breakdown PDF

Foot and Ankle  Ortho - Foot and Ankle Exam Breakdown Ankle Sprain - 15 Low vs. High Ankle Sprains Low Ankle Sprain High Ankle Sprain MOI Inversion + Plantar Flex...

Foot and Ankle  Ortho - Foot and Ankle Exam Breakdown Ankle Sprain - 15 Low vs. High Ankle Sprains Low Ankle Sprain High Ankle Sprain MOI Inversion + Plantar Flexion TIbial ER and/or Ankle DF Structures ATFL, PTFL, Calcaneofibular Ligt. Syndesmotic injury Prognosis Shorter than high ankle sprain (1w) 15 - 46 days (2-7 weeks) Fibularis Long & Brevis DF + INV injury Fibularis Tertius PF + INV injury Low Ankle Sprain 40% of cases develop into persisting symptoms resulting in long standing dysfunction of Chronic Ankle Instability (CAI): Chronic pain Reoccurring sensation of instability Reccurent episodes of giving away Loss of function Chronic Ankle Instability ICF Impairments l Anterior Talofibular Ligament (ATFL) Provides primary restraint to inversion moment when the ankle is in a plantar-flexed position Maximal displacement of the talus from an applied anteriorly directed force was found to occur with the ankle in 10 deg plantar flexion when compared to 0 deg or 20 of plantar flexion ○ Relevance: perform anterior drawer test in 10 deg of PF 50% of ATFL tears occur with avulsions from the fibula, other half are mid-substance tears First to tear with low ankle sprain Calcaneofibular Ligament (CFL) Stronger and thicker than ATFL Although tension within the ligament increases within DF, it resists ankle INV throughout full ROM Since CFL crosses both the ankle and subtalar joints, injury to this ligament (Grade 3) may have a more profound functional effect on the ankle complex compared to isolated injuries to the ATFL (Grade 2) Posterior Talofibular Ligament (PTFL) Strongest of the lateral ligaments and rarely injured in low ankle sprains Provides functions to provide transverse plane rotatory stability Movements that involve extreme ankle DF and foot (tibial) ER, and pronation along with limb IR may cause injury to the PTFL ○ Motions associated with high ankle sprain Low Ankle Sprain Grades Return to Sport 6.5 days → 12 days → 6w or 42 days → (30d longer than grade II) Ottawa Ankle Rules (Grade A) Mid foot ○ Lateral malleolus ○ Medial malleolus Ankle ○ Navicular ○ Base of the 5th Unable to weight bear 4 steps Bernese Ankle Rules (Grade A) Functional Tests - 90% of uninvolved side (Grade B) Lateral hop for distance Side hop test 6m crossover hop test Physical Examination Strength impairment Ankle girth - swelling Mobility Dynamic Balance ○ Forward Reach Test - 4cm BESS test Special tests: anterior drawer and talar tilt test Intervention - Ankle Sprain General Interventions MICE OKC is safe and effective in early rehab, but CKC challenge muscle more Progressively load patients MWM Treat lateral line chain REFER TO CPG CHART Acute/Protected Motion Phase of Rehab A: B: MICE : Progressive Loading/Sensorimotor Training Phase of Rehab A: C: Achilles Tendinopathy - 8 Basic patient examination Gradual onset of pain Pain 2-6 cm to achilles insertion Pain with tendon palpation Positive arc sign Positive Royal London Hospital test Tendons are broad proximally, round in the middle, and broad again distally at calcaneus This spiraling causes Soleus oriented (inserted) anterior and medial Gastroc oriented (inserted) posterior and lateral Rearfoot eversion/pronation tensions which components of the Achilles most? Midportion Vascular density is greatest proximally and least in the mid-portion of the Achilles tendon Tendon model (based on changes and distribution of disorganization within the tendon) 1. Reactive tendinopathy 2. Tendon dysrepair 3. Degenerative tendinopathy (jelly paratenon) Instrinsic Risk Factors - Achilles Tendinopathy Decreased DF ROM Abnormal increased or decreased subtalar joint ROM Decreased PF strength Increased foot pronation Abnormal tendon structure Extrinsic Risk Factors Training errors in runners Environmental Faulty equipment Sports participation/active MOI - Ruptures Most common mechanims is: ○ Forceful push-off ○ Forceful PF → DF Signs/Symptoms ○ Pop or snap, pain, decreased DF or function Symptoms - Midportion Achilles Tendinopathy Intermittent pain - related to exercise of activity Morning stiffness or arising pain ○ Reports of pain or stiffness upon WB after prolonged rest or sleep Warm-up phenomenon ○ Pain upon commencing walking or running that improves after a few minutes Unstable disorder ○ As condition worsens, a progression from pain felt towards the end of the exercise session to pain throughout the duration of activity occurs Signs - Midportion Achilles Tendinopathy Thickened nodule Palpation test Decrease PF endurance - unilateral heel raises (normal = 20) Arch sign - area of palpated “swelling” moves with DF and PF Royal London Hospital Test Midportion Insertional Cause Overuse, sudden increase in Compression from end range DF stretch-shortening activities Stretching Yes (Grade C) Contraindicated Heel Raises Elevated step Start on flat floor ONLY Eccentrics Yes, especially athletic pts Less favorable, especially for unathletic pts Physical Performance Measures Jump tests: hopping, counter movement jump (CMJ), drop CMJ Strength tests: concnetric and eccentric/concentric heel raises Endurance test - repitive heel raises 71-100% of patients with achilles tendinopahty are able to return to their prior level of activie with minimal or no complaints Intervention 1-RM: Single-Leg Heel Raise Up to “minimal” pain allowed Tyler Cuddeford recommends up 300% BW Progressive Resistive Eccentric Exercise Program Concentric phase ○ Double leg heel raise Eccentric phase ○ Slow controlled lowering on single leg Starting weight ○ 80% 1RM ○ 150% BW and increased to 1RM Source of loading ○ Leg press machine ○ Calf raise machine Foot and Heel Pain - 3 Plantar Fasciitis Plantar Fasciitis Chronic Appears in all ages Active and sedentary 24 hour behavior First steps of the day are most painful Pain intensifies again as the day progresses Aggravating work-related factors ○ Prolonged standing ○ Jumping off equipment ○ Prolonged walking Pain with WB after prolonged rest Night pain rare Risk Factors Running: ○ On road, in cleats, rear-foot strike, crossover gait (gen foot pain) Jumping jobs (USPS driver) Decreased DF Increased or decreased arch height ○ Normal 131-152 deg Hamstring tightness Leg length discrepancy High BMI How to Dx Pain with palpation of proximal plantar fascia insertion Limited active and passive talocrural DF ROM Negative tarsal tunnel test Positive Windlass test Positive medial longiduninal arch angle Treatment Ankle and Hallux ROM and Gait - 2 DF needed: DF needed for lateral step down Walk (TSt): 10 (non WB) Good: 55 deg DF Run: 20 (non WB) Moderate: 45 deg DF Full squat: 40 (WB) Poor: 35 deg DF Sample Questions - Achilles General Evidence Based Practice -2 Hip  Ortho - Hip Exam Breakdown Pathology/Presentation - 6 How to assess for certain pathologies - 7 Intervention for particular pathologies - 9 Movement and compensations that could occur - 2 CPG - 2 Case study similar to study in slides - 4 Hip dysplasia Pathology Dysplasia - shallow acetabulum/decreased coverageof femoral head Instability - increased stress on anterior capsul More common in women DDH - Developmental Dysplasia of Hip → Intervention - DHH Genetic pre-disposition Pavlik harness: birth to 6m Ligament laxity Avoid swaddling legs together Intrauterine crowding/breech position Avoid sling carriers that don’t support Postnatal positioning femurs Hip spica cast: 3-6m Presentation - Adult Insidious onset of symptoms Moderate to severe groin pain/lateral hip pain Activity restriction = decreased pain Limp Positive impingement sign (secondary to instability) May have catching or popping sensation Intervention - Adult Goal: reduce risk of early onset OA (dx related to joint instability) PT ○ Progress from isometric → concentric → eccentric ○ Activity modification education: avoid high impact sports and painful activities ○ Lumbopelvic and LE neuromuscular control - double to single leg ○ Periacitbular ostemotomy (PAO) for severe case ○ Derotational osteotomy of femur  Slipped Capital Femoral Epiphysis Pathology Displacement of femoral head in relation to femoral neck Occurs in adolescents Weaknesss of epiphyseal plate Femoral head slips inferiorly and posteriorly More frequently in boys Categorized as stable or unstable Presentation Muscle guarding +/ trendelenburg Intermittent groin pain, hip, knee, &/or thigh pain Pain worse with activity Antalgic gait Limited IR ROM Compensatory ER w hip flexion - Drehmann sign Presentation - Unstable SCFE Sudden onse tof hip/thigh pain (often after fall/injury) Inability to WB Position of ER of affected leg LLD - affected leg may appear shorter Legg-Calve'-Perthes Pathology Idiopathic loss of blood supply to femoral head ischemia Osteonectrosis/collapse of femoral head/neck More common in boys ages 4-10 Resultant deformity of femoral head and OA Presentation Growin, thigh, medial knee pain Antalgic gait &/or + trendelenburg Decreased hip abductor function Muscle spasms Limited ROM Thigh atrophy and sometimes limb shortening Intervention Intervention goal - prevent collapse of femoral head Containment: bracing, NWB, bed rest, casting with hips abducted Surgical: osteotomy PT post surgery  Osteoarthritis Pathology Primary aging/genetic predisposition (age >50) Secondary ○ Previous injury ○ Metabolic abnormalities ○ SCFE, LCP, femoral anteversion, dysplasia, FAI CAM lesion Degredation of articular cartilage Narrowing joint space Osteophytes Sclerosis of bone “Loose bodies” or debris Presentation - Clinical Prediction Rule Must have all 5 1. Squatting as aggravating factor 2. Positive scour test for groin or lateral hip pain 3. Active hip flexion causing lateral hip pain 4. Passive IR less than 24 deg 5. Active hip extension causing hip pain Intervention Flexibilty, strengthening, and endurance exercises - A Manual therapy (soft tissue and joint mob) - A Functional gait and balance training - B Patient education combined with exercise - B Modalities - B Weight loss - C MWM shown to be beneficial to immediately decrease hip pain to increase hip function during PT  Rheumatoid Arthritis Pathology Systemic - autoimmune Involves synovial lining, cartilage, and bone Begins age 15-50 Presentation Groin pain Concurrent swelling, redness, increased temp in other joints General feeling of fatigue, weight loss, fever, cardiac, and respiratory symptoms Morning stiffness > 1 hour + rheumatoid factor Symptoms bilateral may occur suddenly or slowly Intervention Pain management Assistive device Education ROM/strengthening to prevent further joint damage Synovectomy (cartilage still intact) THA (more difficult secondary to bone loss/density) Gluteal Tendinopathy Pathology “Failed-healing” response w disorganziaed collagen bundles More often in females Insidious onset Middle aged Presentation Pain w resisted IR, ER, and abd Pain w palpation around greater trochanter Pain w passive adduction Pain w 30 SLS test ○ Positive trendelenburg sign w increased pain as test progressed) ○ Greater hip adduction and pelvic obliquity with movement PT - Intervention Load management ○ Reduction of compressive forces ○ Strengthening of the gluteal muscles Improve pelvic core control Change faulty movement patterns (excessive adduction) Eccentric exercise (to normalize tendon structure) Education (avoid excessive SLS, crossing legs, sleeping on side)  Femoral Acetabular Impingement Syndrome Pathology FAI - abnormal acetabular and femoral head/neck morphology FAIS - a movement related disorder with symptoms and clinical findings Leading cause of labral tears Casues chondral damage and leads to OA 3 types ○ CAM ○ Pincer ○ Combined (CAM and pincer) CAM deformity Femoral irregularity/aspherical 2x prevalent in males Exotosis on femoral head and neck Abnormal contact of femoral head and acetabulum Damge to acetabular cartilage then subsequent damage to labrum Pistol grip deformity Pincer deformity Refers to acetbular irregularity - over coverage Premature abutment of femoral neck on anterior acetabular rim Pinching of labrum Radiographic finding CAM morphology - increased femoral neck diameter Pincer morphology - increased acetabular depth, decreased acetabular inclination, acetubular retroversion A presence of a CAM or Pincer deformity does not equal a clinical dx of FAIS Presentation Active young adults Slow-onset, persistent, intermittent groin pain + FADIR (positive impingement sign) Decrease in ROM (flexion and IR primarily) Symptoms - clicking, catching, locking, stiffness Aggravated with cutting, lateral movements, starting/stopping, long periods of ambulating Aggravated with squatting, driving, sitting extended time PT Intervention - FAIS Greater Trochanteric Pain Syndrome (GTPS) Pathology Umbrella term for a cluster of symptoms May include ○ Trochanteric bursitis ○ Abductor tendinopahty abnormal mechanical loads with altered cellular response (primary cause) ○ External coxa saltans (external snapping hip) Presentation Indisidous, chronic, intermittent or constant, proximal lateral hip pain (may radiate to the distal thigh) Pain with palpation of greater trochanter Inability to lay on affected side Limping Difficulty with sit to stand transfer and stair climbing Sitting with affected leg crossed Positive 30 second single leg stand test (due to pain not necessarily weakness)  Labral Lesions Pathology Associated with OA ○ Risk of chondral damage doubles with presence of labral lesion Labrum functions as: ○ Shock absorber ○ Pressure distributor ○ Joint stabilizer ○ Contributes to joint proprioception Presentation Anterior hip/groin pain Catching, locking, clicking, or giving away sensation Limitations in ROM, particular in rotation Dull pain, episodic sharp pain, worsens with activity or prolonged sitting Provocation tests ○ + FADIR = anterior tear ○ + EABER = posterior pain/posterior tear Conservative Treatment Anti-inflammatory meds Limit pivoting motions/modify ADL’s Trial 10-12 weeks of PT ○ Limit anteriorly directed forces on hip ○ Strengthen inhibited muscles ○ Joint mobilization Surgical Intervention Debridement/resection vs repair Goal = to preserve seal effect of labrum Lateral labral tear (has vascular supply to heal) Larbal repair (grafts) ○ Can use ITB, gracilis, semitendinosis  Iliotibial Band Syndrome Pathology Lateral hip or knee pain Weaker hip abd strength Related to increased peak hip adduction and knee IR (during stance) Relationship of hip abductor weakness, side-to-side imbalances in strength Intervention = activate glute med while minimizing activation of TFL Avulsion Fractures Pathology Location: Most seen in boys ages 14-17 Presentation Sudden pain Limited active motion Weakness Conservative Treatment = limit motion and stress at site Ischemic Necrosis of Femoral Head (AVN) Pathology Avascular necrosis bone tissue death Femoral head blood supply interrupted Presentation Groin pain (exacerbated by WB and relieved by rest) ○ Worsens over time and with use Limitation in ROM in non-capsular pattern Crepitius/antalgic gait Seen on imaging Treatment = NWB/Surgery  Coxa Saltans/Snapping Hip Pathology Intra-articular (any derangement of inferior hip joint) ○ Labral tear ○ Ligamentum teres tear ○ Loose body Extra-articular → ○ Internal ○ External Presentation Catching, clicking, “stuck” sensation May or may not have pain Maybe lateral with visible snap - ITB or gMax May be deep anterior with audible snap - iliopsoas Glute med weakness often associated with internal coxa saltans Conservative Treatment Asymptomatic - most “snapping” is benign Symptomatic ○ Treat iliopsoas tightness ○ Neuromuscular eccentric control of iliopsoas ○ Modify movement patterns (ex: imbalance between gMax and TFL) ○ Strengthen ER and abductors Muscular Lesions Hamstring Injury Increased risk = previous hamstring injury, imbalance, poor flexiblity, limited ankle ROM Assessment: taking shoes off test (100%) Prevention - exercise ○ In lengthening positions ○ Eccentric ○ Hip extension/glute strengthening Hamstring Tendinopathy/Tendinosis Overuse injury → fails to heal → chronic Pain in lower gluteal region (at times radiating into hamstrings) Increased running speed and sitting = increased pain Stretching of hamstrings = worsening Palpable pain and tenderness of ischial tuberosity w resisted knee flexion Treatment = progressive eccentric hamstring strengthening at higher hip angles Adductors Adductor role ○ Adduct thigh in open chain ○ Stabilize LE in all planes in closed chain ○ Decelerates hip extension into toe off, concentrically assists w hip flexion during swing (particularly during running)  Gluteal Syndrome Pathology Cluster of complex pain generators in posterior hip buttock region - possible referral of leg and foot pain Commonly attributed to piriformis - close relationship between piriformis and sciatic nerve Non-disconegenic extrapelvic entrapment of sciatic nerve Structures that can cause entrapment: ○ Piriformis (piriformis syndrome) ○ Fibrous bands of tissues with blood vessels ○ Hamstring (hamstring syndrome) Presentation Buttock pain - worse w prolonged sitting or activity Referred pain to knee - numbness and paresthesia Glute max atrophy Positive SLR and slump test (exacerbated by hip flexion/rotation) Isometric piriformis contraction may exacerbate symptoms Assessment FAIR test - piriformis stretch or piriformis contraction Straight leg raise Neural mobilizations of sciatic nerve (slump test) Piriformis/ischial palpation positive for reproduction of pain Intervention Relative rest, activity modification Glute med and glute max strengthening ○ Need to offload piriformis Alteration of sitting position Avoid stretching hamstrings Nerve flossing  Athletic Pubalgia/Core Muscle Injury (CMI) Pathology Chronic abdominal and groin pain sometimes radiating into perineum/proximal adductors Acute or insidious onset Exacerbated by kicking, cutting, and sprinting Muscle imbalance - chronic overload of musculature outside hip joint Shearing force across pubic symphysis from repetitive motion against a fixed extremity = avulsion of fascia/musculature of posterior inguinal wall Rectus abdominus and adductor longus intimately involved in most core muscle injuries Risk Factors Adductor to abductor strength ratio Delay of abdominal muscle recruitment Decreased levels of pre-season sport specific train ing More common in males/active population Structural associations: FAI and dysplasia → Repetitive turning and twisting sports - core rotation on planted foot Presenation Pubic, medial thigh/groin pain Exertional adductor/inguinal pain Pain with: ○ Palpation of → ○ Resisted sit up ○ Resisted hip adduction &/or SLR ○ Pain w coughing Decreased hip IR Increased lumbar extension / decreased hip extension Intervention Hip Chart  Pathology Presentation Common Imparments/Movement Assessment Treatment Dysfunction FAIS - Slow onset of persistent/intermittent groin pain - Decrease in ROM (flexion and - ROM (flex and IR) - Modify ADL and positions to minimize joint - Increased pain w hip in flexed position IR) - SCOUR (gen test) loading - Clicking, catching, locking, stiffness - Reduced strength and motor - FADIR, DIRI - ant - Avoid repetitive deep hip flex and IR - Aggravated by sports movements and control - EABER, DEXRIT - posterior - Hip strengthening walking/sitting for extended time - pain with deep squat, prolonged - Lat Rim Impingement - Postural control/core stabilization sitting, criss-cross - Joint mob/stretch in pain-free ROM - Neuromuscular re-ed Labral Tear - Ant hip/groin pain - Limitations in ROM, particularly - FADIR = ant tear -Limit pivoting motions and anteriorly directed - Catching, locking, or giving away sensation rotation - EABER = posterior pain/tear forces on hip, modify ADLs - Dull pain, episodic sharp, worsens w activity or - Capsular laxity/hip hypermobility - Passive accessory motion - Strengthen inhibited motions prolonged sitting - Dysplasia - ROM (flex, IR, ER) - Joint mob (post/inf glide) Osteoarthritis - Ant/Lat hip pain during WB - Hip IR ROM < 24 -Clinical Prediction Rule - Stretch ERs and Flexors - Morning stiffness < 60 min - Hip IR and flex 15 deg less than - Scour’s test - Joint mobs: inf glide, long axis distraction, MWM non non-painful side - Drehman sign at 90 deg flex and IR - ROM: IR < 24 deg - Strengthening w motor control emphasis and - Pain during active hip flexion or offloading of structures extension, during passive IR - Functional gait and balance training Athletic - Pubic, medial thigh/groin pain - Decreased Hip IR and ext - Muscle imbalances: Abd/Add -Stability and motor control Pubalgia - Core - Pain w palpation of certain structures, resisted sit - Increased lumbar ext - Decreased ROM - Core ex Muscle Injury ups/hip add/SLR, coughing - FADER - no stretching Greater - Indisidous, chronic, intermittent or constant, - Limp - Palpation of GT -Strengthen glutes Trochanteric proximal lateral hip pain - Difficulty w sit to stand transfer - 30 second SLS test - Improve postural control Pain Syndrome - Unable to lie on affected side and stair climbing - Lag sign - Movement coordination - Weak glute med - Eccentric ex - Sit with affectedleg crossed - Weak postural control Deep Gluteal -Buttock pain (worse w prolonged sitting or activity) - Glute weakness - SLR - Glute med and max strengthening Syndrome - Referred pain to knee - parasthesia/numbness - Slump test - Alteration of sitting position - Glute max atrophy - FAIR - Nerve flossing - Palpation of piriformnis/ischial - Stretch piriformis (theory #1) tub - No stretching hamstrings