Ortho Foot and Ankle Exam Breakdown PDF

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...

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 Joker Lohman 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 palpation ○ Lateral malleolus ○ Medial malleolus Ankle palpation ○ 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 Jabar Lohman 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 putsstressonmidportion 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