LEC.17. ANKLE AND FOOT.pptx ANKLE AND FOOT

ANKLE AND FOOT

1. ANKLE AND FOOT EXAMINATION AND SPECIAL TEST DR.ABDUL RASHAD IIRS

2. OBJECTIVES Anatomy of foot and ankle Examination Special Test

3. OVERVIEW The ankle and foot is a complex structure comprised of 28 bones (including 2 sesamoid bones) and 55 articulations (including 30 synovial joints), interconnected by ligaments and muscles In addition to sustaining substantial forces, the foot and ankle serve to convert the rotational movements that occur with weight bearing activities into sagittal , frontal, and transverse movements

4. ANATOMY Anatomically and biomechanically, the foot is often subdivided into: The rearfoot or hindfoot (the talus and calcaneus ) The midfoot (the navicular , cuboid and the 3 cuneiforms) The forefoot (the 14 bones of the toes, the 5 metatarsals, and the medial and lateral sesamoids )

5. ANATOMY Ankle joint Articulation of dome of talus in ankle mortice Hinge joint

6. Lateral ligament complex Lateral complex Ant. talofibular calcaneofibular Post. talofibular Syndesmosis Ant. Inf. tibiofibular Post.Inf . tibiofibular

7. Syndesmotic Structures Syndesmosis : Ant. Inf. Tibiofibular ligament Post. Inf. Tibiofibular ligament Transverse tibiofibular ligament Interosseous membrane

8. Medial Ankle Structures Major Ligament complex is called the Deltoid Ligament. It is the strongest of the ankle ligaments

9. Subtalar joint The subtalar joint is a synovial, bicondylar compound joint consisting of two separate, modified ovoid surfaces with their own joint cavities (one male and one female)

10. EXAMINATION

11. STEPS in the PHYSICAL EXAMINATION Consent Privacy Exposure Observation Palpation Range of motion Neurovascular assessment Special tests

12. Exposure Both shoes and socks off. At least have trousers rolled up to the knees, preferably down to underwear

13. Observation Built Posture Weight bearing: equal on both sides Compare weight bearing and non wreight bearing position of foot in Anterior View Posterior View Lateral View See for Contour of Foot Soft tissue swelling Bony callosity

14. Observation- Deformities Forefoot Varus mid tarsal joint- Inversion Subtalar joint- Neutral Forefoot Valgus mid tarsal joint- Eversion Subtalar joint- Neutral

15. Observation- Deformities… Talipes Eqinus Plantar flexed foot Can cause plantar fascitis , metatarsalgia

16. Observation- Deformities… Claw Toes MTP joint- Hyper Extension IP joint- Flexion Hammer Toes MTP- Hyperextended PIP- Flexed DIP- Hyperextended

17. Observation –Deformities…

18. PALPATION SURFACE ANATOMY IS THE KEY!!! Palpate for Local rise of temperature Local tenderness Palpation of specific areas

19. Range of Motion

20. Range of Motion Ankle motion Check the range of motion Dorsiflexion - 10 to 30 Reduce the talonavicular joint Plantar flexion – 20 to 50

21. Range of Motion… Hind foot – Inversion and Eversion Patient sitting on stool with knee flexed at 70 degree Hold ankle firmly from dorsum to fix talus by dosiflexion Hold body of calcaneum in between thumb on one side and index and middle finger on other side with other hand Turn in for inversion and turn out for eversion I= 35 degree E= 25 degree

22. Range of Motion Adduction and Abduction of Fore foot Hold hind foot from dorsum with one hand Hold forefoot with other hand Passively deviate forefoot inward for adduction and outward for adduction

23. SPECIAL TEST

24. Anterior Drawer Test Steps Athlete is sitting over the edge of the table with the knee bent Examiner stabilizes the lower leg with one hand & cups the calcaneus with the forearm supporting the foot in slight plantar flextion (~ 20° ) and slight inversion (few degrees) Examiner draws the calcaneus & talus anteriorly and slighlty medially Positive Test Pain, anterior translation dimple/ sulcus , and/or "clunk" Positive Test Implications ATF ligament sprain/capsular sprain

25. Heel Tap ("Bump") Test Steps Athlete is sitting or lying supine, with the involved foot off the end of the table & the knee straight Examiner stabilizes the lower leg with one hand & bumps the calcaneus with the other hand Examiner bumps the calcaneus 2–3 times with progressively more force Positive Test Pain (at area of complaint) Positive Test Implications Possible fracture

26. Squeeze Test Steps Athlete is sitting or lying with his/her knee extended Examiner cups his/her hands behind the tibia & fibula, away from the site of pain Examiner compresses the tibia & fibula, gradually adding more pressure Positive Test None Positive Test Implications Possible fracture

27. Side–to–Side Test Steps Athlete is sitting (or supine with the knee slightly flexed) Examiner stabilizes the lower leg with one hand Examiner grasps the rearfoot and slides the talus/ calcaneus laterally and medially Positive Test Pain; noticeable "clunk" Positive Test Implications

28. Percussion Test Steps Athlete is sitting with the involved leg off the end of the table Examiner taps distally from the involved structure Positive Test Pain Positive Test Implications Possible fracture

29. Intermetatarsal Glide Test Steps Athlete is supine or sitting with his/her knees extended Examiner is standing in front of the athlete's feet Examiner grasps the heads of the two metatarsals Examiner moves the two metatarsal heads in opposite directions Examiner repeats the procedure until all four intermetatarsal joints have been evaluated Positive Test Pain or increased glide Positive Test Implications Trauma to deep transverse metatarsal ligament and/or interosseus

30. Interdigital Neuroma Test Steps Athlete is positioned in the supine position on the table Examiner uses the eraser end of a pencil to apply pressure to the intermetatarsal space Positive Test Replication of symptoms Positive Test Implications Interdigital neuroma

31. Homan's Sign Test Steps Athlete is sitting or supine with the knee extended Examiner passively dorsiflexes foot while knee is extended Examiner palpates the calf Positive Test Calf pain

32. Tinel's Sign Test Steps Athlete is supine with the hip of the affected side externally rotated and the foot slightly everted Examiner taps over the tarsal tunnel Positive Test Radiating pain in the foot and toes Positive Test Implications Tarsal tunnel syndrome

33. Thompson's Test Steps Athlete is prone with his/her knee extended Examiner squeezes the calf musculature while observing for ankle plantar flexion Positive Test Foot does not plantar flex when calf is squeezed Positive Test Implications Achilles tendon rupture

34. Supple Ples Planus Test Steps Athlete is sitting on the edge of the table Examiner is positioned on a stool facing the athlete Examiner notes the presence of a medial longitudinal arch Examiner has the athlete stand with his/her body weight evenly distributed Positive Test Medial longitudinal arch disappears when weight bearing Positive Test Implications Supple Pes Planus

35. Kleiger's (External Rotation) Test Steps Athlete is sitting with his/her legs over the edge of the table Examiner stabilizes the lower leg with one hand Examiner grasps the medial aspect of the foot while supporting the ankle in neutral Examiner rotates the foot laterally Positive Test Medial/lateral joint pain Positive Test Implications Deltoid ligament sprain

36. Inversion Talar Tilt Test Steps Athlete is sitting with his/her legs over the edge of the table Examiner grasps the calcaneus with one hand & stabilizes the lower leg with the other hand Examiner provides inversion stress rolling the calcaneus inward while the ankle is in neutral Examiner provides an inversion stress by rolling the calcaneus inward while the ankle is in the plantar flexed position Positive Test Talus tilts or gaps excessively; pain Positive Test Implications Involvement of ATF

37. Eversion Talar Tilt Test Steps Athlete is sitting with his/her legs over the edge of the table Examiner grasps the calcaneus with one hand & stabilizes the lower leg with the other hand Examiner provides an eversion stress rolling the calcaneus outward while the ankle is neutral Positive Test Talus tilts Positive Test Implications Deltoid ligament sprain

38. Fracture Test Steps Athlete is supine or seated with his/her feet off the end of the table Examiner grasps the foot around the mid–shaft of the metatarsals & squeezes metatarsals or compresses the bone from one end to the other and rotates the bone Positive Test Pain and/or crepitus Positive Test Implications Possible MT fracture

39. Feiss ' Line Test Steps Athlete is sitting with his/her feet off the end of the table Examiner places a mark on the apex of the medial malleolus , the navicular tubercle & the plantar aspect of the 1st MTP joint & draws a line connecting the marks Examiner has the athlete stand with his/her feet approximately 1' apart & the weight evenly distributed Examiner marks the new position of the navicular tubercle Positive Test Navicular drops more than 10 mm Positive Test Implications Hyperpronation of the foot

40. Last but not the least…. DON’T FORGET TO EXAMINE SPINE , HIP AND KNEE !!!!