5/14/2014

FOOT & ANKLE EXAMINATION WORKSHOP Morteza Khodaee, MD, MPH Ashley Chrisman, PA University of Colorado School of Medicine May 17, 2014

ANATOMY Hindfoot

Inferior Tibiofibular Joint Syndesmosis type with minimum movement Ant. & post. inferior tibiofibular, transverse tibiofibular, and interosseus ligament

1

5/14/2014

ANATOMY Hindfoot

Talocrural (Ankle) Joint Formed by Talus, Med. & Lat Malleoli Uniaxial and modified hinged type Plantar flexion to 50° and dorsiflexion to 20° ATF & PTF, and calcaneofibular lig. laterally Deltoid lig. medially

ANATOMY Hindfoot

Subtalar (Talocalcanean) Joint Formed by talus, calcaneus, navicular, and cuboid Supination 45°-60° and pronation 15°-30°

2

5/14/2014

ANATOMY

LATERAL VIEW

ANATOMY

MEDIAL VIEW

3

5/14/2014

ANATOMY

ANTERIOR VIEW

ANATOMY

POSTERIOR VIEW

4

5/14/2014

ANATOMY Midfoot Chopart’s Joint Midtarsal joints between the taluscalcaneus and the navicular-cuboid Minimum movement

ANATOMY

Forefoot

Tarsometatarsal (Lisfranc’s) Joints Intermetatarsal Joints Metatarsophalangeal Joints Toe extension, lateral four toes (MTP 40°), big toe (MTP 70°) Toe flexion, lateral four toes (MTP 40°), big toe (MTP 45°) Interphalangeal Joints Toe extension, lateral four toes (PIP 0°, DIP 30°), big toe (IP 0°) Toe flexion, lateral four toes (PIP 35°, DIP 60°), big toe (IP 90°)

5

5/14/2014

EVALUATION History Mechanism of Injury Presence of transient or fixed deformity of the foot & ankle at the time of injury Level of activities after the injury

EVALUATION History Swelling or bruising (ecchymosis) Pain characters (location, intensity, type, duration, aggravating and alleviating factors) History of previous injury

6

5/14/2014

PHYSICAL EXAMINATION Observation Lateral View

c

a. Calcaneal apophysitis (Sever’s) b. Achilles tendinosis c. Achilles rupture d. Retrocalcaneal bursitis e. Post. ankle impingement f. Calcaneofibular lig g. Sinus tarsi h. Ant. talofibular lig i. Ant. ankle impingement j. Avulsion Fx of 5th MT

PHYSICAL EXAMINATION Observation Medial View

a. Calcaneal apophysitis (Sever’s) b. Achilles tendinosis c. Achilles rupture d. Retrocalcaneal bursitis

c

e

f

b d a

e. Tarsal tunnel syndrome f. Med. ankle sprain g. Entrapment site 1st branch of lat. plantar n. h. Entrapment site of med. plantar n.

h g

7

5/14/2014

PHYSICAL EXAMINATION Observation Dorsal Foot & Ankle a. Ant. ankle impingement b. Lat. talar dome OCD c. Navicular stress fracture d. Lisfranc sprain e. Ant. tarsal tunnel syndrome f. Bunionette g. Bunion h. Hallux rigidus i. Avascular necrosis of 2nd MT head j. Morton’s neuroma k. Paronychia

a c d e f

j i

h g

k

PHYSICAL EXAMINATION Observation Plantar Foot & Ankle a

a.Plantar fat pad b.Plantar fasciitis c.Avulsion fracture of the 5th MT d.Stress fracture of the 3rd MT e.Stress fracture of the 2nd MT f. Sesamoiditis g.Metatarsalgia

b

c

ed f

g

g g

g

8

5/14/2014

PHYSICAL EXAMINATION Observation

Swelling Ecchymosis

PHYSICAL EXAMINATION Observation (Cont’)

Deformities

Ankle Dislocation

Ankle ganglion cyst

9

5/14/2014

PHYSICAL EXAMINATION Observation Non-weight-bearing (openchain) Weight-bearing (closed-chain)

PHYSICAL EXAMINATION Observation (Cont’) Pes planus (flat foot)

10

5/14/2014

PHYSICAL EXAMINATION Observation (Cont’)

Left Achilles tendon rupture

PHYSICAL EXAMINATION Observation (Cont’)

Pes cavus (hollow foot) Splay foot (broadening of the forefoot)

11

5/14/2014

PHYSICAL EXAMINATION Observation (Cont’) Bunion (hallux valgus, callus, thickened bursa, and exostosis)

PHYSICAL EXAMINATION Observation (Cont’) Bunionette (tailor’s bunion) and Plantar Callus

12

5/14/2014

PHYSICAL EXAMINATION

Observation (Cont’) Hallux Rigidus (stiff big toe) Mostly due to osteoarthritis of 1st MTP

PHYSICAL EXAMINATION

Observation (Cont’) Hammer Toe

13

5/14/2014

PHYSICAL EXAMINATION Range of Motion (active & passive) Ankle plantar flexion 50° Ankle dorsiflexion 20° Supination 45°-60° (inversion, adduction, and plantar flexion) Pronation 15°-30° (eversion, abduction, and dorsiflexion) Resisted Isometric Movements Supination

Pronation

PHYSICAL EXAMINATION Palpation Medial & lateral malleoli Medial & lateral ligament complexes Base of 5th metatarsal Distal tibiofibuar joint Talus, calcaneus, navicular, cuneiform, and cuboid bones Achilles tendon Peroneal tendons Metatersal bones MTP, PIP, and DIP joints Neurovascular exam (DP & PT pulses, cap refill, sensation)

14

5/14/2014

PHYSICAL EXAMINATION Special Tests

Thompson test for Achilles tendon rupture

Negative

PHYSICAL EXAMINATION Thompson test

15

5/14/2014

PHYSICAL EXAMINATION Special Tests (Cont’) Anterior drawer test (anterior talofibular ligament integrity test)

PHYSICAL EXAMINATION Anterior drawer test

16

5/14/2014

PHYSICAL EXAMINATION Anterior drawer test - prone

PHYSICAL EXAMINATION Special Tests (Cont’) Talar tilt test

Assessing CF lig in anatomic (90°) position Assessing ATF lig when ankle is plantar flexed (inversion stress test)

17

5/14/2014

PHYSICAL EXAMINATION Talar tilt test

PHYSICAL EXAMINATION Special Tests (Cont’) Squeeze test of the leg (distal tibiofibular compression test) for syndesmosis injury

positive, if elicits pain over the distal anterior syndesmosis

18

5/14/2014

PHYSICAL EXAMINATION

Special Tests (Cont’) Coronal (side-to-side) drawer or Cotton test for syndesmosis injury

PHYSICAL EXAMINATION Special Tests (Cont’) External rotation stress test for syndesmosis injury

19

5/14/2014

PHYSICAL EXAMINATION Special Tests (Cont’) Dorsiflexioneversion test to reproduce the symptoms of tarsal tunnel syndrome Tinel’s sign at the ankle

PHYSICAL EXAMINATION Special Tests (Cont’) Homans’ sign

Pain in the calf with passive and forced dorsiflexion of ankle

Peroneal tendons subluxation/dislocation test

Peroneus lungus (resisted eversion in a dorsiflexed ankle) Peroneus brevis (resisted dorsiflexion of 1st metatarsal in an everted foot)

20