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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
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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°
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ANATOMY
LATERAL VIEW
ANATOMY
MEDIAL VIEW
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ANATOMY
ANTERIOR VIEW
ANATOMY
POSTERIOR VIEW
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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°)
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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
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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
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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
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PHYSICAL EXAMINATION Observation
Swelling Ecchymosis
PHYSICAL EXAMINATION Observation (Cont’)
Deformities
Ankle Dislocation
Ankle ganglion cyst
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PHYSICAL EXAMINATION Observation Non-weight-bearing (openchain) Weight-bearing (closed-chain)
PHYSICAL EXAMINATION Observation (Cont’) Pes planus (flat foot)
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PHYSICAL EXAMINATION Observation (Cont’)
Left Achilles tendon rupture
PHYSICAL EXAMINATION Observation (Cont’)
Pes cavus (hollow foot) Splay foot (broadening of the forefoot)
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PHYSICAL EXAMINATION Observation (Cont’) Bunion (hallux valgus, callus, thickened bursa, and exostosis)
PHYSICAL EXAMINATION Observation (Cont’) Bunionette (tailor’s bunion) and Plantar Callus
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PHYSICAL EXAMINATION
Observation (Cont’) Hallux Rigidus (stiff big toe) Mostly due to osteoarthritis of 1st MTP
PHYSICAL EXAMINATION
Observation (Cont’) Hammer Toe
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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)
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PHYSICAL EXAMINATION Special Tests
Thompson test for Achilles tendon rupture
Negative
PHYSICAL EXAMINATION Thompson test
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PHYSICAL EXAMINATION Special Tests (Cont’) Anterior drawer test (anterior talofibular ligament integrity test)
PHYSICAL EXAMINATION Anterior drawer test
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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)
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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
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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
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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)
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