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FOOT & ANKLE EXAMINATION WORKSHOPMorteza Khodaee, MD, MPHAshley Chrisman, PAUniversity of Colorado School of MedicineMay 17, 2014

ANATOMYHindfoot

Inferior Tibiofibular JointSyndesmosis type with minimum movementAnt. & post. inferior tibiofibular, transverse tibiofibular, and interosseus ligament

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ANATOMYHindfoot

Talocrural (Ankle) JointFormed by Talus, Med. & Lat MalleoliUniaxial and modified hinged typePlantar flexion to 50° and dorsiflexion to 20°ATF & PTF, and calcaneofibular lig. laterallyDeltoid lig. medially

ANATOMYHindfoot

Subtalar (Talocalcanean) JointFormed by talus, calcaneus, navicular, and cuboidSupination 45°-60° and pronation 15°-30°

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ANATOMYLATERAL VIEW

ANATOMYMEDIAL VIEW

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ANATOMYANTERIOR VIEW

ANATOMYPOSTERIOR VIEW

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ANATOMY

Midfoot

Chopart’s Joint

Midtarsal joints between the talus-calcaneus and the navicular-cuboidMinimum movement

ANATOMY ForefootTarsometatarsal (Lisfranc’s) JointsIntermetatarsal JointsMetatarsophalangeal Joints

Toe extension, lateral four toes (MTP 40°), big toe (MTP 70°)Toe flexion, lateral four toes (MTP 40°), big toe (MTP 45°)

Interphalangeal JointsToe 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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EVALUATIONHistoryMechanism of InjuryPresence of transient or fixed deformity of the foot & ankle at the time of injuryLevel of activities after the injury

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

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PHYSICAL EXAMINATIONObservationLateral View

a. Calcanealapophysitis (Sever’s)

b. Achilles tendinosisc. Achilles ruptured. Retrocalcaneal

bursitise. Post. ankle

impingementf. Calcaneofibular ligg. Sinus tarsih. Ant. talofibular ligi. Ant. ankle

impingementj. Avulsion Fx of 5th MT

c

PHYSICAL EXAMINATIONObservationMedial View

e. Tarsal tunnel syndromef. Med. ankle spraing. Entrapment site 1st branch

of lat. plantar n.h. Entrapment site of med.

plantar n.

a. Calcaneal apophysitis(Sever’s)

b. Achilles tendinosisc. Achilles ruptured. Retrocalcaneal bursitis

a

bc

d

e f

gh

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PHYSICAL EXAMINATIONObservation

Dorsal Foot & Anklea. Ant. ankle impingementb. Lat. talar dome OCDc. Navicular stress fractured. Lisfranc spraine. Ant. tarsal tunnel syndromef. Bunionetteg. Bunionh. Hallux rigidusi. Avascular necrosis of 2nd MT headj. Morton’s neuromak. Paronychia

a

e

i

k

jh

c

f

d

g

PHYSICAL EXAMINATIONObservation

Plantar Foot & Ankle

a.Plantar fat padb.Plantar fasciitisc.Avulsion fracture of the

5th MTd.Stress fracture of the 3rd

MTe.Stress fracture of the 2nd

MTf. Sesamoiditisg.Metatarsalgia

a

f

e d

c

b

ggg g

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PHYSICAL EXAMINATION

Observation

Swelling

Ecchymosis

PHYSICAL EXAMINATIONObservation

(Cont’)

Deformities

Ankle Dislocation Ankle ganglion cyst

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PHYSICAL EXAMINATION

Observation

Non-weight-bearing (open-chain)

Weight-bearing (closed-chain)

PHYSICAL EXAMINATIONObservation (Cont’)

Pes planus (flat foot)

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PHYSICAL EXAMINATIONObservation (Cont’)

Left Achilles tendon rupture

PHYSICAL EXAMINATIONObservation (Cont’)

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

forefoot)

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Observation (Cont’)

Bunion (hallux valgus, callus, thickened bursa, and exostosis)

PHYSICAL EXAMINATION

PHYSICAL EXAMINATIONObservation (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 EXAMINATIONRange 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 EXAMINATIONPalpation

Medial & lateral malleoliMedial & lateral ligament complexesBase of 5th metatarsalDistal tibiofibuar jointTalus, calcaneus, navicular, cuneiform, and cuboid bonesAchilles tendonPeroneal tendonsMetatersal bonesMTP, PIP, and DIP jointsNeurovascular exam (DP & PT pulses, cap refill, sensation)

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PHYSICAL EXAMINATIONSpecial Tests

Thompson test for Achilles tendon rupture

Negative

PHYSICAL EXAMINATIONThompson test

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PHYSICAL EXAMINATION

Special Tests (Cont’)

Anterior drawer test (anterior talofibular ligament integrity test)

PHYSICAL EXAMINATIONAnterior drawer test

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PHYSICAL EXAMINATIONAnterior drawer test - prone

PHYSICAL EXAMINATION

Special Tests (Cont’)

Talar tilt testAssessing CF lig in anatomic (90°) positionAssessing ATF ligwhen ankle is plantar flexed (inversion stress test)

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PHYSICAL EXAMINATIONTalar tilt test

PHYSICAL EXAMINATIONSpecial Tests (Cont’)

Squeeze test of the leg (distal tibiofibularcompression 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 EXAMINATIONSpecial Tests

(Cont’)

Dorsiflexion-eversion test to reproduce the symptoms of tarsal tunnel syndromeTinel’s sign at the ankle

PHYSICAL EXAMINATIONSpecial Tests (Cont’)

Homans’ signPain 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)