the foot and ankle evaluation. history past has this ever happened beforehas this ever happened...
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The Foot and Ankle The Foot and Ankle EvaluationEvaluation
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HistoryPastPast• Has this ever happened BeforeHas this ever happened Before
MechanismMechanism• What happenedWhat happened• How did it happenHow did it happen• When did it happenWhen did it happen• What specific mvmt caused the injury?What specific mvmt caused the injury?• Did you fall? How did you land?Did you fall? How did you land?• Which direction did the body part move?Which direction did the body part move?
Changes in symptomsChanges in symptoms• Symptoms incr. or decr. since injurySymptoms incr. or decr. since injury• Taking any meds?Taking any meds?• Treating it on your own at allTreating it on your own at all
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History
Sounds or Sensations– Did you feel any unusual
sensations when it occurred?
– Did you hear any unusual sounds when it occurred?
PainPain• Where does it hurt?Where does it hurt?
Point with ONE fingerPoint with ONE finger
• Rate the painRate the painScale of 1-10Scale of 1-10
• What makes it hurt?What makes it hurt?Specific movements?Specific movements?
positioningpositioning• When does it hurt? When does it hurt? • Can you describe the Can you describe the
pain?pain?
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Observation/InspectionMovement– How do they move?– How did he walk in?– What mannerisms did he use during the history?– Facial expressions
Asymmetries/ Deformity– Do both sides look the same?
Obvious deformity– Swelling - Lumps– Markings - Redness/ Discoloration
Sounds
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Pes Planus or Cavus
• Structural Deformities
• Pes Planus = flat footed/ no arch
• Pes Cavus = high arch
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ObservationStructural Deformities– Valgus or varus
Gait (walking pattern)Shoe Wear
Worn down on the heel = walks mostly on heelsWorn only on ball of foot = walks flat footed or only on toesEtc.
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The Gait Cycle
Heel Strike – shock absorptionHeel Strike – shock absorptionToe-off – propel forwardToe-off – propel forward
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The Gait Cycle
Have you ever watched people walk?
What do you notice?
Do you think that this can leave people at risk to injuries?
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PalpationUsed to confirm or deny assessments.
Start away from the injury and move toward the site of pain (about 2-3 inches when appropriate)
Palpate Bilaterally (both sides)
Start w/ light pressure then move to deeper palpation
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PalpationNotice–Point Tenderness
Specific site of pain
–Trigger Points
–CrepitusGrinding, crunching, or crackling sensation with the rubbing of tissues
Tissue Density
Increased Spasm
Scarring
Decreased
Swelling
Hemorrhage
SymmetryAre both sides equal
Temperature
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Special Tests
1st Special Tests– Fracture Tests
____________
____________
____________
– ________ ___ ________________________
____________ or ____________
Range of motion
Passive Resistive
LeverBump
Compression
Active
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Types of Injuries• Sprain • – tear of a ligament• Strain • – tear/ pull of a muscle• “-itis” • – irritation of
• Tendonitis – irritation of a tendon (joins muscle to bone)• Bursitis – irritation of a bursae (fluid filled sac under tendons)
• Fracture • – break of a bone (complete or incomplete• Dislocation • – Joint pops out and stays out• Subluxation • – joint pops out and goes back in
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Ankle InjuriesGrade 1– Stretching or slight tear – Mild pain
Little to no disability
Grade 2– Moderate tear
Moderate pain and disabilityTrouble weight bearing (PWB)Swelling and Bruising may occur
Grade 3– Severe/Total tear of the ligament– Often causes ankle to subluxate
DisablingCannot weight-bear (NWB) – put weight/ pressure on it.
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• Fracture (fx)– Avulsion fx
– Piece of bone broken off
– Transverse fx“crack” Straight across
- Evaluation:- Pain with pressure
- Specific site (over bone)- High on the pain scale
- Immediate swelling (tell tale sign IF it happens) - Bump, lever, or compression painful
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Ankle Injuries
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Fracture Tests• Bump – bump/ tap the end of the bone AWAY
from the site of pain
• Lever – (can only be used with long bones or 2 parallel bones) – a- squeeze both bones AWAY from the site of
pain– b- apply a bending force to the long bones at
each end if pain is in the middle of the bone
• Compression – apply pressure at both ends of the bone simultaneously
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Achilles InjuriesTendonitis – irritation of the tendon
Initially slight painOnly hurts after practice/ activity
As it progresses pain lasts longer and gets irritated with even regular walkingHurts to dorsiflex (stretch/ lengthen the tendon)Painful to the touch
Achilles Tendon Rupture (complete tear)– *Common w/ athletes 30+– Cannot “see” the tendon– Gastroc/ Soleus recoil (ball up) towards knee– Athlete cannot plantarflex the foot/ push off
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Special Test – Achilles RuptureThompson Test– Positioning
Athlete prone with leg off the tableBoth hands on the calf
– TestSqueeze calf at proximal 1/3
of lower leg– Positive
Foot does not plantarflex
TRY IT!! Have your partner lie on your desk
http://www.youtube.com/watch?v=HPkaNdG2uus
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Ankle InjuriesInversion Sprain– PF and inversion
Tears Anterior Talofibular– Pure Inversion
Tears Calcaneofibular
Eversion Sprain– Deltoid ligament
Syndesmotic Sprain (“high” ankle sprain)– Tear anterior and posterior tib-fib– External rotational or forced df
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Anterior tibiofibular
ligament
Calcaneofibular ligament
Anterior talofibular
ligament
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Ankle Sprains• The only difference between a sprain of the talofibular,
tibiofibular, and calcaneofibular ligaments are the location of pain when it comes to the H.O.and P…..
– History• Lateral ankle pain after “rolling” or “twisting” it• Pain scale depends on the severity and the person• If treating with ice, it helps• May hear a “pop”, but not common
– Observation and Palpation• May see/ feel swelling• Possible limp• Possible bruising (if it has been a couple days)• Specific site of pain
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Anterior Talo-fibular sprain
• Pain location
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Anterior Drawer– ATaloFib
Positioning– Have the athlete sit with their leg off the table .– Grasp calcaneus w/ one hand– Let foot lie on your forearm– Other hand on tibia
Test– Dorsiflex foot slightly– Pull Calcaneus forward while push tibia backward
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Special Tests
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Anterior Drawer cont
•Positive Test–Foot slides forward (laxity)–Makes a clunking sound/ sensation–Pain
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Grades of Sprains
• Grade 1 = mild pain, no laxity (movement/ looseness)
• Grade 2 = moderate pain, some laxity
• Grade 3 = severe pain and a lot of laxity
• **If no pain, but is lax (loose) then that is a negative test
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Pain Locations
• Deltoid sprain
• Anterior Tibio-fibular sprain (syndesmotic/ high)
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Special Tests – Deltoid Lig.Kleiger’s Test– Positioning
Patient seated w/ ankle over the tableStabilize the lower legHold the medial aspect of the foot and evert the foot
– Testrotate the foot laterally
– PositivePain over the deltoid ligament Pain over the lateral malleolus (indicates a syndesmotic sprain)
http://www.youtube.com/watch?v=eDeQcAs9A5M
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Tendinitis sites
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Foot InjuriesCalcaneus– Heel Spurs– Bursitis– Contusion
Plantar Fasciitis– Common
problem Pain in the proximal arch and heel
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Foot Injuries
Morton’s toe– Short Great Toe
Usually benign, may cause probs w/ running
Jones Fracture– Fracture of 5th metatarsal
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Foot Injuries
Bunion– Caused by poorly fitting shoes
Hammertoe– Flexion contracture of toes
Turf Toe– Hyperextension
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Other Conditions/ Injuries
Tibial Contusion - bruise
Muscle Cramps
Muscle Strain
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Other Conditions/ Injuries
Shin splints– Catch-all term for anterior pain
Stress fractures, muscle strains and chronic compartment syndrome
Medial Tibial Stress Syndrome– Due to repetitive microtrauma– Weak muscles - Poor shoes– Overtraining -Running surface– Malalignment
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Grades of MTSSGrade 1 – pain after activity
Grade 2 – pain during and after activity – No performance affects
Grade 3– Before during and after– Affects performance
Grade 4– Activity impossible/ too painful
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Compartment Syndrome– Acute – secondary to
trauma– Exertional – activity
related– Symptoms
Deep Aching Pain
Tightness and Swelling
Pain w/ stretching
Reduced circulation and sensation
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Management of Ankle InjuriesSwelling Management
- RICE – Rest Ice Compression Elevation
- METH – Mobility Elevation Traction Heat
Inversion Ankle Sprains– Light Compression with Horseshoe– Massage– Begin ROM exercises
Syndesmotic Sprain– Takes MUCH longer to heal– Rest/ Immobilize for at least 6-10 days before beginning
ROM exercises
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Management of Ankle Injuries
Achilles Tendon Rupture– Surgical Repair or– Cast for 6-8 weeks
Contusion– Doughnut pad to reduce risk of repeated force– Light ROM– Light stretching
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Management of Ankle Injuries
Cramps/ Spasms– Massage– Overpressure (trigger point)– Stretching– Monitor hydration and electrolytes if this
becomes chronic
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ManagementMedial Tibial Stress Syndrome (MTSS)– Modification of activity– Gait analysis– massage– Stretching– Arch taping – Compression
http://www.youtube.com/watch?v=ea4cInVmIv4
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Achilles TendinitisDecrease intensity of activity/ what is aggravating it
Stretching of calf and foot muscles
Look at foot alignment
Recent change in running surface, distance, form, or intensity
Heat
Massage
Heel Lifts
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Plantar Fascitis
Comfortable movements (ROM)
Stretch foot and lower leg
Add tennis ball stretch
Strengthen lower leg and foot
Check foot alignment
Tape arches
Night Splint
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In-Grown Toe Nail
Soak in hot water for 10-15 minutes
Lift edge of nail and put small piece of cotton under to elevate the nail
Apply antiseptic and cover with a sterile dressing
Or cut a “v” into middle of nail (grows and pulls toward center)
If pus present, refer to MD for antibiotics
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Management of Ingrown Toe Nail