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foot-and-ankle-exam

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					Sean Jenkins
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The ankle and foot exam and osteopathic techniques for dysfunction
   1. Exam: vitals and general appearance, gait eval, inspection and palp, ROM, strength,
      stability tests (anterior drawer and talar tilt) other special tests, neuro and vascular status
          a. Inspection: look at foot and ankle and not areas of swelling, color changes,
               deformities
          b. Palpation: palpate for pain and palpate the tendons looking for tenderness, as
               well as the ligaments. Compare results to opposite side. Palpate the entire length
               of the tibia an fibula
                    i. Soft tissue landmarks:
                             1. Anterior: Tibialis anterior, Extensor hallucis longus and brevis,
                                Extensor digitorum, Dorsalis pedis
                             2. Medial: Tibialis posterior, Flexor digitorum, Flexor halluces,
                                Posterior tibial artery
                             3. Lateral: Peroneus longis and brevis, ATF, CF ligaments, , Cuboid,
                                5th MT base
                             4. Plantar: Plantar fascia, Sesamoids of 1st MTP, Cuboid
                             5. Posterior: Calcanus & achilles tendon
   2. Functional arches of foot:
          a. Lateral longitudinal arch: calcaneus, cuboid, 4tha dn 5th MTs
          b. Medial longitudinal arch: calcaneus, talus, navicular, cuneiforms, and 1st 3 MT
          c. Metatarsal arch: articulations of the MT heads w/ phalanges
          d. Transverse arch: cuneiforms, navicular and cuboid
                    i. Arch assessment: inspection and Forward squat test to look for
                        flattening and pronation of the foot.
   3. Mortise joint: ankle joint
   4. Motions of ankle:
          a. Dorsifleixon, plantarflexion, inversion, eversion, supination (combo of inversion,
               forefoot adduction and flexion), pronation (combo of eversion, forefoot abduction
               and extension)
   5. Swing test: test for talar dysfunction, detects loss of ROM. Foot kept parallel to floor and
      knee is flexed. Then swing foot back as far as it can go
          a. For dorsiflexion to occur talus must glide posteriorly inot the mortise, if it can’t
               do that it is “anterior dysfunction of the talus which is what the swing test tests
               for.
   6. Anterior drawer test: tests anterior talofibular ligament. Pull heel forward and test for
      laxity. + is if there is asymm btw the ankles
   7. Talar tilt test: test Calcaneal fibular ligament, basically invert the foot while
      stabilizing the ankle joint
   8. Reverse talar tilt: test deltoid lig, basically the opposite as above
Sean Jenkins
Happy studying

   9. External rotation test: detects high ankle sprains or injuuires to anterior or posterior
       tibiofibular ligaments. Stabilize leg then externally rotate foot. + if affected side opens
       up > than normal side
   10. Squeeze test: test for high ankle sprains by compressing tibia and fibula together in mid
       leg causing pain in the mortise joint
   11. Thompson test: squeeze gastroc and see if foot flexes. Tests integrity of Achilles tendon
   12. Midfoot palpation: twist of midfoot lig can repro pain if injuried. They are the lig of that
       connect navicular, cuboid, cuniforms to proximal MT. test the ability of midfoot to rotate
   13. MTP, PIP, DIP motion:
           a. First MTP: dorsiflex (important for gait push off)
           b. Test MTP, PIP, DIP joint stability med/lat as well as plantar/dorsally
   14. Dorsal surface innervation: L4-5, S1, saphenous nerve, superficial and deep peroneal,
       sural nerve




   15. Plantar surface innervation:
          a. Medial calcaneal
          b. Saphenous
          c. Medial plantar
          d. Lat plantar
          e. Sural nerve
   16. Pulses:
          a. Posterior tibial artery: posterior of medial malleolus
          b. Dorsalis pedis: lateral to extensor halluces longus
   17. Gen concepts of OMT of lower extremity:
          a. Usually when swelling occurs start tx with lymphatic drainage and correct
               dysfunction of hip
          b. Do motion testing of nearby joints and focus on restricted area
          c. Test muscles surrounding that joint as well as flexibility, compare bilaterally
   18. Ankle sprains:
          a. MOI: inversion, plantar flexion causing talus to have anterior dysfunction, causes
               peroneal muscles to be stretched, pulls distal fibula anteriorly and proximal moves
               posteriorly, usually the ATF lig injured
          b. Exam: prominent edema, decreased Rom, pain at ATF, increased anterior drawer,
               talar tilt, + swing test, late ecchymosis.
          c. Pt may complain of: anterior talar pain, sense of jamming with attempted
               dorsiflexion, reduced calf stretch when attempted
Sean Jenkins
Happy studying

          d. Tx of anterior talus: Muscle energy, keep foot parallel to floor til barrier, have pt
             plantarflex while maintaining position, take to new barrier and repeate 3-5X
          e. HVLA talus: stand at end of talbe, wrap fingers around top of foot with thumbs
             in sole of foot. Dorsiflex ankle to barrier, small sharp tug preformed in J motion
             out and up




   19. Navicular dysfunction:
          a. Causes:
                   i. Chronic posterior tibialis dysfunction (tendinosis): most common, post.
                      Tibialis inserts on navicular, insufficiency contributes to medial arch
                      collapse
                  ii. Calcaneo-navicular (spring) lig insufficiency
                 iii. Acute inversion ankle sprain: peroneus longus inserts on medial
                      cuneiform bone and 1st MT. with inversion muscle tendon stretches
                      causing collapse of arch via navicular cuneiform ligament. \
          b. Palpation of medial arch reveals more prominent navicular, may see increased
              pronation of foot in forward squat test
          c. Tx:
                   i. Strain-Counterstrain: find tender point while pt prone, basically fold
                      foot around it and maintain position for 90 seconds and return passively
                      and recheck.
   20. Cuboid dysfunction:
          a. Cause:
                   i. usually due to chronic peroneus muscle dysfunction which inserts on
                      cuboid and if insufficiency happens  collapse of lateral arch
                  ii. calcaneo-cuboid ligament insufficiency.
                 iii. Concomitant navicular dysfunction
          b. Palpation find more prominent cuboid bone in lateral plantar arch. May have
              supinated foot while standing
          c. Tx
                   i. Strain-coutnerstrain: finde tender point and fold foot around it and hold
                      for 90 sec and return passively and recheck.
                  ii. HVLA: thumb over plantar aspect of cuboid, plantar flex foot to barrier
                      then apply dorsolateral thrust and recheck.
   21. Tx of Fibular head dysfunction (muscle energy)
          a. Posterior fib head: Grasp the affected extremity, Control motion, Evert and
              dorsiflex foot to barrier, ATF position and tension, While applying anterolateral
Sean Jenkins
Happy studying

                 force to proximal fibula, have the patient internally rotate & invert foot against
                 operator resistance for 5 seconds, Patient relaxes 1-2 seconds, Take up the “slack”
                 and engage new barrier, Repeat 3-5 x, RECHECK

				
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posted:3/31/2012
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