PHYSICAL EXAMINATION PROCEDURES by sbVzY4Sx

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									                PHYSICAL EXAMINATION PROCEDURES
                           FOR THE ANKLE AND FOOT
                                                            Tom McPoil, PhD, PT, ATC, FAPTA


1) History and Subjective Examination
   a) The goal of the history is to determine if the patient’s symptoms or problem is secondary to
      excessive mechanical loading as well as to delineate what foot region or tissues are being
      stressed. The following questions can be used to guide the examiner in taking the history.
      i) Is there a position, movement or activity that either relieves or intensifies the symptoms?
      ii) Are you awakened at night with pain?
      iii) What are your symptoms like when you first arise in the morning, versus during the day
           with activity?
      iv) Do your symptoms increase with activity?
      v) Have x-rays been taken? Were the x-rays weight bearing or non-weight bearing?
      vi) Have you had any recent injuries not related to the present symptoms?
      vii) History of medications; How do you rate your general health; Have you had a
           significant recent weight loss?
      viii) If evaluating a child, it is important to determine if there has been a recent growth
           spurt.
      ix) The types of footwear most often used for work and recreational activities.
      x) A family or personal history of any of the following problems should also be
           determined:

              (a) rheumatoid arthritis
              (b) lower extremity weakness
              (c) diabetes mellitus
              (d) flat feet or high arches
              (e) ever worn special shoes
              (f) sprain ankles frequently
              (g) ever worn foot orthoses
              (h) osteoarthritis
              (i) neurological problems
              (j) circulatory problems
              (k) foot wounds or ulcers
              (l) cold or burning feet
              (m) toenail problems
              (n) edema or swelling of feet




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       xi) Patient Reports

          Traumatic incident resulting in forced inversion or     -Ankle sprain
          eversion                                                -Ankle fracture
                                                                  -Possible fibular nerve
                                                                  involvement with inversion
          Trauma to ankle that included tibial rotation on a      -Syndesmotic sprain
          planted foot
          Tenderness of anterior shin with symptoms               Medial Tibial Stress Syndrome
          aggravated by repetitive weight-bearing activities      (MTSS)
          Traumatic event causing initial heel pain and can       Achilles tendon injury
          no longer plantarflex the ankle
          Pain with stretching of calf muscles as well as         Achilles tendinopathy
          during walking and running
          Pain in bottom of heel and with first few steps         Plantar fasciitis
          when arising from bed in morning as well as after
          prolonged periods of walking and standing
          Pain and/or parathesias on the plantar surface of the   Tarsal tunnel
          foot                                                    Sciatica
                                                                  Lumbar radiculopathy
          Pain on plantar surface of the foot between the 2nd     Interdigital neuroma (2nd & 3rd)
          & 3rd or 4th & 5th metatarsal heads. Pain can           Morton’s neuroma (4th & 5th)
          increase with walking especially in footwear with
          hard outsoles or high heels

ACUTE CONDITIONS AFFECTING THE FOOT
AND ANKLE

1) Ankle Sprain
   a) Common Symptoms
      i) History of trauma with pain and possible
           swelling at site of injury
      ii) Report of ankle instability when performing
           dynamic activity
      iii) When to order radiographs for after an acute
           ankle sprain
           (1) Patient should be referred for radiographs if
               bone tenderness is exhibited at A or B or C
               or D or if cannot bear weight immediately
               after injury or during examination (4 steps
               regardless of limp) Ottawa Ankle Rules
               (a) Bachmann LM, et al: British Medical
                   Journal, 2003:326, 417
       iv) BERNESE ANKLE RULES


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       (1) Developed to enhance the detection of ankle and midfoot region fractures as specificity of
           the Ottawa Ankle Rules is low at 11.5 to 50%
       (2) In a study on 354 patients with low-energy, inversion-type ankle sprains, the Bernese rules
           produced a sensitivity of 100% and a specificity of 91%
           (a) Eggli et al: Journal of Trauma 2009; 59:1268.
       (3) The tests included:
           (a) Indirect Fibular Stress
               (i) Lateral malleolus is compressed approx 10 cm proximal to fibular tip.




           (b) Direct Medial Malleolar Stress
               (i) Thumb is pressed flatly on the medial
                   malleolus. Direct palpation of the tip of
                   the thumb is avoided!




           (c) Compression of the Midfoot and Hindfoot
               (i) One hand fixes the calcaneus in neutral
                   position, and the other hand applies a
                   longitudinal load on the forefoot to
                   compress the midfoot and hindfoot




b) Specific Examination Procedures
   i) Figure 8 girth measurement for determining effusion/edema
      (1) This measurement is performed while the patient is in supine or long-sitting. The
          ankle to be measured is placed in neutral with the rearfoot neither everted nor
          inverted. In the case of an acute ankle injury, the position of the ankle may have to
          be in 15o to 20o of plantarflexion. The tape measure is then placed:
          (a) midway between the tibialis anterior tendon and the lateral malleolus;
          (b) drawn medially and placed just distal to the navicular tuberosity;
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       (c) then pulled across the arch to just proximal or behind the base of the 5th
           metatarsal;
       (d) then pulled the across tibialis tendon and around the ankle joint just distal to the
           medial malleolus; and
       (e) finally pulled across the Achilles tendon and back to the starting point.
       (f) Tape should be placed over the following bony landmarks
           (i) Tuberosity of the navicular
           (ii) Base of the 5th metatarsal
           (iii)Distal tip of the lateral malleolus
           (iv) Distal tip of the medial malleolus
       (g) Reliability – Intra = .93-.98; Inter = .99
           (i) Pugia ML, et al: JOSPT, 2001, 31:384
           (ii) Mawdsley RH et al: JOSPT, 2000, 30:149
ii) Palpation over the site of injury
iii) Ligamentous testing
    (1) INVERSION SPRAIN
        (a) Anterior Drawer Test
            (i) Have patient sit over end of table with knee flexed to 90o
                 1. Kovaleski et al: J Ath Train 43:242, 2008
            (ii) Examiner places
                 one hand on lower
                 leg and uses other
                 hand to maintain
                 ankle in 10o of
                 plantarflexion and
                 move calcaneus in
                 anterior direction.
            (iii)Positive test =
                 talus glides out of
                 mortise anteriorly
            (iv) Anterior drawer & pain with palpation & hematoma
                 1. < 48 hours after injury – Sens = .71; Spec = .33; +LR = 1.06; -LR = .88
                 2. 5 days after injury – Sens = .96; Spec = .84; +LR = 6.0; -LR = .05

       (b) Inversion Stress Test (Talar Tilt Test)
           (i) Often done with patient
                under local anesthesia
           (ii) If talar tilt is > 15o than
                non-involved side,
                strong indication that
                patient has a complete
                rupture of the ATF &
                CF




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       (2) TIBIOFIBULAR SYNDESMOTIC INJURY
           (a) Cotton Test
               (i) Patient supine. Examiner assess amount of talar translation from a medial to
                    lateral direction by grasping the calcaneus of involved ankle while stabilizing
                    tibia with other hand
               (ii) Positive test = pain provoked or movement observed when compared to
                    uninjured side
           (b) External Rotation Test (Kleiger test)
               (i) Patient supine. Examiner grasps the calcaneus of the involved ankle and
                    externally rotates the foot (talus) while stabilizing tibia with other hand.
               (ii) Positive test = pain provoked at anterolateral aspect of distal tibiofibular
                    syndesmosis or movement observed when compared to uninjured side
           (c) Squeeze Test
               (i) Patient supine. The examiner uses his thenar eminences to squeeze or
                    compress the fibula and tibia at the midpoint of the calf.
               (ii) Positive test = pain provoked in distal tibiofibular syndesmosis
           (d) Fibula Translation Test
               (i) Patient supine. Examiner places the thenar eminence of one hand anterior to
                    lateral malleolus and places his other thenar eminence over the medial
                    malleolus. The lateral malleolus is then translated posterior while the medial
                    malleolus is stabilized.
               (ii) Positive test = pain provoked
           (e) Significant relationship has been established with diagnosis of syndesmotic
               sprain and all 4 of the above tests along with limited dorsiflexion
               (i) External Rotation had fewest false-positives; Fibular translation the most!
                   1. Beumer A et al: Acta Orthop Scand: 2002:73:667

b) Differential Diagnosis
   ii) Fracture of the base of the 5th metatarsal
   iii) Growth plate fracture - if patient is 13 years of age or younger; OR if they have had a
       growth spurt within the last 12 months

c) Anteriolateral Impingement of the Ankle
   ii) Symptoms include complaints of chronic pain as a result of the anterior aspect of the
       tibia compressing the superior portion of the neck of the talus as well as soft tissues in
       the region.
   iii) Common in individuals who have had a history of ankle sprains and have excessive
       foot pronation and abduction of forefoot
   iv) Specific Examination Procedures
       (1) Anterior Impingement Test
           (a) Patient seated. Examiner grasps calcaneus with one hand and uses the other
               hand to grasp the forefoot and maintain a plantarflexed position. The examiner
               then uses the thumb of his hand grasping the calcaneus to place pressure over
               the site of symptoms. The examiner then moves the foot from a plantarflexed to
               dorsiflexed position while thumb pressure is maintained


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                       Plantarflexed                           DorsiFlexed
                         Position                               Position




              (b) Positive test = pain provoked over site of symptoms greater in dorsiflexion than
                  plantarflexion
              (c) Sens = .95; Spec = .88; +LR = 7.91; -LR = .06
                  (i) Molloy S, et al: J Bone Jt Surg Br: 2003; 85: 330

2) Hypomobility of the ankle and foot articulations secondary to post-fracture, post-trauma or
   after period of immobilization
   a) Common Symptoms
       ii) Limited foot mobility with possible fixed inverted posture of the rearfoot
       iii) Pain in ankle/foot during weight bearing activities
       iv) Inability to load the medial aspect of the forefoot, especially the 1st metatarsal head
   b) Specific Examination Procedures
       ii) Palpation of involved regions
       iii) Weight-bearing assessment to determine forefoot loading, especially the medial column
           (1st met head)
       iv) Assessment of rearfoot & midfoot posture while sitting with knees flexed to 90o then
           while standing
       v) Joint mobility testing
           (1) Distal Tib-Fib Joint
                (a) A-P Mobs




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(2) Talocrural Joint
    (a) A-P Glide




   (b) P-A Glide




   (c) Distraction




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   (3) Subtalar Joint
       (a) Distraction




       (b) Rocking




    (4) Intertarsal and Intermetatarsal
        (a) Sweeping of the rays and midfoot
        (b) Dorsal - Plantar gliding of the rays
    (5) MTP, PIP, DIP joints
        (a) Anterior
        (b) Plantar
        (c) Distraction
vi) Homan’s Sign
    (1) To R/O possible thombophlebitis




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CHRONIC INJURIES AFFECTING THE FOOT AND ANKLE

6) Plantar Fasciitis
   a) Specific Examination Procedures
      i) Pain with palpation at the insertion of the medial band of the plantar fascia
           (anteromedial aspect of heel and not directly on the bottom of the heel)
      ii) Can also report pain with palpation
           (1) of the central band of the plantar fascia in the midfoot region
           (2) over the medial, lateral, and lower posterior aspect of calcaneus, indicating fascial
               plane irritation
      iii) Talocrural Joint ROM
           (1) Test with Knee Extended (gastrocnemius)
           (2) Test with Knee Flexed (soleus)
      iv) First MTP Joint Extension
           (1) Patient should have 60 to 65 degrees of 1st MTP joint extension with ankle
               (talocrural) joint slightly plantarflexed over edge of table
           (2) Patient should be able to maintain the 60 to 65 degrees of 1st MTP joint extended
               position while the ankle joint is moved from slight plantarflexed position to neutral
               position of the ankle joint
   b) Differential Diagnosis
      i) Heel Bruise (Stone Bruise)
      ii) Heel Spur (confirmed by x-ray)
      iii) Tarsal Tunnel Syndrome
           (1) Assess symptoms with foot eversion and ankle dorsiflexion maintained for at least
               30 seconds
               (a) Add Tinel’s sign if still have no symptoms
                   (i) Predictive of tarsal tunnel syndrome
                   (ii) Kinoshita M, et al:J Bone Joint Surg 2001:83:1835)
       iv) Sever Disease (calcaneal apophysitis) – if patient is 13 years of age or younger
           (1) Indicated if pain is elicited when squeezing the medial and lateral aspects of
               calcaneus with the thenar eminences of both hands

7) Metatarsalgia
   a) Specific Examination Procedures
      i) Palpation of the metatarsal heads and interdigital spaces for pain as well as possible
           callus
      ii) Dorsal and plantar gliding of the all five rays
           (1) Determine overall mobility
           (2) Determine ability of the rays to conform to metatarsal pad
      iii) Examine for claw toes
           (1) Determine if reducible or non-reducible
   b) Differential Diagnosis
      i) Interdigital Neuroma
      ii) Stress Reaction/Fracture of Metatarsal Heads
           (1) Tuning Fork

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8) Medial Tibial Stress Syndrome
   a) Specific Examination Procedures
      i) Pain with palpation of distal 2/3’s of posteromedial border of the tibial
           (1) Pain should be over diffuse area at least 5 cm in length
      ii) Pain with hopping
      iii) Pain with contraction of Flexor Digitorum Longus through max excursion
   b) Differential Diagnosis
      i) Tibial stress fracture
           (1) Pain is usually more specific, not as diffuse as with MTSS
           (2) Tuning Fork – is Sensitive (75%) but not Specific (67%) so cannot rule-out if test
               negative (Lesho EP: Military Med, 1997, 162:802)
           (3) Continuous Ultrasound – not sensitive enough to identify individuals with tibial
               stress fracture (Romani WA: JOSPT, 200, 30:444)
      ii) Posterior Tibial Tendonitis
           (1) Palpation of the muscle tendon over the region of the medial malleolus
           (2) Possible reproduction of symptoms with contraction of muscle through maximum
               excursion
      iii) Exertional Compartment Syndrome
           (1) Observe for redness and tightness of lower leg on involved side
           (2) Assess for reduction in sensation over distribution of the superficial and deep
               peroneal nerves

9) Achilles Tendinopathy
   a) Specific Examination Procedures
      i) Thompson’s test
           (1) Assesses continuity of the Achilles tendon
           (2) Palpate tendon for areas of gapping and thickening
           (3) Sens = .96
      ii) Palpate retrocalcaneal and superficial calcaneal bursa
      iii) Muscle testing the gastrocnemius and soleus
      iv) Talocalcaneal joint ROM
           (1) Test with knee extended
           (2) Test with knee flexed
   b) Differential Diagnoses
      i) Flexor hallucis tendonitis
      ii) Retrocalcaneal burisitis




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TESTS TO ASSESS FOOT POSTURE

   Foot Posture Index (FPI-6) – developed by A. Redmond, 2005
       o Redmond et al: Clin Biomech 21:89-98, 2006
       o http://www.leeds.ac.uk/medicine/FASTER/FPI/index.htm
   The FPI is a clinical tool designed to allow the clinician to quantify foot posture
       o Supinated, pronated or normal position
   The clinician assigns a score to six different observations of foot posture
       o Pronated posture = positive score
       o Normal postures = zero
       o Supinated postures = negative scores
       o The aggregate score give an estimate of overall foot posture
   The clinical criteria used for the FPI-6
       o Talar head position
                To assess talar head position, palpate the head of the talus
                    with the patient in relaxed standing posture and then as
                    slowly raise and lower their arch without lifting their
                    forefoot off of the floor. When the medial aspect of the
                    head of the talus is congruent with the medial aspect of the
                    navicular, the subtalar joint is in neutral position. Now as
                    the patient to relax their foot and judge the resting position
                    of the talus.
       o Supra & Infra lateral malleolar curvature
       o Calcaneal frontal plane position
       o Prominence in the region of the talonavicular joint
       o Height and congruence of the medial longitudinal arch
       o Abduction and Adduction of the forefoot
   Before assessing the patient is:
       o Instructed to march-in-place for several steps – then stop and place their feet in a
           comfortable stance position
       o Asked to relax their feet, place equal weight on their feet, and look straight ahead with
           their arms at their sides.
       o Told that it is important that they do NOT move while the assessment is occurring.




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   The final FPI score is a whole number between -12 and +12
       o Classification of foot posture:
                 Normal = 0 to +5
                 Pronated = +6 to +9; Highly Pronated > +10
                 Supinated = -1 to -4; Highly Supinated > -5
   Reliability
       o Intra-rater is HIGH; Inter-rater is MODERATE
       o Cornwall et al; JAPMA, 2008




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