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The Foot and Ankle

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					The Foot and Ankle
    Evaluation
                History
Past
– Has this ever happened Before
Mechanism
– What happened
– How did it happen
– When did it happen
– What specific mvmt caused the injury?
– Did you fall? How did you land?
– Which direction did the body part move?
Changes in symptoms
– Symptoms incr. or decr. since injury
– Taking any meds?
– Treating it on your own at all
                    History
Pain                        Sounds or
– Where does it hurt?       Sensations
    Point with ONE finger   – Did you feel any
                              unusual sensations
– Rate the pain               when it occurred?
    Scale of 1-10           – Did you hear any
– What makes it hurt?         unusual sounds when it
                              occurred?
    Specific movements?
    positioning
– When does it hurt?
– Can you describe the
  pain?
Observation/Inspection
Movement
– 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
       Pes Planus or Cavus
Structural
  Deformities
• Pes Planus =
  flat footed/ no
  arch
Pes Cavus =
  high arch
           Observation
Structural Deformities
– Valgus or varus
Gait (walking pattern)
Shoe Wear
 Worn down on the heel = walks mostly
 on heels
 Worn only on ball of foot = walks flat
 footed or only on toes
 Etc.
                The Gait Cycle




Heel Strike – shock absorption
Toe-off – propel forward
        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?
          Palpation
Used 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
           Palpation
Notice                     Tissue Density
                             Increased
–Point Tenderness               Spasm
  Specific site of pain         Scarring
–Trigger Points              Decreased
                                Swelling
–Crepitus                       Hemorrhage
  Grinding, crunching,     Symmetry
  or crackling sensation     Are both sides equal
  with the rubbing of
  tissues                  Temperature
         Special Tests
1st Special Tests
   Range
– ________ ___of        motion
                 ____________
    Active
    ____________
     Passive
    ____________ or Assistive
                    ____________
– Fracture Tests
     Bump
    ____________
     Lever
    ____________
     Compression
    ____________
            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
                Ankle Injuries
Grade 1
– Stretching or slight tear
– Mild pain
    Little to no disability
Grade 2
– Moderate tear
    Moderate pain and diability
    Trouble weight bearing (PWB)
    Swelling and Bruising may occur
Grade 3
– Severe/Total tear of the ligament
– Often causes ankle to subluxate
    Disabling
    Cannot weight-bear (NWB) – put weight/ pressure on it.
             Ankle Injuries
Fibular fracture (fx)
– Avulsion fx
  – Piece of bone broken off
– Transverse fx
    “crack” Straight across
Peroneal tendon subluxation/
dislocation
  The tissue that holds the tendon in
  place behind the fibula is torn and
  therefore the tendon snaps over the
  fibula when walking.
              Achilles Injuries
Tendonitis – irritation of the tendon
  Initially
     slight pain
     Only hurts after practice/ activity
  As it progresses pain lasts longer and gets
  irritated with even regular walking
  Hurts 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
 Special Test – Achilles Rupture
  Thompson Test
   – Positioning
        Athlete prone with leg off the table
        Both hands on the calf
   – Test
        Squeeze calf at proximal 1/3 of lower leg
   – Positive
        Foot does not plantarflex


   TRY IT!!
Have your partner lie on your desk
            Ankle Injuries
Inversion 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
      Special Tests - ATF
Anterior Drawer
– ATaloFib
   Positioning
     – Grasp calcaneus w/ one hand
     – Let foot lie on your forearm
     – Other hand on tibia
   Test
     – Pull Calcaneus forward while push tibia backward
   Positive Test
     – Foot slides forward
     – Makes a clunking sound/ sensation
     – Pain (if pain only then grade 1 sprain)
Special Tests – ATaF or PTaF
Talar Tilt
– Positioning
    Stabilize tibia
    Grasp calcaneus
– Test
    Invert calcanus
– Positive
    Excessive motion
    Pain
 Special Tests – Deltoid Lig.
Kleiger’s Test
– Positioning
    Patient seated w/ ankle over the table
    Stabilize the lower leg
    Hold the medial aspect of the foot and evert
    the foot
– Test
    rotate the foot laterally
– Positive
    Pain over the deltoid ligament
    Pain over the lateral malleolus (indicates a
    syndesmotic sprain)
Tendinitis sites
             Foot Injuries
Calcaneus
– Heel Spurs
– Bursitis
– Contusion
Cuboid
– Subluxation
Tarsal
– Lisfranc
    Disloc./fx
            Foot Injuries
Morton’s toe
– Short Great Toe
    Usually benign, may cause probs w/ running
Plantar Fasciitis
– Common problem
    Pain in the proximal arch and heel
Jones Fracture
– Fracture of 5th met
           Foot Injuries
Bunion
– Caused by poorly fitting
  shoes
Hammertoe
– Flexion contracture of toes
Turf Toe
– Hyperextension
  Other Conditions/ Injuries
Tibial Contusion

Muscle Cramps

Muscle Strain
  Other Conditions/ Injuries
Shinsplints
– 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
         Grades of MTSS
Grade 1
– pain after activity
Grade 2
– pain before and after activity
– No performance affects
Grade 3
– Before during and after
– Affects performance
Grade 4
– Activity impossible/ too painful
  Compartment Syndrome
Compartment Syndrome
– Acute – secondary to trauma
– Exertional – activity related
– Symptoms
   Deep Aching Pain
   Tightness and Swelling
   Pain w/ stretching
   Reduced circulation and sensation
Management of Ankle Injuries
Inversion Ankle Sprains
– RICE
– Compression with Horseshoe
– Reduce Weight-bearing
– Begin ROM exercises
Syndesmotic Sprain
– RICE
– Take MUCH longer to heal
– Immobilize for at least 6-10 days before
  beginning ROM exercises
Management of Ankle Injuries
Achilles Tendon Rupture
– Surgical Repair or
– Cast for 6-8 weeks
Contusion
– RIC
– Doughnut pad
– Light ROM
– Light stretching
Management of Ankle Injuries
Cramps/ Spasms
– Massage
– Overpressure (trigger point)
– Stretching
– Monitor hydration and electrolytes if this
  becomes chronic
           Management
Medial Tibial Stress Syndrome
(MTSS)
– Rest
– Modification of activity
– Gait analysis

– Ice massage
– Stretching
– Arch taping
– Compression
       Achilles Tendinitis
Rest
Stretching of calf and foot muscles
Look at foot alignment
Recent change in running surface,
distance, form, or intensity
Decrease what is aggravating Achilles
Heat
Massage
Heel Lifts
        Plantar Fascitis
Rest, Ice
Stretch foot and lower leg
Add tennis ball stretch
Strengthen lower leg and foot
Check foot alignment
Tape arches
Night Splint
       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
Management of Ingrown Toe Nail

				
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posted:12/25/2012
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