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Ankle and Foot

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									Musculoskeletal Branching Exam – Ankle and Foot

•      Must examine both sides to pass exam.

Exam maneuver                                                 Focus
I.     Introduction
       States name and purpose
       States would wash hands

II.    General Appearance
       Observes patient for habitus, posture,
       level of comfort, signs of distress

III.   Vital signs* (verbalizes)
       A. Takes or verifies temperature
       B. Counts radial pulse (15 seconds)
       C. Counts respirations
       D. Takes blood pressure R. arm
     Prepare patient
    Student must have both lower extremities adequately
    exposed from the knees down.
IV.    Inspection
       A. Evaluates the medial longitudinal arch with:
           1. patient standing                                        pes planus, pes cavus
           2. patient sitting
       B. . Observes ankle (lateral and medial aspects)       swelling, deformity
       C. Observes foot (between toes and plantar surface)           bunions, callouses, hammer toes,
                                                                     corns ingrown toenails
VI.    Palpation Ankle and Foot
       A. Palpates bony landmarks:*
           1. Laterally:
                  a. Fibular head (at knee)                           pain=fracture (remember
                  b. Lateral malleolus (start high and go             point tenderness over boney
                      distally)                                       prominence means R/O
                  c. base of 5th metatarsal                           fracture)
           2. . Medially:
                  a. medial malleolus (start high and go
                      distally)
           3. Palpate metatarsal heads                                Pain(fracture, metatarsalgia)
       B. Soft Tissue landmarks*
           1. laterally:                                              pain, swelling
                  a. Anterior talofibular ligament.                   most comm. injured ankle lig.
                  b. Calcaneofibular ligament
                  c. Posterior talofibular ligament
                  d. Peroneal tendons (palpate                        pain, tenosynovitis
                  behind lateral malleolus)
           2. Medially:
                  a. Deltoid ligament                                 pain, swelling
                  b. posterior tibialis tendon (palpate       pain, tenosynovitis
                   behind medial malleolus)
           3. Posteriorly
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               a. Achilles tendon (palpate                             pain, swelling
               Along entire tendon)
            4. Plantar surface
               a. plantar aponeurosis (start at                        pain (plantar faciitis
               origin on calcancus)
               b. between metarsal heads                               Morton’s neuroma
        C. Circulation*
           1. Check dorsalis pedis                              12-15% of pop. do not have
           2. Check posterior tibialis                                1° blood supply to foot
           3. Check capillary refill (if ankle, foot
                swollen)
VII.    Neuro Exam
        A. Range of Motion*:
            1. Have patient dorsiflex/plantar flex ankle
            2. Have patient evert/invert foot                   pain, tenosynovitis, of peroneal or posterior
               against resistance                                        tibial tendon
        B. Sensation (sharp/dull)*
            1. checks lateral aspect of foot                           Sural nerve (S1)
            2. checks medial aspect of foot                            Saphenous nerve (L4)
            3. checks web space between                                Peroneal nerve (L5)
               1st & 2nd MT


VIII.   SPECIAL TESTS:
        A. Thompson’s test                                             Achilles tendon rupture (partial/complete)
               1. With patient prone on table (or
               use chair method) and with both ankles
               off table, squeeze calf and note plantar
               flexion of foot.
               2. Compare with other side
        B. Anterior Drawer
               1. With foot in neutral position,                       If anterior movement of foot
               move calcaneus forward with one                         assume anterior talofibular
                hand while pushing tibia/fibula                        ligament has been torn
                posteriorly. Compare with other ankle.
               2. Repeat at 90°
        C. Talar Tilt (perform only if Anterior drawer                 abnormal movement implies
           is positive)                                                both anterior talofibular and
               1. Hold calcaneous and invert foot               calcaneofibular ligaments are
               2. Compare with other ankle                      torn

•     Remember:A shoe problem can cause a foot problem and a foot problem can deform a good shoe.
             Don’t forget to examine the pair of shoes the patient wears most often.
* May do in any sequence.




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