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									   CHAPTER TWO

THE FOOT AND ANKLE

    COMPLEX




        20
ANATOMY / PALPATION
1. Label the following bones and bone structures on the given pictures.

a. Lateral Malleolus                              n. Styloid Process 5th Metatarsal
b. Entire fibula                                  o. Sesamoid bones
c. Talar Dome                                     p. Phalanges (label each)
d. Lateral Calcaneus- identifies peroneal         q. Deltoid Ligament
    tubercle                                      r. Anterior Talofibular Ligament
e. Posterior Calcaneus-identifies                 s. Calcaneofibular Ligament
    calcaneal tubercle                            t. Posterior Talofibular Ligament
f. Medial Calcaneus-identifies                    u. Bifurcate Ligament
    sustentaculum tali                            v. Deltoid Ligament
g. Medial Malleolus                               w. Calcaneonavicular ('Spring')
h. Entire Tibia                                   Ligament
i. Inferior Calcaneus-identifies medial           x. Distal tib-fib ligaments (syndesmosis)
    tubercle                                      y. Peroneal Longus/Brevis Tendons
j. Navicular-identifies navicular tubercle        z. Peroneal Tertius Tendon
k. Three cuneiforms                               aa. Extensor Hallicus Longus (ankle to
l. Cuboid                                         hallux)
m. Metatarsals 1-5

Lateral View




                                             21
Medial View




2. On a partner locate the above bones and bone processes(from #1). Using a grease pencil or
some other writing instrument for the skin mark and label these bones. During an assessment,
remember that many of these bony structures serve as attachments for muscles, tendons and
ligaments. Also if sharp and/or intense pain is felt by an athlete during their palpation, it may be
an indication of fracture.

3. Locate the joints of the phalanges, be able to locate and name these joints. What type of
motion is available at the metatarsophalangeal joints?



4. On a partner please draw the location of the ligaments on the lateral and medial ankle. Be sure
to use a grease pencil or other suitable writing instrument. When done show them to your
instructor or laboratory assistant. As ankle sprains typically involve damage to these ligaments, it
is extremely important in being able to locate them. Remember that eliciting pain while stressing
or palpating ligaments is a good indicator of ligament involvement.



5. Gently invert or turn in the ankle of your partner after completing the sketching of the ankle
ligaments. By watching the movement of skin as you turn the ankle which ligaments appear to be



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the most susceptible to damage? When done add the motions of plantarflexion and then
dorsiflexion to the ankle inversion. Which ligaments tend to be stretched with which motions?

           ANKLE MOTION                                LIGAMENT INVOLVED
Inversion Only
Inversion with Plantarflexion
Inversion with Dorsiflexion

6. Gently evert or turn out the ankle. Which ligament(s) are now being stretched?



7. Which ligaments combine to form the deltoid ligament?




8. While you were inverting and everting the ankle which motion was easier-inversion or
eversion? What anatomical reasons account for the difference in motion?

       a.

       b.


9. On the medial side of your partner's foot, place a mark on the medial head of the first
metatarsal, navicular tubercle and in the center of the medial malleolus while the foot is non-
weightbearing. Draw a straight line from the metatarsal head to the medial malleolus. This is
called a Feiss Line. Is the navicular tubercle on this line? If the navicular is below the line the
person is considered to have_________________________, while the existence of the tubercle
above this line is called ______________________________.


10. Repeat the above procedure with your subject weightbearing. Is there a difference from the
non-weightbearing condition? Explain what you found.




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11. Examine the bottom of your subject's foot. Locate the medial tubercle underneath the
calcaneus[heel bone]; note the thick band like structure which attaches at this point and extends
down towards the toes. What do you call this band of connective tissue?




12. Look at the underside of your partner's foot and locate the third phalange. Directly proximal
to this toe within the ball of the foot you should notice a mild depression in the soft tissue. This is
the Metatarsal Arch.




13. On the anterior distal portion of your partner's ankle note the gap between the distal tibia and
fibula. During weightbearing there is a force that tries to separate these two bones. What
structures prevent this separation from occurring?




14. Imagine that your partner has damaged the supporting distal anterior structures of the ankle
commonly called a Syndesmotic Ankle Sprain. By moving the ankle through various planes of
motion determine which motion would most likely cause the greatest pain to this area. Why




MUSCLE ANATOMY
On the available drawings, sketch and label the following musculotendinous structures. On the
table associated with each muscle fill in the blanks with the appropriate information. As you
locate each structure and learn of its origin, insertion, and primary motor function, try to locate
them if possible on yourself or on a partner. You may use any anatomy or course text to complete
this activity.

Peroneal Longus
      Origin:
      Insertion:
      Nerve Innervation:
      Primary Motor Functions:



Peroneal Brevis
      Origin:


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       Insertion:
       Nerve Innervation:
       Primary Motor Functions:


Peroneal Tertius:
      Origin:
      Insertion:
      Nerve Innervation:
      Primary Motor Functions:


Anterior Tibialis
      Origin:
       Insertion:
       Nerve Innervation:
       Primary Motor Functions:


Posterior Tibialis
       Origin:
       Insertion:
       Nerve Innervation:
       Primary Motor Functions:


Extensor Hallicus Longus
      Origin:
      Insertion:
      Nerve Innervation:
      Primary Motor Functions:


Extensor Digitorum Longus
      Origin:
      Insertion:
      Nerve Innervation:
      Primary Motor Functions:



Extensor Digitorum Brevis
      Origin:


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         Insertion:
         Nerve Innervation:
         Primary Motor Function:


Flexor Hallicus Longus
       Origin:
       Insertion:
       Nerve Innervation:
       Primary Motor Functions:


Gastrocnemius
      Origin:
         Insertion:
         Nerve Innervation:
         Primary Motor Functions:


Flexor Digitorum Longus
       Origin:
       Insertion:
         Nerve Innervation:
         Primary Motor Function:


Soleus
         Origin:
         Insertion:
         Nerve Innervation:
         Primary Motor Functions:


Plantaris
       Origin:
       Insertion:
       Nerve Innervation:
       Primary Motor Functions:


MANUAL MUSCLE TESTING




                                    26
It should be remembered by the student that to determine which muscle is involved in a
muscle strain, it is important to isolate the muscle by applying resistance to a motion that
only that muscle does well. In addition to providing a diagnostic tool to identify which
muscle or muscle(s) may be involved, strength testing provides the examiner a means to
determine extent of damage with the injury by quantifying strength loss. Muscle testing
also provides a means to assess the function of the motor nerves which innervate that
muscle.

While performing manual muscle testing it its imperative that you isolate the muscle by
positioning the body part and applying resistance to the muscle in a manner that only that
muscle is primarily functioning. For example, the tibialis anterior is an invertor and
dorsiflexor of the ankle; by resisting both motions at the same time, pain elicited in this
maneuver would probably be tibialis anterior in nature.

In addition a musculotendinosous unit can also be isolated by stretching the desired
muscle in a directly opposite to its primary motions. For example the peroneal tertius
muscle is an ankle evertor and dorsiflexor. By passively inverting and plantarflexing the
ankle you would isolate the peroneal tertius and elicit pain along its length if it was
injured.

A. Dorsiflexors-
1. Tibialis Anterior
   a. Places hand superior to ankle to stabilize movement
   b. Places contralateral hand on anteromedial foot
   c. Has patient attempt to invert and dorsiflex the ankle
   d. Resists ankle inversion & dorsiflexion
   e. Repeats bilaterally

2. Peroneal Tertius
   a. Places hand superior to ankle to stabilize movement
   b. Places contralateral hand on anteromedial foot
   c. Has patient attempt to invert and dorsiflex the ankle
   d. Resists ankle inversion & dorsiflexion
   e. Repeats bilaterally


B. Plantarflexors-
3. Gastrocnemius/Plantaris
   a.Instructs patient to lie supine (if applicable)
   b.Places contralateral hand on distal posterior lower leg
   c. Has patient place knee into extension
   d.Places contralateral hand over metatarsal heads (plantarsurface)
   e. Has patient attempt ankle plantarflexion
   f. Resists ankle plantarflexion
   g. Repeats test bilaterally


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4. Soleus
   a.Instructs patient to lie supine (if applicable)
   b.Places contralateral hand on distal posterior lower leg
   c. Has patient place knee into90 degrees flexion
   d.Places contralateral hand over metatarsal heads (plantarsurface)
   e. Has patient attempt ankle plantarflexion
   f. Resists ankle plantarflexion
   g. Repeats test bilaterally

C. Inversion-
5. Tibialis Posterior
   a. Places hand proximal to medial ankle joint
   b. Places contralateral hand over medial foot
   c. Has patient internally rotate foot
   d. Has patient invert & plantarflex ankle
   e. Resists ankle inversion & plantarflexion
   f. Repeats bilaterally

D. Eversion
6. Peroneal Longus/Brevis
   a. Places hand proximal to lateral ankle joint
   b. Places contralateral hand over lateral foot
   c. Has patient externally rotate foot
   d. Has patient evert & plantarflex ankle
   e. Resists ankle eversion & plantarflexion
   f. Repeats bilaterally


RANGE OF MOTION

A normal range of motion is necessary for the ankle and foot to satisfy its needs for
proper gait and function. In many low leg conditions, pain and dysfunction can be
attributed to an inadequate range of motion somewhere in the foot or leg. Although the
relationship of ankle/foot motion to lower extremity problems will be discussed in a later
chapter(See Gait); the ability to assess range of motion of the various foot and ankle
joints will be discussed here.

Important to proper gait is the available motion at the toes especially the hallux. The
most important motion may be that of hyperextension. Ideally each toe should have at
least 90 degrees of passive hyperextension with the metatarsal supported. If the hallux is
not capable of achieving this amount of motion it is considered to be hallux limitus. If no
hyperextension is possible by the hallux(actually fairly common), the person is
considered to have Hallux rigidus.




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15. Using your text, fill in the expected norms of motion for the joints listed.

          JOINT                     DORSIFLEXION                 PLANTARFLEXION
Ankle Joint
Mid tarsal Joint
Metarsophalangeal Jts.

          JOINT                       INVERSION                       EVERSION
Ankle Joint


16. On your partner test the available motion at the toes, checking both flexion and
hyperextension. While performing this skill be sure to stabilize the metatarsal head with
one hand while passively moving the toe with the other. What is the available motion at
the joints?



17. Goniometry – The goniometer provides an objective measure of joint motion. The
good clinician should be proficient in its use. Joint measures are important in the initial
assessment of the injury and is a very important tool in assessing improvement of the
patient during rehabilitation. The following movements and techniques have been
selected as those which are required for the entry level athletic trainer to have competency
in.

Using the time available, practice these techniques on your partner in the lab. However to
be become truly proficient at these techniques practice outside of the classroom as well.

A. Active ROM (w/goniometer)
1. Dorsiflexion
   a. Aligns axis of rotation over lateral malleolus
   b. Aligns stationary arm along fibula
   c. Aligns movement arm parallel to 5th metatarsal
   d. Tells patient to dorsiflex ankle
   e. Maintains movement arm's relationship w/ 5th met
   f. Verbally & correctly determines degree of
  dorsiflexion

2. Plantarflexion (w/goniometer)
   a. Aligns axis of rotation over lateral malleolus
   b. Aligns stationary arm along fibula
   c. Aligns movement arm parallel to 5th metatarsal
   d. Tells patient to plantarflex ankle


                                             29
                                                    th
 e. Maintains movement arm's relationship w/ 5 met
 f. Verbally & correctly determines degree of
 plantarflexion

3. Inversion (w/goniometer)
   a. Aligns axis w/anterior ankle joint
   b. Aligns stationary arm w/ 3rd metatarsal
   c. Aligns movement arm w/ 3rd metatarsal
   d. Has patient invert ankle
   e. Moves movement arm w/ 3rd metatarsal while
   maintaining stationary arm position
   f. Provides measure of ankle inversion

4. Eversion (w/goniometer)
   a. Aligns axis w/anterior ankle joint
   b. Aligns stationary arm w/ 3rd metatarsal
   c. Aligns movement arm w/ 3rd metatarsal
   d. Has patient evert ankle
   e. Moves movement arm w/ 3rd metatarsal while
   maintaining stationary arm position
   f. Provides measure of ankle eversion

B. Passive ROM
1. Repeats above motions

        The ankle's motion is considered triplanar, in other words can occur through three
different planes. The ankle motions of supination and pronation are in fact combinations
of three single plane motions. However we will look at supination and pronation with a
later chapter(see Gait), and will concentrate primarily on the single plane motions of
dorsiflexion and plantarflexion(sagittal plane) and inversion and eversion(frontal plane).

        Adequate Dorsiflexion is necessary for proper function of the foot, ankle, and
virtually all of the lower extremity. If the motion is insufficient, the individual will be
prone to several acute and chronic conditions; to include ankle sprains, arch strains,
achilles tendonitis etc. As a result it is imperative that assessing ankle dorsiflexion be
done for all lower leg dysfunction including acute injuries.


18. Now have the athlete plantarflex her/his ankle. How much motion is present?
Compare bilaterally.


19. Which of the two motions is greater?



                                              30
20.. Test dorsiflexion passively on your partner. Be sure to turn the foot inward a small
amount(supination) before applying pressure. The small bones are "loose packed" with
the foot in a neutral or turned out position(pronation), therefore passive dorsiflexion
without supinating the foot will result in the small foot bones spreading and giving the
appearance of greater dorsiflexion. What values did you achieve?



21. Would it be helpful to test ankle dorsiflexion with the knee straight and bent? If so,
explain why and if not explain why it would not make a difference.




22. Have your subject lie prone[face down] on a table. Have her/him turn the ankle
in[toward the body midline], this is considered inversion. Return the foot to neutral now
turn out[away from the body midline] this is considered eversion. Which is greater?
What reasons would make one motion greater than the other [clue: think skeletal
anatomy]




It is important to remember that dorsiflexion and plantarflexion are talocrural motions,
in other words occurs at the articulation of the upper talus with the ankle mortice
produced by the distal portions of the fibula and tibia. This group of three bones: the
talus, distal fibula, and distal tibia create the true ankle joint. Whereas the motions of
inversion and eversion are subtalar meaning the motion occurs below the talus at its
articulation with the calcaneus. Therefore inversion and eversion are not true ankle joint
motions!


23. Explain why the motions of inversion and eversion occur below the true ankle joint
and not within it?




                                             31
24. What are the normal values for ankle inversion and eversion? Would it be helpful to
have more than the normal motion available? Explain your answer.




Remember that in addition to the above Primary Motions there exist Accessory Motions
as well. Accessory motions are small sliding, rolling and/or gliding motions that occur
between bones. They are not measurable but are necessary for proper joint function.
Your textbook describes many of these motions and how to test for them.


NEUROLOGY
Please fill in the following chart. For the dermatome section write the area of the lower
leg where sensation differences would be noticeable. For the myotome list which motion
should resisted to assess the motor capabilities of the selected nerve root. Finally note the
location of the nerve root reflex if any.

Nerve     Dermatome                Myotome                    Reflex
Root

L4


L5


S1


S2



25. Using the above chart of foot and low leg dermatomes, draw an outline of the general
dermatome areas on your partner with a grease pencil. Using a brush, pin, or other
object(s) apply stimulation to these areas. Have your partner note any difference in
sensation. It is helpful to apply different pressures bilaterally to determine if the subject
can detect differences. When done with an actual patient it can be done to determine if
the individual is being truthful with their responses.




                                             32
26. Using a neurological hammer attempt the reflex for L4, L5 and S1. Do so by applying
a rapid blow to the tendon. Be sure not to apply too great a pressure to avoid injuring the
subject. Compare bilaterally, and remember that in practice you should test the
uninjured/uninvolved side first. Note any differences and any comments regarding these
tests below.




27. On the following drawing below sketch the sensation areas of the following
Cutaneous Nerves:
       Lateral Cutaneous            Saphenous
       Superficial Peroneal         Deep Peroneal
       Sural




                                            33
SPECIAL TESTS
As with virtually all joints of the human body there are tests designed to test the integrity
and/or function of ankle joint structures. All are based on the anatomy and with a solid
anatomical background these tests will be easy to remember even if you cannot remember
their names (of course for my tests and the NATA examination, knowing the names will
make it much it easier to pass). In fact with a little imagination and your knowledge of
anatomy you can even make your own tests up!

To facilitate your learning of the ankle special tests and the special tests of other joints
seen in subsequent chapters, each special test will have a checklist which can be used as a
guide for their application. Have your partner check them off as you complete each part of
the skill.

Remember that the NATA oral practical is primarily a test of skills, and this checklist can
be helpful in allowing you to prepare for that examination in the future.

Therefore if you are ever evaluating someone and are at a loss for words or in this case at
loss of what to do; picture the person's anatomy in your head and try to determine what
would adequately stress the imagined body structure.

Generally speaking while performing any special test, DO THEM BILATERALLY!!!
preferably with the non-involved side tested first. One person's apparently torn ligament
is another man's normal; so do your test bilaterally and compare.

Also when testing ligaments or muscle structures apply pressure firmly but over an
interval of time-therefore no sudden forceful movements which will scare the injured
athlete causing the area to tense up and make your tests relatively worthless. Apply
enough pressure to get the job done; don't be so light with your force that you think
everything is ok when its not, but at the same time don't try to rip the joint apart and make
an injury that wasn't there already.


The key to performing special tests well is to practice, practice and when you are
done with practicing then practice some more. It will improve your confidence
[shaking from nerves while testing someone's injured body part will not be a good way
to develop their trust], and you will remember them a lot better. Also performing the
special tests are fairly easy, the difficulty becomes in interpreting the amount of
damage present, how long the damage has been present etc. which only comes with
PRACTICE.




                                             34
                              ANTERIOR DRAWER TEST

PURPOSE:To stress the ________________________________ Ligament, the most
commonly injured ligament in the human ankle.

METHOD: This test isolates one of the functions of the ____________________
Ligament. You as the examiner will be trying to pull the ankle anteriorly, drawing the
talus forward from underneath the mortice.

TECHNIQUE:


a. Has patient permit foot to drop over edge of table
 or relaxes ankle while supine                                 YES            NO

b. Has patient flex knee to 15 degrees                         YES            NO

c. Grasps anterior lower leg, just superior to ankle
    joint                                                      YES            NO

d. Cups contralateral hand around calcaneus,
  supporting foot w/forearm                                    YES            NO

e. Attempts to glide lower ankle anteriorly while
   stabilizing lower leg                                       YES            NO

f. Assesses amount of laxity @ ankle                           YES            NO

g. Repeats test bilaterally                                    YES            NO

In a first degree ankle sprain there will be little or no movement present as compared
bilaterally with this test, however it will elicit pain. A second degree sprain will elicit a
considerable amount of motion but you will generally feel a sticking point to the motion,
whereas a third degree sprain will give you the feeling that the joint can be taken
completely apart.




                                              35
                                    TALAR TILT TESTS
                                (also known as the Rock Test)

PURPOSE: To test the integrity of the various medial and lateral ligaments of the ankle.
Medially this includes the ____________ ligament with its anterior talotibial,
calcaneotibial(superficial and deep) and posterior talotibial portions. Laterally, it can be
used to test the ________________________, _____________________, and the
_________________________ Ligaments.

METHOD: Isolates the various ligaments or portions of the ligaments and applies tensile
loading to assess their capability to resist.

TECHNIQUE:note where applicable write name of ligament tested.

Talar Tilt –inversion for lateral ligaments

a.Instructs patient to relax ankle or permit it to hang
over table                                                      YES           NO

b. Positions self anterior to patient                           YES           NO

c. Stabilizes lower leg w/ 1 hand                               YES           NO

d. Grasps calcaneus & maintains foot in neutral                 YES           NO

e. Inverts ankle passively( _____________)                      YES           NO

f. Inverts ankle with ankle plantarflexed ( ___________)        YES           NO

g. Inverts ankle with ankle dorsiflexed (.____________.)        YES           NO

3. Talar Tilt-eversion to test medial ligaments
a. Instructs patient to relax ankle or let it hang over table   YES           NO

b. Positions self anterior to patient                           YES           NO

c. Stabilizes lower leg w/ 1 hand                               YES           NO

d. Grasps calcaneus & maintains foot in neutral                 YES           NO

e. Attempts to evert ankle passively ( ___________.)            YES           NO

Key to this test is to compare amount of motion available at each position. This test
effectively isolates each ligament. Pain will indicate which ligament is involved unless
there is a complete acute tear. More motion indicates more severe damage.


                                               36
                                     HOMAN SIGN

PURPOSE: To rule out vascular pathology to include thrombophlebitis in the calf region


TECHNIQUE:


a. Has patient lie supine or be seated w/knee extended     YES            NO

b. Supports calcaneus w/ 1 hand                            YES            NO

c. Places opposite hand on plantar surface of foot         YES            NO

d. Dorsiflexes ankle while maintaining knee ext.           YES            NO

___________________________________________________________________

                                  THOMPSON TEST

PURPOSE: To test the integrity of the achilles tendon

METHOD: Causes a contraction of the gastrocnemius muscle which in turn should result
in mild plantarflexion of the ankle. If the achilles tendon has been torn plantarflexion
cannot occur solely due to the gastrocnemius.

TECHNIQUE:
  a. Has patient lie prone w/foot unsupported        YES   NO

  b. Stands @ patient's side                         YES   NO

  c. Grasps posterior calf musculature               YES   NO

  d. Squeezes posterior calf musculature             YES   NO

  e. Notes level of ankle of plantarflexion          YES   NO

A positive test would be one where there is no ankle movement. Be aware of false
negatives as compression of the peroneals, soleus and tibialis posterior can cause
plantarflexion. Also pain may not be present due to severing of nerve.




                                              37
                                        KLEIGER TEST

PURPOSE: Determines involvement of anterior portion of deltoid ligament in an ankle
injury.

METHOD: The anterior portion of the deltoid ligament can become involved during an
inversion ankle sprain. This happens due to a rotational component common to the
mechanism of most inversion sprains. This test recreates a rotational force which applies
a tensile force to the anterior portion of the deltoid ligament.

TECHNIQUE:

a. Instructs patient to relax ankle or let it hang over table   YES          NO

b. Positions self anterior to patient                           YES          NO

c. Stabilizes lower leg w/ 1 hand, avoiding too much
pressure that would compress the distal tibiofibular
syndesomosis                                                    YES          NO

d. Grasps medial aspect of foot                                 YES          NO

e. Attempts to laterally rotate foot                            YES          NO

f. Notes location of pain: medial=deltoid ligament,
   lateral= syndesmosis                                         YES          NO

Note that due to the position of the ankle, it is unlikely to see any laxity which would be
rare to occur anyway. A positive sign would be pain. This test may also be helpful in
determining involvement of the lower syndemosis structures of the ankle.




                                               38
                                       STORK TEST

PURPOSE: To evaluate the proprioceptive function of the lower extremity.

METHOD: Places the subject in a compromising position forcing her/him to actively
contract smaller muscles to maintain balance.

TECHNIQUE:

       Have athlete/partner stand up                         YES     NO

       Have athlete/partner stand one leg                    YES     NO

       Have athlete/partner place foot of free leg           YES     NO
              knee of supporting leg

       Watch for swaying motion                              YES     NO

       Repeat bilaterally                                    YES     NO


As the athlete/subject performs this test observe her/his ability to maintain balance on the
weightbearing extremity. Typically the injured limb is compared to the healthy limb,
looking for a greater difficulty in maintaining one's balance. The greater the sway present
as compared bilaterally, the greater the proprioceptive deficits.

However this test may be used with individuals who experience chronic bilateral lower
limb problems or as a screening device to predict injury. In this case a bilateral
comparison may not be indicated and your judgement should be based on the amount of
sway present in your subject.




                                             39
                                    FRACTURE TESTS

PURPOSE: To apply compressive and/or vibratory stress on bone structures to determine
possibility of fracture when deformity not present.

METHOD: By applying stimuli/pressure away from a potential fracture site (as
determined by palpation and mechanism injury) the possibility of an existing fracture may
be increased by eliciting referred pain over the injured area.

Compression Test

a. Has patient lie supine or seated w/knee extended          YES             NO

b. Positions self alongside ankle                            YES             NO

c. Cups both hands behind fibula & tibia                     YES             NO

d. Gently squeezes hands together                            YES             NO

e. Gradually moves hands towarsd injured area                YES             NO

f. Observes for patient apprehension                         YES             NO

This test is effective and is enhanced by the contraction of the lower extremity muscles
which all have attachment sites at or beyond the ankle.


Wedge Test

a. Has patient lie supine                                    YES             NO

b. Grasps posterior low leg w/non-dom hand                   YES             NO

c. Gently strikes calcaneus w/heel of dominant hand          YES             NO

d. Gradually increases pressure until pain felt              YES             NO

e. Observes for patient apprehension                         YES             NO

This test can also be an effective aid in ruling out fractures. However be aware of false
negatives for both. If sharp pain is present over a boney structure or you are concerned
always go the conservative route and splint.




                                             40
                       REVIEW OF AN ANKLE EVALUATION

I. ACHIEVE THOROUGH HISTORY OF THE INJURY
      1. Mechanism of Injury-Which way did it go?, etc.
      2. Has it happened before?
      3. How long ago did you injure it?
      4. What type of pain do you feel? Is there throbbing?
      5. Did you rule out injury to another body site?

II. OBSERVE THE INJURY
       1. Is there deformity?
       2. Is there swelling or discoloration?
       3. What position is the ankle/foot in?
       4. Did you check alignment of landmarks(Feiss Line)
       5. Did you observe bilaterally?

III. PALPATION
       1. Check bones, did you locate all of them?
       2. Is there pain found within a boney structure?
       3. Do you notice any deformity?
       4. Check soft tissue structures
       5. Is the pain along a joint line? If so, which ligament(s) can be found at this site?
       6. Is the pain primarily along muscle, tendon, ligament or along a combination of
                the three?
       7. Do you feel crepitus, effusion or deformity?
       8. Did you palpate bilaterally?
       9. Did you check for pulse?

IV. STRENGTH
       1. Did you check strength?
       2. Were you able to isolate the various important muscles?
       3. Did you locate determine muscles are involved with the injury?
       4. Were they weak?
       5. Was pain elicited during a contraction against resistance?
       6. Could the present weakness be due to nerve involvement?
       7. Is there good overall muscle tone present about the ankle      (especially the
gastroc/soleus complex and the tibialis anterior)
       8. Did you evaluate strength bilaterally?

V. RANGE OF MOTION
      1. Did you assess range of motion actively?
      2. Did you assess range of motion passively?
      3. Was one greater? If so, why?
      4. Did you check motions of all involved joints?
      5. Is the ankle dorsiflexion present adequate?


                                              41
       6. Is the ankle inversion/eversion excessive?
       7. Is there hallux rigidus or limitus
       8. If one or motions are limited, how come?
       9. Did you compare them bilaterally?


VI. NEUROLOGICAL
      1. Was there any strength differences possible due to nerve dysfunction?
      2. Does the person complain of general weakness, tingling or some other
               sensation?
      3. Did check all of the dermatomes for sensation?
      4. Did you check all of the dermatomes bilaterally?
      5. Did you check all relevant reflexes?
      6. Is there a difference?
      7. Did you check reflexes bilaterally?
      8. If neurological symptoms/signs are found, are they due to a back or hip
               problem? Or are they related to some nerve damage distal from the nerve
               roots?
      9. Did you check proprioception?
      10. Did you proprioception bilaterally?

VII. SPECIAL TESTS
       1. Did you perform all relevant special tests?
       2. Did you perform all relevant special tests bilaterally?
       3. Did any special test elicit pain or laxity?
       4. Was laxity compared bilaterally?
       5. If pain felt, what structure might be involved?
       6. If laxity present was an end feel found?
       7. If no end feel what is the degree of injury?

VIII. ANALYSIS OF ASSESSMENT
       1. Was pain mostly in bone or soft tissue?
       2. Based on injury mechanism what would most likely be
       injured?
       3. Does assessment agree with injury mechanism?
       4. Which special tests were positive? What do they assess?
       5. How does the injured foot/ankle compare with the
       contralateral side?
       6. Besides pain, were there any other symptoms or signs that may indicate a
                fracture?{to include how long pain present}
       7. If laxity found how much? second degree? third degree?
       8. Is there involvement of any other body part? Referred Pain?
       9. If chronic injury, what is the source?
       10. If acute was there any contributors?
       11. What is your final assessment?


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CRITICAL THINKING

1. How much hyperextension should be available at the first metatarsophalangeal to allow
proper gait? Think of a linebacker on a football team. In such a position he needs to
remain on his toes for a considerable portion of the time, often using this point of ground
contact to apply pressure for propulsion. What problems/injuries can you think of would
occur if the range of motion at the hallux is insufficient? Please explain.




2. If hallux hyperextension is limited, what type of condition would be present?




3. Explain how flat feet or excessive weight/force can contribute to pain or damage to the
plantar fasciae. It may be helpful to have the subject alternate the foot between weight
and nonweightbearing to determine this answer.




4. How does the taping of the arch or a good arch support prevent unnecessary strain in
the plantar region?




5. Occasionally an athlete may experience pain in the area of the metatarsal arch and an
assessment will reveal a callus formation instead of the typical soft tissue depression.
What would cause this callus formation to occur?



6. Inadequate dorsiflexion greatly disrupts the normal mechanics of the lower extremity.
As with all alterating of the lower extremity motion, mechanical stresses are multiplied.
What lower leg conditions/injuries can be attributed to inadequate dorsiflexion at the
ankle?




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7. Why would a patient complain of discomfort in the anterior ankle if you were
attempting to stretch the achilles




8. How does the presence of a tight achilles result in increased inversion ankle sprains?




9. How does a tight achilles account for increased plantar pathology?




10. An athlete reports to an injury mechanism of inversion with plantarflexion, which soft
tissue structure(s) should you suspect to be involved?




11. You assess an acute ankle injury, and find a positive anterior drawer test, and a
positive talar tilt test with the ankle in both the neutral and plantarflexed positions, what
structures appear to be damaged?




12. What musculotendonus structures are important in the control of foot pronation
during normal gait?




13. Describe in detail some of the various conditions commonly associated as ‘shin
splints’?




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14. What tendon has the ability to subluxate the cuboid bone of the foot?



15. List the dynamic and static supporters of the longitudinal arch?




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