The Foot and Ankle Evaluation

1. The Foot and Ankle Evaluation

2. 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

3. History Sounds or Sensations Did you feel any unusual sensations when it occurred? Did you hear any unusual sounds when it occurred? • Pain • Where does it hurt? • Point with ONE finger • Rate the pain • Scale of 1-10 • What makes it hurt? • Specific movements? • positioning • When does it hurt? • Can you describe the pain?

4. 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

5. Pes Planus or Cavus Structural Deformities Pes Planus = flat footed/ no arch Pes Cavus = high arch

6. 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.

8. The Gait Cycle Heel Strike – shock absorption Toe-off – propel forward

9. 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?

10. 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

11. Palpation Notice Point Tenderness Specific site of pain Trigger Points Crepitus Grinding, crunching, or crackling sensation with the rubbing of tissues Tissue Density Increased Spasm Scarring Decreased Swelling Hemorrhage Symmetry Are both sides equal Temperature

12. Special Tests 1st Special Tests ________ ___ ____________ ____________ ____________ or ____________ Fracture Tests ____________ ____________ ____________ Range of motion Active Passive Assistive Bump Lever Compression

13. 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

14. 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.

16. 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.

17. 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

18. 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

19. 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

20. 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)

21. Special Tests – ATaF or PTaF Talar Tilt Positioning Stabilize tibia Grasp calcaneus Test Invert calcanus Positive Excessive motion Pain

22. 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)

23. Tendinitis sites

24. Foot Injuries Calcaneus Heel Spurs Bursitis Contusion Cuboid Subluxation Tarsal Lisfranc Disloc./fx

25. 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

26. Foot Injuries Bunion Caused by poorly fitting shoes Hammertoe Flexion contracture of toes Turf Toe Hyperextension

27. Other Conditions/ Injuries Tibial Contusion Muscle Cramps Muscle Strain

28. 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

29. 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

30. 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

31. 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

32. Management of Ankle Injuries Achilles Tendon Rupture Surgical Repair or Cast for 6-8 weeks Contusion RIC Doughnut pad Light ROM Light stretching

33. Management of Ankle Injuries Cramps/ Spasms Massage Overpressure (trigger point) Stretching Monitor hydration and electrolytes if this becomes chronic

34. Management Medial Tibial Stress Syndrome (MTSS) Rest Modification of activity Gait analysis Ice massage Stretching Arch taping Compression

35. 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

36. 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

37. 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

38. Management of Ingrown Toe Nail