Foot & Ankle Examination Workshop Morteza Khodaee, MD, MPH, FACSM, FAAFP Associate Professor Department of Family Medicine University of Colorado

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1 Foot & Ankle Examination Workshop Morteza Khodaee, MD, MPH, FACSM, FAAFP Associate Professor Department of Family Medicine University of Colorado School of Medicine July 4, 2013

2 Objectives Participants will be able to: Select the most effective and evidence based physical examination tests to establish the diagnosis. Demonstrate proficiency in a number of examination techniques, including inspection, palpation, range of motion, and special tests Determine when imaging may be needed for an ankle injury based on the Ottawa foot and ankle rules.

3 Anatomy Hindfoot Inferior Tibiofibular Joint Syndesmosis type with minimum movement Ant. & post. inferior tibiofibular, transverse tibiofibular, and interosseus ligament

4 Anatomy Hindfoot Talocrural (Ankle) Joint Formed by Talus, Med. & Lat Malleoli Uniaxial and modified hinged type Plantar flexion to 50 and dorsiflexion to 20 ATF & PTF, and calcaneofibular lig. laterally Deltoid lig. medially

5 Anatomy Hindfoot Subtalar (Talocalcanean) Joint Formed by talus, calcaneus, navicular, and cuboid Supination and pronation 15-30

6 Anatomy Lateral View

7 Anatomy Medial View

8 Anatomy Anterior View

9 Anatomy Posterior View

10 Anatomy Midfoot Chopart s Joint Midtarsal joints between the taluscalcaneus and the navicular-cuboid Minimum movement

11 Anatomy Forefoot Tarsometatarsal (Lisfranc s) Joints Intermetatarsal Joints Metatarsophalangeal Joints Toe extension, lateral four toes (MTP 40 ), big toe (MTP 70 ) Toe flexion, lateral four toes (MTP 40 ), big toe (MTP 45 ) Interphalangeal Joints Toe extension, lateral four toes (PIP 0, DIP 30 ), big toe (IP 0 ) Toe flexion, lateral four toes (PIP 35, DIP 60 ), big toe (IP 90 )

12 History Evaluation Mechanism of Injury Presence of transient or fixed deformity of the foot & ankle at the time of injury Level of activities after the injury

13 History Evaluation Swelling or bruising (ecchymosis) Pain characters (location, intensity, type, duration, aggravating and alleviating factors) History of previous injury

14 c Physical Examination Observation Lateral View a. Calcaneal apophysitis (Sever s) b. Achilles tendinosis c. Achilles rupture d. Retrocalcaneal bursitis e. Post. ankle impingement f. Calcaneofibular lig g. Sinus tarsi h. Ant. talofibular lig i. Ant. ankle impingement j. Avulsion Fx of 5 th MT

15 Physical Examination Observation a. Calcaneal apophysitis (Sever s) b. Achilles tendinosis c. Achilles rupture d. Retrocalcaneal bursitis Medial View e. Tarsal tunnel syndrome f. Med. ankle sprain g. Entrapment site 1 st branch of lat. plantar n. h. Entrapment site of med. plantar n. c e f b a d g h

$Physical Examination Observation Dorsal Foot & Ankle a. Ant. ankle impingement b. Lat. talar dome OCD c. Navicular stress fracture d. Lisfranc sprain e. Ant. tarsal tunnel syndrome f.$

16 Physical Examination Observation Dorsal Foot & Ankle a. Ant. ankle impingement b. Lat. talar dome OCD c. Navicular stress fracture d. Lisfranc sprain e. Ant. tarsal tunnel syndrome f. Bunionette g. Bunion h. Hallux rigidus i. Avascular necrosis of 2 nd MT head j. Morton s neuroma k. Paronychia f a e j i c d h g k

$Avulsion fracture of the 5 th MT d. Stress fracture of the 3 rd MT e. Stress fracture of the 2 nd MT f. Sesamoiditis g.$

17 Physical Examination Observation Plantar Foot & Ankle a a. Plantar fat pad b. Plantar fasciitis c. Avulsion fracture of the 5 th MT d. Stress fracture of the 3 rd MT e. Stress fracture of the 2 nd MT f. Sesamoiditis g. Metatarsalgia f b e d g g g c g

18 Physical Examination Observation Swelling Ecchymosis

19 Deformities Physical Examination Observation (Cont ) Ankle Dislocation Ankle ganglion cyst

20 Physical Examination Observation Non-weight-bearing (open-chain) Weight-bearing (closed-chain)

21 Physical Examination Observation (Cont ) Pes planus (flat foot)

22 Physical Examination Observation (Cont ) Left Achilles tendon rupture

23 Physical Examination Observation (Cont ) Pes cavus (hollow foot) Splay foot (broadening of the forefoot)

24 Physical Examination Observation (Cont ) Bunion (hallux valgus, callus, thickened bursa, and exostosis)

25 Physical Examination Observation (Cont ) Bunionette (tailor s bunion) and Plantar Callus

26 Physical Examination Observation (Cont ) Hallux Rigidus (stiff big toe) Mostly due to osteoarthritis of 1 st MTP

27 Physical Examination Observation (Cont ) Hammer Toe

(inversion, adduction, and plantar flexion) Pronation 15-30

28 Physical Examination Range of Motion (active & passive) Ankle plantar flexion 50 Ankle dorsiflexion 20 Supination (inversion, adduction, and plantar flexion) Pronation (eversion, abduction, and dorsiflexion) Resisted Isometric Movements Supination Pronation

29 Physical Examination Palpation Medial & lateral malleoli Medial & lateral ligament complexes Base of 5 th metatarsal Distal tibiofibuar joint Talus, calcaneus, navicular, cuneiform, and cuboid bones Achilles tendon Peroneal tendons Metatersal bones MTP, PIP, and DIP joints Neurovascular exam (DP & PT pulses, cap refill, sensation)

30 Physical Examination Special Tests Thompson test for Achilles tendon rupture Negative

31 Physical Examination Special Tests (Cont ) Anterior drawer test (anterior talofibular ligament integrity test)

32 Physical Examination Special Tests (Cont ) Talar tilt test Assessing CF lig in anatomic (90 ) position Assessing ATF lig when ankle is plantar flexed (inversion stress test)

33 Physical Examination Special Tests (Cont ) Squeeze test of the leg (distal tibiofibular compression test) for syndesmosis injury positive, if elicits pain over the distal anterior syndesmosis

34 Physical Examination Special Tests (Cont ) Coronal (side-to-side) drawer or Cotton test for syndesmosis injury

35 Physical Examination Special Tests (Cont ) External rotation stress test for syndesmosis injury

36 Physical Examination Special Tests (Cont ) Dorsiflexioneversion test to reproduce the symptoms of tarsal tunnel syndrome Tinel s sign at the ankle

subluxation/dislocation test Peroneus lungus (resisted eversion in a

37 Physical Examination Special Tests (Cont ) Homans sign Pain in the calf with passive and forced dorsiflexion of ankle Peroneal tendons subluxation/dislocation test Peroneus lungus (resisted eversion in a dorsiflexed ankle) Peroneus brevis (resisted dorsiflexion of 1st metatarsal in an everted foot)

38 Diagnostic Imaging Plain Film Radiography Anteroposterior view Medial tibiofibular clear space (between the fibula and the peroneal incisura of the tibia) normally <4 mm Tibiofibular overlap <6 mm is abnormal

Diagnostic Imaging Plain Film Radiography Mortise (internal oblique 15-30 ) view Tibiofibular overlap <1 mm is

39 Diagnostic Imaging Plain Film Radiography Mortise (internal oblique ) view Tibiofibular overlap <1 mm is abnormal Uniform 3 4 mm space around the talus (space between the talar margin and medial and lateral malleolus)

40 Diagnostic Imaging Plain Film Radiography Lateral View

Diagnostic Imaging Ottawa ankle rules for acute injury (<10 days) for patient >18 years of age Bone tenderness at posterior edge or tip of distal 6 cm of

41 Diagnostic Imaging Ottawa ankle rules for acute injury (<10 days) for patient >18 years of age Bone tenderness at posterior edge or tip of distal 6 cm of medial and lateral malleoli Bone tenderness at base of 5 th metatarsal and navicular bone Inability to bear weight (4 steps) immediately and in the office

Case # 1 HPI: A 33 yo presents for a 5 year Hx of L 4 th toe pain. Pain has been getting worse in the last few ms. S/P NSVD 4 ms ago. She started 4-5 miles/wk running since 3wks ago.

42 Case # 1 HPI: A 33 yo presents for a 5 year Hx of L 4 th toe pain. Pain has been getting worse in the last few ms. S/P NSVD 4 ms ago. She started 4-5 miles/wk running since 3wks ago. Pain radiates up to her metatarsal and down to her 3 rd -4 th toes. She has numbness and tingling which goes away 10 minutes after running. Tennis shoes makes the symptoms worse. Barefoot walking does not aggravate the symptoms. 42

43 Case # 1 Con t PSH: R partial meniscectomy 1997 ØPMH, ØSH, ØFH, ØMeds PE: Mild B genu varum. Mild tenderness in the head of L 4 th metatarsal and the area between the 3 rd and 4 th metatarsal. Normal ROM. Squeeze test cause tingling and numbness in her 4 th toe. 43

44 Case # 1 Con t Imaging: X-ray (AP, obl) Os Peroneum 44

45 Case # 1 Con t Imaging: X-ray 45

46 Case # 1 Con t Imaging: MRI 46

47 Case # 1 Con t Imaging: MRI 47

48 Morton Neuroma Interdigital neuroma Common condition that involves enlargement of the interdigital nerve of the foot Most commonly 3 rd intermetatarsal space Pathophysiology: controversial is not a nerve tumor no inflammatory cells or cystic components Compression, ischemia, or intermetatarsal bursits 48

49 Morton Neuroma DDx: Metatarsal stress Fx, tendon sheath ganglion, foreign body reaction, nerve sheath tumor, strain of the plantar capsule, Freiberg s disease (infarction), and capsulitis or bursitis at the level of the plantar MTPJ Tx: Metatarsal pad, appropriate shoes (wide toe box, adequate cushioning, and heels 1-2 cm), cortisone injection, and surgery (distal nerve excision and intermetatarsal ligament release) 49

50 Hx: Case # 2 HPI: A 42 yo presents for a wk Hx of L midfoot pain. He has been running 3-4 miles 5 times a week for the last 6 years. Pain is worse with running. Pain starts at the beginning of his run. He has been using the same brand of running shoes. He mainly runs outside. ØPMH, ØPSH, ØFH, ØSH PE: Mild-Mod L 3 rd dorsal metatarsal tenderness. 50

51 Case # 2 Con t Imaging: X-ray: AP 51

52 Case # 2 Con t Imaging: X-ray: oblique 52

would be ok Crutches with partial wt-bearing may be necessary if routine walking is

53 Case # 2 Con t Dx: Distal L 3 rd metatarsal stress Fx Tx: Eliminate running and jumping, walking Non-pain producing and non-wt bearing activities (swimming, biking) would be ok Crutches with partial wt-bearing may be necessary if routine walking is painful Some cases would need a short-leg walking cast with advance to hard sole shoe 53

54 Case # 2 Con t Imaging: X-ray 4 ½ wks later (AP) 54

55 Case # 2 Con t Imaging: X-ray 4 ½ wks later (oblique) 55

56 Case # 2 Con t Imaging: MRI 7 wks later 56

57 References Young CC, Niedfeldt MW, Morris GA, Eerkes KJ. Clinical examination of the foot and ankle. Prim Care Mar;32(1): Saleh A, Sadeghpour R, Munyak J. Foot and ankle update. Prim Care Jun;40(2): Wrobel JS, Armstrong DG. Reliability and validity of current physical examination techniques of the foot and ankle. J Am Podiatr Med Assoc May-Jun;98(3): Pommering TL, Kluchurosky L, Hall SL. Ankle and foot injuries in pediatric and adult athletes. Prim Care Mar;32(1): David J. Magee. (2002). Orthopedic Physical Assessment (4th ed.). Elsevier Sciences (USA) Wolfe MW, Uhl TL, Mattacola CG, McCluskey LC. Management of ankle sprains. Am Fam Physician Jan 1;63(1): Henry Gray. Gray's Anatomy of the Human Body Aldridge T. Diagnosing heel pain in adults. Am Fam Physician Jul 15;70(2):332-8 Tu P, Bytomski JR. Diagnosis of heel pain. Am Fam Physician Oct 15;84(8):909-16

Copyright 2004, Yoshiyuki Shiratori. All right reserved.

Copyright 2004, Yoshiyuki Shiratori. All right reserved. Ankle and Leg Evaluation 1. History Chief Complaint: A. What happened? B. Is it a sharp or dull pain? C. How long have you had the pain? D. Can you pinpoint the pain? E. Do you have any numbness or tingling?