Foot and Ankle Physical Exam. The Big Picture: - Gait analysis - Exam standing - Exam sitting - Provocative maneuvers
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1 Foot and Ankle Physical Exam The Big Picture: - Gait analysis - Exam standing - Exam sitting - Provocative maneuvers 1. Gait analysis Physical Exam 2. Examination Standing Alignment Swelling 3. Examination Sitting Neurovascular exam Skin Range-of-motion / stability Strength testing Palpation 4. Provocative maneuvers Gait Gait Analysis - Begins and ends with heel strike of same foot - Stance: heel strike foot flat toe off (push-off)
2 Stride length: Step length: Walking: Running: Distance between two ipsilateral heel strikes Distance between heel strikes of opposing limbs One foot always on ground Gait Brief period with both feet of the ground Intervals of Stance 1 st Interval: Heel strike foot flat Eccentric tib ant contraction 2 nd Interval: Foot flat midstance Eccentric gastrocs contraction 3 rd Interval: Midstance Toe off Concentric gastrocs contraction Walking velocity: Factor of stride length and cadence (Swing: Concentric tib ant contraction) Pathologic Gait Gait analysis... Antalgic: Shortened stance on painful side Steppage: Leg lifts higher to clear ground Calcaneal: Exaggerated heel weight-bearing... posterior weakness Waddling: Broad-based, pelvis drops towards raised leg during swing... proximal myopathy Trandelenburg: Trunk towards weak side during stance... abductor weakness 1. Overall alignment 2. Heel strike Heel contact? Foot slap? 3. Midstance arch collapse? Valgus/varus thrust? 4. Push-off 5. Observe from front, back, and side
3 Walk around the patient... Exam Standing Understand the foot as a tripod... Foot as Tripod... Ground pressure ~ evenly distributed: -1 st metatarsal head - Lesser metatarsals - Heel Pes planus: - Medial overload Pes cavus: - Lateral overload
4 Pes planus 1. Pes planus 2. Pes planovalgus 3. Adult acquired flatfoot deformity 4. Posterior tibial tendon dysfunction (PTTD) 5. Foot pronation - Hindfoot valgus - Forefoot abduction Pes planus Pes cavovarus Low arch Medial tenderness/swelling with PTTD - High arch - Hindfoot varus - 1 st metatarsal plantarflexion (cavus) - Forefoot adduction
5 Pes cavovarus Also... - Forefoot Alignment - Swelling - Skin changes Examination Standing Exam Sitting Heel varus Heel valgus
6 Examination Sitting Stage III PTTD... Rigid Flatfoot - Fixed Deformity - Accommodative orthotics/bracing - Arthrodesis... Is any deformity rigid or flexible? Examination Sitting Neurovascular exam... pulses Neurovascular exam Skin Range of motion Strength testing Palpation / Tenderness Refer for vascular evaluation if not palpable
7 Neurovascular exam... Skin... Semmes Weinstein monofilament: for protective sensation Focal vs. diffuse IPK Accommodative orthotics vs. calf stretching Range of Motion...
8 Strength testing... Strength testing... Grading Strength: 0/5 No contraction 1/5 Flicker, no movement 2/5 Movement but not against gravity 3/5 Moves against gravity 4/5 Against resistance 5/5 Full strength Strength testing... Strength testing Plantarflexion / gastrocsoleus... heel walking elicits foot slap
9 Strength testing... Posterior tib Strength testing... peroneals... start from abducted position to neutralize anterior tib Subluxed peroneals... Palpation... Joint Line (ankle) Hindfoot
10 Medial and Lateral Palpation... Palpation... Palpate against resistance, leaving exam fingers free to palpate Medial ankle: Posterior Tibal Tendon Rx: Boot then PT and orthotics My preferred treatment... Physical Therapy 6 weeks Alvarez RG, et al. Foot and Ankle Int l, 2006 Lateral ankle... peroneals
11 Palpation... 5 th metatarsal base Cast/Boot and NWB for Zone II/IIII Anterior Process of Calcaneus Anterior Process of Calcaneus CT if any doubt Take home physical exam Non- or touch-down weight-bearing in boot or cast
12 Palpation... Lisfranc Articulation Morton s Neuroma Image and/or refer for all acute injuries Diagnosis - webspace tenderness - Mulder s click - Diagnostic lidocaine injection - MRI or ultrasound Morton s Neuroma Provocative Maneuvers Initial rx: wide shoes, single injection, orthotics with metatarsal pad
13 Toe Anterior Drawer Test... MTP Instability MP joint drawer test Toe Anterior Drawer Test... MTP Instability Initial rx: Budin splint, taping, boot, NSAIDs, orthotics - Taping - Splint - NSAIDs - Boot - Orthotics Lesser MTP Instability Initial Treatment Options
14 Budin Splint: (6-12 weeks) Surgery: shortening metatarsal osteotomy Heel Squeeze Test... Calcaneal Stress Fracture Lateral wall tenderness... calcaneal stress fx WB as tolerated in a boot, check Vitamin D, DEXA?
15 Ankle Instability... Silfverskiold Test Anterior Drawer Talar Tilt PT +/- orthotics with lateral post for chronic instability Single-leg heel rise test for Weak Posterior Tibial Tendon Thompson Test: Achilles Rupture Abnormal if: - unable to perform - heel stays in valgus Rx: Surgery vs Functional Rehab (not just casting)
16 1. Gait analysis Physical Exam 2. Examination Standing Alignment Swelling 3. Examination Sitting Skin Range-of-motion / stability Neurovascular exam Strength testing Palpation 4. Provocative maneuvers Common Causes of Hip Pain Physical Examination of the Hip Osteoarthritis Osteonecrosis Sciatica Stress Fracture Infection Impingement / labral tear Trochanteric Bursitis IT Band Pathology
17 Physical Exam 1. Gait analysis 2. Examination Standing Hip / spinal alignment Crouch may be hip contracture 3. Examination Supine Palpation Range-of-motion Strength testing Distal pulses 4. Provocative maneuvers Gait Analysis Pathologic Gait Antalgic: Shortened stance on painful side Steppage: Leg lifts higher to clear ground Waddling: Broad-based, pelvis drops towards raised leg during swing... proximal myopathy Trandelenburg: Trunk towards weak side during stance... abductor weakness Look at posture leaning forward might be spine
18 Antalgic gait... - Limping - Shortened stance phase on painful / affected limb Steppage gait... - Compensatory for foot drop - Exaggerated hip flexion allows foot on weak side to clear ground - Tibialis anterior weakness - RX: AFO brace, Refer, especially if acute Trandelenburg gait... - Weak abductors - Superior gluteal nerve - Prior hip surgery
19 Exam Standing... Exam Standing - Walk around the patient - Overall posture - Pelvic tilt Scoliosis Leg length discrepancy - Crouch Hip contracture Spinal hyperlordosis - Adductor contracture Exam Supine... - Palpation know your anatomy / landmarks Exam Supine - Range of motion.... Flexion: Extension: IR/ER: / Strength and sensation testing - Don t forget distal pulses
20 Exam Supine... - Inspection - Swelling, ecchymosis - Palpation - Abdomen / inguinal region - Lateral vs medial - Low back and posterior hip/pelvis - Range of motion - Flexion/extension - Internal/external rotation - Obligate external rotation with hip flexion.... CAM lesion Exam Supine... - Strength Testing - Hip flexors, ABductors, ADductors - Distal muscles for spine helath - Provocative testing - Log Roll (fracture, infection, RA, AVN, etc) - Straight leg raise (radiculopathy) - Ober s test (IT band, trochanteric bursitis) - FABER (Flexion ABduction External Rotation) Impingement / Labral Tear - FADIR (Flexion ADduction Internal Rotation Impingement Log roll Special Tests... - Fracture - Infection - Advanced chronic pathology - Image and/or refer!
21 Straight-leg raise - Lumbar nerve root irritation - Positive:... radicular sx s reproduced Treatment: - PT, injections, time - Refer if neurologic deficits Faber / Patrick Test - SI joint - Intra-articular pathology - Inflammatory disease - Iliopsoas strain - SI joint - Intra-articular pathology - Inflammatory disease - Iliopsoas strain FadIR Test - Femoroacetabular Impingement (FAI) Ober s test...orthoinfo.com AAOS FAI RX: NSAIDs, injection, PT, arthroscopy - Iliotibial band - Contracted, inflamed, or painful - Positive: Affected leg remains elevated / abducted after released - Rx: PT, NSAIDs, rarely surgery
22 Gaenslen s test Thomas test - Leg lifts off table with contralateral hip flexion - Test for hip flexion contracture Big picture... - Always consider joints above and join below - Lateral pain and tenderness... IT band, greater trochanter, radicular - Anterior / medial pain... Hip joint proper (arthritis, fx, infection, AVN, impingement) Inguinal and abdominal pathology (e.g. hernia) - Posterior pain and tenderness... SI joint, radicular pain, hamstrings, ischium Thank you!
23 Anterior Hip Pain DDX: Perform this exam Order these tests Treat with NSAIDs, Injection, referral Lateral Hip Pain DDX: Perform this exam Order these tests Treat with NSAID s, Injection, referral Posterior Hip Pain DDX: Perform this exam Order these tests Treat with NSAID s, Injection, referral
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