sajith ankle

CLINICAL EXAMINATION OF ANKLE&FOOTDr.SAJITH KURIAN PG M.S Ortho, Department of orthopaedicsCOIMBATORE MEDICAL COLLEGE

TITLES

HISTORY GENERAL EXAMINATION LOCAL EXAMINATION 1)INSPECTION 2)PALPATION 3)RANGE OF MOTION 4)MEASUREMENTS

HISTORY 1)Age:CTEV present since birth,TEV secondry to polio,neural tube

defects etc.appear later.CVT noticed at walking age around 1 year 2)SEX:CTEV common in boys ASSOCIATED DISEASES :fever with myalgia and weakness of limbs in

polio

PAIN

1)site, 2)radiation, 3)type, 4)character 5)aggravating factors 6)relieving factors 7)diurnal variation 8)postural variation

SWELLING Duration Onset Progress aggravating factors,relieving factors effect of any treatment received diurnal and postural variation associated with deformity in other foot

LIMP onset Duration painless or painful progressive or not

INSTABILITY duration Onset unilateral or bilateral on even or uneven surfaces

DEFORMITYOnset(at birth (CTEV)OR appeared later (aquired clubfoot)appears at around 1 year in CVT,after an episode of fever and myalgia with weakness of limbs and muscles polio,progress ,any treatment received,response to any such treatment

GENERAL EXAMINATIONExamine hip and spine for congenital hip dislocation,myelomeningocelespinal dysraphism,Arthrogryposis multiplex congenita

INSPECTION Foot examination should always start with patients

footwear look for Shoe upper deformation & sole wear (it can tell

about severity and chronicity of foot deformity or neuromuscular imbalance especially in assymetrical cases

It can tell about the expectations of the paients

Inspection has three major aspects 1)standing inspection 2)gait assessment 3)sitting inspection

STANDING INSPECTION Imp: some critical deformities wiil be appreciated only

while standing Digree of hallux valgus and pronation, Lesser toe deformity in particular deviation between the

2nd and 3rd toes in comparison to asymptomatic side Forefoot abductus and adducts And arch height

Ask the patient to turn to opposite side Look for alignment of heel relative to leg Look for abnormal visualisation of digits laterally(the “

TOO MANY TOES” sign seen in pes planus with forefoot adductus)

GAIT ASSESSMENT Avoidance patterns associated with HALLUX

RIGIDUS(no great toe extension after heel off) Toe walking:plantar fascitis,heel pain syndrome or stress

frscture (to avoid heel wt bearing) External rotation gait:ankle arthodesis

SITTING INSPECTION Patient must be sitting at the edge of the

table with legs hanging freely Entire lowerlimb should be examined Neurological examination should be done as

defecits produce different deformities of foot and toes

INSPECTION OF ANTERIOR ASPECT 1)alignment: great toe(hallux valgus/varus)other toes(claw,hammer,mallet)

Relations of forefoot,midfoot,hindfoot w.r.t each other and lower leg 2)Condition of skin: any discolouration,ulcers,dialated veins

3)TOES notice transverse skin crease at I-P joint(lost in polio) Thickened cornified skin over dorsum(heloma durum)

seen in toe deformities Toe nail deformities in fungal infections. Paronychia ,ingrowing toe nail Osteophytes medially over 1st MTP joint is BUNION and

lateral aspect of 5th MTP joint is called BUNIONETTE

5)TENDON tendons of EHL andEDL are visible over foot and anterior aspect of ankle by active contraction of muscles6)Relation of medial and lateral malleoli:normally lateral is below and posterior to medial malleoli7)Any swelling over malleoli:seen in trauma, tendinitis ,bursitis 8)Anterior crest of tibia and subcutaneous border may show swelling,deformities

INSPECTION OF LATERAL ASPECT

Visualise lateral malleolus ,5th MT base ,tendo achilles and peroneus brevis tendon,look for any swelling

INSPECTION OF POSTERIOR ASPECT1)Alignment : varus/valgus,too many toes sign2)heel:size,pattern and position3)Tell the patient to stand on tips of toes(windlass effect-inversion and incresed height of medial arch)4)Plantar fat pad,calcaeneal tuberosity(abnormally increased prominenece of superior aspect is hagelund deformity or pump-bump)

5)Retro-calcaneal bursa:bursitis6)Achilles tendon :tendinitis,rapture,swelling at the level of malleoli is seen in tendinitis and over whole length is seen in rapture7)Calf atrophy(compared to normal):Residum of CTEV,TA rupture or prolonged immobilisatiion

INSPECTION OF MEDIAL ASPECT Medial longitudinal arch:cavus or planus or rocker

bottom deformity(in diabetes or improperly treated CTEV

Bony prominences :medial malleolus,head of 1st MT,calcaneal tuberosity and navicular tuberosity(prominent accessory in accessory navicular)

Tibialis posterior tendon made visible by active contraction .structures underneath flexor retinaculum of ankle-tibialis posterior,flexor digitorum longus,posterior tibial artery,posterior tibial nerve and flexor hallucis longus

INSPECTION OF PLANTAR ASPECT Callosity suggests point of weight bearing.Normally

seen over metatarsal heads and lateral margin of foot.painful calluses over MT heads are seen in claw toe and hammer toes

Corns are localised thickening of skin over pressure areas.Two types hard and soft

Ulcerations:Diabetes,abnormal bony prominences Warts and fungal infections

PALPATION PALPATION OF ANTERIOR ASPECT

1)Local rise of temperature 2)Tenderness :over the anterior tibial crest (in stress

fracture ). Over the talar dome: palpated anterolaterally with

maximal passive plantar flexion at ankle (in OCD).Over talo-navicular joint in osteoarthritis

Also palpate cuneiforms,metatarsals (stress fractures,bunions,gout ,septic arthritis,frieberg infarction)

Tenderness in interdigital spaces suggest Mortons neuroma

4)SWELLING:over stress fractures,osteophytes over joints.effusion of joints –cross fluctuation can be demonstrated between anterolateral and ateromedial swellings in full plantar flexion.Also seen between posterolateral and posteromedial swellings in full dorsiflexion

5)tendons (tautness,tenderness,ump or any gap,diffuse swelling,crepitus)

Toes palpate for corns ,ingrowing toe nails Tinels sign over deep peroneal nerve

PALPATION OF LATERAL ASPECT 1)lateral malleolus ,anterior talo-fibular

ligament and calcaneo-fibular ligament for swelling and tenderness

2)Peroneal tendons 3)calcaeneum in severs diseas 4)over sinus tarsi in subtalar arthritis 5)over fibular shaft :stress fractures

INSPECTON OF POSTERIOR ASPECT 1)Over gastro soleus:In tendo achilles rupture tenderness

gap and swelling at 2-6 cm above TA insertion 2) over posterior tuberosity of calcaneum:Tender

swelling in retro calcaneal bursitis

INSPECTION OF MEDIAL ASPECT Medial malleolus and subcutaneous border of tibia Head of talus Navicular tuberosity :tender swelling in accessory

naviculum 4)tendons of FHL,FDL @TP Tinel sign over posterior tibial nerve and medial and

lateral plantar nerves

PALPATION OF PLANTAR ASPECT Callosities tendor Sesamoids for tenderness Plantar fascia tenderness ,tenderness on

hyper extending the toes,painfull nodues Plantar fat pad tenderness

RANGE OF MOTION

Ankle : normal dorsi flexion and palntar flexion are 20 and 50 degrees each

Ankle tested with fore foot in inversion and hind foot in neutral with one hand gripped in such a way that any movements of the the subtalar and mid tarsal joints are excluded

Assess the dorsiflexion in both knee flexion and extension in cases of gastrocnemius contracture

Subtalar joint :normal inversion-40 and eversion 20 degrees each

Examined in prone position Hold dorsum of the foot with one hand such that head of

talus is stabilised between thumb and index,hold calcaneum with thumb and index of other hand

Forefoot :abduction and adduction(normal is jog)with calcaneum stabilized in neutral postion

Great toe :MCP extension -70 flexion -45 digrees IP-extension -0 and flexion-90 digrees lesser toes :MCP flexion and extension are 90 & 0 IP 40 each also test for adduction and abduction

Muscles 1)grossly ankle and plantar flexors are tested by toe

walking 2)ankle dorsiflexors by toe walking 3)evertors by walking on medial border 4)invertors on walking on lateral border

MEASUREMENTS Longitudinal ;true and apparent limb length Heel length :from tip of medial malleolus vertically

down to point of heel Foot length :medial(from back of heel to tip of great toe)

and lateral(to tip of 5th toe) Circumferential :at thigh,calf and foot

DISTAL NEUROVASCULAR DEFICITS

Look for ATA & PTA Complete neurological examination of ankle

SPECIAL TESTS All are done with leg hanging freely at the edge of table 1)ANTERIOR DRAWER TEST:

tests for ant talo-fibular lig: grasp just above the ankle with one hand and

hold heel with other.Gently pull heel forward with an internal rotatory movement to foot.

Observe for ant translation and prominence of talar head anteriolaterallyDifference of 3-5mm in laxity between two sides with a soft end point or skin tenting anteriolaterally by talar dome is significant

INVERSION STRESS TEST(varus stress test):tests for calcaneo-fibular ligament

Maximally dorsiflex ankle and apply inversion stress test to calcaneum.abnormal inversion of talus at ankle is significant

PERONEAL TENDON INSTABILITY TEST Rotate ankle from maximal dorsiflexion to eversion to

plantar plantar flexion to inversion Palpate posterior to lat malleolus .if peroneal tendons

subluxate or dilocate anterior to malleolus ,suggests instability

THOMSON TEST

FIRST METATARSAL RISE TEST For tibialis posterior tendon Patient is made to stand.from behind of the

patient ,rotate leg into ext rotation.if 1st mt rises of the ground, it suggests instability

Opposite is Rose test

Mortons test :compress 1st and 5th mt heads if neuroma present patient will complaint pain I same space

Homan test :pain in calf on passive dorsiflexion of ankle seen in DVT