foot & ankle examination workshop - · pdf filetalocrural (ankle) joint ... clinical...

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

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.

Anatomy Hindfoot

Inferior Tibiofibular Joint

Syndesmosis type with minimum movement

Ant. & post. inferior tibiofibular, transverse

tibiofibular, and interosseus ligament

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

Anatomy Hindfoot

Subtalar (Talocalcanean) Joint

Formed by talus, calcaneus, navicular, and

cuboid

Supination 45°-60° and pronation 15°-30°

Anatomy Lateral View

Anatomy Medial View

Anatomy Anterior View

Anatomy Posterior View

Anatomy

Midfoot

Chopart’s Joint

Midtarsal joints

between the talus-

calcaneus and the

navicular-cuboid

Minimum movement

http://education.yahoo.com/reference/gray/illustrations/figure?id=358

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°)

Evaluation History

Mechanism of Injury

Presence of transient or fixed deformity

of the foot & ankle at the time of injury

Level of activities after the injury

Evaluation History

Swelling or bruising (ecchymosis)

Pain characters (location, intensity, type,

duration, aggravating and alleviating

factors)

History of previous injury

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 5th MT

c


Medial View e. Tarsal tunnel syndrome

f. Med. ankle sprain

g. Entrapment site 1st branch of

lat. plantar n.

h. Entrapment site of med.

plantar n.

a. Calcaneal apophysitis

(Sever’s)

b. Achilles tendinosis

c. Achilles rupture

d. Retrocalcaneal bursitis

a

b

c

d

e f

g

h


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 2nd MT head

j. Morton’s neuroma

k. Paronychia

a

e

i

k

j

h

c

f

d

g


Plantar Foot & Ankle

a.Plantar fat pad

b.Plantar fasciitis

c. Avulsion fracture of the 5th

MT

d.Stress fracture of the 3rd MT

e.Stress fracture of the 2nd MT

f. Sesamoiditis

g.Metatarsalgia

a

f

e d

c

b

g g

g g

Physical

Examination

Observation

Swelling

Ecchymosis


(Cont’)

Deformities

Ankle Dislocation Ankle ganglion cyst

Physical Examination

Observation

Non-weight-bearing (open-chain)

Weight-bearing (closed-chain)


Observation (Cont’)

Pes planus (flat foot)


Observation (Cont’) Left Achilles tendon rupture



Pes cavus (hollow foot)

Splay foot (broadening of the forefoot)


Bunion (hallux valgus, callus, thickened

bursa, and exostosis)




Bunionette (tailor’s bunion) and Plantar Callus

Observation

(Cont’)

Hallux Rigidus

(stiff big toe)

Mostly due to

osteoarthritis of

1st MTP


Observation

(Cont’)

Hammer Toe


Physical Examination Range of Motion (active & passive)

Ankle plantar flexion 50°

Ankle dorsiflexion 20°

Supination 45°-60° (inversion, adduction,

and plantar flexion)

Pronation 15°-30° (eversion, abduction,

and dorsiflexion)

Resisted Isometric Movements

Supination Pronation

Physical Examination Palpation

Medial & lateral malleoli

Medial & lateral ligament complexes

Base of 5th 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)


Special Tests Thompson test for Achilles tendon rupture

Negative


Special Tests

(Cont’)

Anterior drawer test

(anterior talofibular

ligament integrity

test)


Special Tests

(Cont’)

Talar tilt test Assessing CF lig in

anatomic (90°)

position

Assessing ATF lig

when ankle is

plantar flexed

(inversion stress

test)


Special Tests (Cont’)

Squeeze test of the leg (distal

tibiofibular compression test)

for syndesmosis injury positive, if elicits pain over the

distal anterior syndesmosis



Coronal (side-to-side)

drawer or Cotton test for

syndesmosis injury


Special Tests

(Cont’)

External rotation

stress test for

syndesmosis injury


Special Tests

(Cont’)

Dorsiflexion-

eversion test to

reproduce the

symptoms of tarsal

tunnel syndrome

Tinel’s sign at the

ankle



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)

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

http://www.jaaos.org/content/vol15/issue6/images/large/330f03.jpeg

Diagnostic Imaging

Plain Film Radiography

Mortise (internal oblique

15°-30°) 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)

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

medial and lateral malleoli

Bone tenderness at base of 5th

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 4th 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 3rd-4th 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

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 4th metatarsal and the area

between the 3rd and 4th metatarsal. Normal

ROM. Squeeze test cause tingling and

numbness in her 4th toe.

43

Case # 1 Con’t

44

Imaging:

– X-ray (AP, obl)

Os Peroneum

Case # 1 Con’t

45

Imaging:

– X-ray

Case # 1 Con’t

46

Imaging:

– MRI

Case # 1

Con’t

47

Imaging:

– MRI

Morton Neuroma

Interdigital neuroma

Common condition that involves enlargement of the interdigital nerve of the foot

Most commonly 3rd intermetatarsal space

Pathophysiology: controversial

is not a nerve tumor

no inflammatory cells or cystic components

Compression, ischemia, or intermetatarsal bursits

48

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

Case # 2

Hx:

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 3rd dorsal metatarsal tenderness.

50

Imaging:

X-ray: AP

51

Case # 2 Con’t

Case # 2 Con’t

Imaging:

X-ray: oblique

52

Case # 2 Con’t

Dx: Distal L 3rd 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

Case # 2 Con’t

Imaging:

X-ray 4 ½ wks later (AP)

54

Case # 2 Con’t

Imaging:

X-ray 4 ½ wks

later (oblique)

55

Case # 2 Con’t

Imaging:

MRI 7 wks later

56

References

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• Wrobel JS, Armstrong DG. Reliability and validity of current physical

examination techniques of the foot and ankle. J Am Podiatr Med Assoc.

2008 May-Jun;98(3):197-206

• Pommering TL, Kluchurosky L, Hall SL. Ankle and foot injuries in pediatric

and adult athletes. Prim Care. 2005 Mar;32(1):133-61

• 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. 2001 Jan 1;63(1):93-104

• Henry Gray. Gray's Anatomy of the Human Body

• Aldridge T. Diagnosing heel pain in adults.

Am Fam Physician. 2004 Jul 15;70(2):332-8

• Tu P, Bytomski JR. Diagnosis of heel pain. Am Fam Physician. 2011 Oct

15;84(8):909-16

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