Transcript The Foot and Ankle - Liberty Union High School District

The Foot and Ankle
Evaluation
History
Past
• Has this ever happened Before
Mechanism
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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
History
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?
Sounds or Sensations
– Did you feel any unusual
sensations when it
occurred?
– Did you hear any unusual
sounds when it occurred?
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
– Markings
Sounds
- Lumps
- Redness/ Discoloration
Pes Planus or
Cavus
• Structural
Deformities
• Pes Planus =
flat footed/ no
arch
• Pes Cavus =
high arch
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.
The Gait Cycle
Heel Strike – shock absorption
Toe-off – propel forward
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?
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
Notice
Palpation
–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
Special Tests
1st Special Tests
– Fracture Tests
Bump
____________
Lever
____________
Compression
____________
Range ___ ____________
of
motion
– ________
Active
____________
Passive
Resistive
____________ or ____________
Types of Injuries
• Sprain
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– tear of a ligament
• Strain
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– tear/ pull of a muscle
• “-itis”
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– irritation of
• Tendonitis – irritation of a tendon (joins muscle to bone)
• Bursitis – irritation of a bursae (fluid filled sac under tendons)
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Fracture
– break of a bone (complete or incomplete
Dislocation
– Joint pops out and stays out
Subluxation
– joint pops out and goes back in
Ankle Injuries
Grade 1
– Stretching or slight tear
– Mild pain
Little to no disability
Grade 2
– Moderate tear
Moderate pain and disability
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.
• Fracture (fx)
– Avulsion fx
– Piece of bone broken off
– Transverse fx
“crack” Straight across
- Evaluation:
- Pain with pressure
- Specific site (over bone)
- High on the pain scale
- Immediate swelling (tell tale sign IF it happens)
- Bump, lever, or compression painful
Ankle Injuries
Fracture Tests
• Bump – bump/ tap the end of the bone AWAY
from the site of pain
• Lever – (can only be used with long bones or
2 parallel bones)
– a- squeeze both bones AWAY from the site of
pain
– b- apply a bending force to the long bones at
each end if pain is in the middle of the bone
• Compression – apply pressure at both ends
of the bone simultaneously
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
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
http://www.youtube.com/watch?v=HPkaNdG2uus
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
Anterior
tibiofibular
ligament
Calcaneofibular
ligament
Anterior
talofibular
ligament
Ankle Sprains
• The only difference between a sprain of the talofibular,
tibiofibular, and calcaneofibular ligaments are the location
of pain when it comes to the H.O.and P…..
– History
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Lateral ankle pain after “rolling” or “twisting” it
Pain scale depends on the severity and the person
If treating with ice, it helps
May hear a “pop”, but not common
– Observation and Palpation
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May see/ feel swelling
Possible limp
Possible bruising (if it has been a couple days)
Specific site of pain
Anterior Talo-fibular sprain
• Pain location
http://www.youtube.com/watch?v=kbqzRWhirOI
Anterior Drawer
–ATaloFib
Special Tests
Positioning
– Have the athlete sit with their leg off the table .
– Grasp calcaneus w/ one hand
– Let foot lie on your forearm
– Other hand on tibia
Test
– Dorsiflex foot slightly
– Pull Calcaneus forward while push tibia backward
Anterior Drawer cont
• Positive Test
–Foot slides forward (laxity)
–Makes a clunking sound/ sensation
–Pain
Grades of Sprains
• Grade 1 = mild pain, no laxity (movement/
looseness)
• Grade 2 = moderate pain, some laxity
• Grade 3 = severe pain and a lot of laxity
• **If no pain, but is lax (loose) then that is a
negative test
Pain Locations
• Deltoid sprain
• Anterior Tibio-fibular
sprain (syndesmotic/
high)
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
http://www.youtube.com/watch?v=eDeQcAs9A5M
rotate the foot laterally
– Positive
Pain over the deltoid ligament
Pain over the lateral malleolus (indicates a
syndesmotic sprain)
Tendinitis sites
Calcaneus
Foot Injuries
– Heel Spurs
– Bursitis
– Contusion
Plantar
Fasciitis
– Common
problem
Pain in the
proximal
arch and
heel
Foot Injuries
Morton’s toe
– Short Great Toe
Usually benign, may cause
probs w/ running
Jones Fracture
– Fracture of 5th metatarsal
Foot Injuries
Bunion
– Caused by poorly fitting shoes
Hammertoe
– Flexion contracture of toes
Turf Toe
– Hyperextension
Other Conditions/ Injuries
Tibial Contusion - bruise
Muscle Cramps
Muscle Strain
Other Conditions/ Injuries
Shin splints
– 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
Grades of MTSS
Grade 1
– pain after activity
Grade 2
– pain during and after activity
– No performance affects
Grade 3
– Before during and after
– Affects performance
Grade 4
– Activity impossible/ too painful
Compartment
Syndrome
– Acute – secondary to
trauma
– Exertional – activity
related
– Symptoms
Deep Aching Pain
Tightness and Swelling
Pain w/ stretching
Reduced circulation and
sensation
Management of Ankle Injuries
Swelling Management
- RICE – Rest Ice Compression Elevation
- METH – Mobility Elevation Traction Heat
Inversion Ankle Sprains
– Light Compression with Horseshoe
– Massage
– Begin ROM exercises
Syndesmotic Sprain
– Takes MUCH longer to heal
– Rest/ Immobilize for at least 6-10 days before
beginning ROM exercises
Management of Ankle Injuries
Achilles Tendon Rupture
– Surgical Repair or
– Cast for 6-8 weeks
Contusion
– Doughnut pad to reduce risk of repeated force
– Light ROM
– Light stretching
Management of Ankle Injuries
Cramps/ Spasms
– Massage
– Overpressure (trigger point)
– Stretching
– Monitor hydration and electrolytes if this
becomes chronic
Management
Medial Tibial Stress Syndrome (MTSS)
– Modification of activity
– Gait analysis
– massage
– Stretching
– Arch taping
– Compression
http://www.youtube.com/watch?v=ea4cInVmIv4
Achilles Tendinitis
Decrease intensity of activity/ what is
aggravating it
Stretching of calf and foot muscles
Look at foot alignment
Recent change in running surface, distance,
form, or intensity
Heat
Massage
Heel Lifts
Plantar Fascitis
Comfortable movements (ROM)
Stretch foot and lower leg
Add tennis ball stretch
Strengthen lower leg and foot
Check foot alignment
Tape arches
Night Splint
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
Management of Ingrown Toe Nail