Transcript Toe Movements - cloudfront.net

Chapter 18 (pp 487-496)
Injuries to the
Foot & Ankle
Objectives
Identify…
• The bones of the foot & ankle
• The ligaments of the foot & ankle
• The muscles of the foot & ankle
• The tendons of the foot & ankle
• The blood vessels & nerves of the foot &
ankle
• Other structures
The bones
• The foot contains 28
bones
– Phalanges (16)
•
•
•
•
Proximal (1-5)
Intermediate (2-5)
Distal (1-5)
Sesamoids (1)
The bones
• The foot contains 28
bones
– Metatarsals (5)
– Tarsal bones (7)
• Cuneiforms
– Medial, intermediate,
lateral
• Cuboid, Navicular
• Talus, Calcaneous
The bones
• Tibia
• Fibula
Phalanges
• There are 14 total
phalanges
– Great toe = 2
– All other toes = 3
• Each toe has a
proximal,
intermediate, &
distal phalange
(except Great toe)
Phalanges
• Great toe has 2
sesamoid bones
– Act like “mini patella”
to increase leverage
and protect the joint
metatarsals
• Each toe has a
corresponding
metatarsal (MT)
• Important areas:
– Head of the 1st MT
– Base of the 5th MT
– In-between the 2-3
MT heads
Tarsal bones
• The tarsal bones make
up the mid- & rear-foot
– Cuneiforms (E, F, G)
• Medial (G)
• Intermediate (F)
• Lateral (E)
–
–
–
–
Cuboid (C)
Navicular (D)
Talus (B)
Calcaneous (A)
Bones of the leg
• Tibia and fibula
extend past the
talus bone
• Distal end is
referred to as the
malleolus
– Medial = tibial
– Lateral = fibular
Bones of the leg
• Tibia
– Larger of the two
bones
– Primary weight
bearing bone
Bones of the leg
• Fibula
– Smaller bone, extends
more distally
– Provides for muscle
attachments
– ≤ 10% weight bearing
the ligaments
• Important ligaments
in the foot:
– Calcaneonavicular
ligament (spring
ligament)
The ligaments
• Medial ankle:
– Deltoid ligament
The ligaments
• Lateral ankle:
– Anterior talofibular
(ATF)
– Calcaneofibular
(CF)
– Posterior talofibular
(PTF)
• Not shown
The ligaments
• Lower leg:
– Distal anterior
tibiofibular ligament
– Distal posterior
tibiofibular ligament
– Interosseous
membrane
articulations
• Interphalangeal (IP, PIP,
DIP)
• Metatarsophalangeal (MP
or MTP) joints
• Intermetatarsal joints
• Tarsometatarsal (TMT)
joints
• Subtalar joint
• Talocrural joint
Subtalar joint
• Articulation of the
talus & calcaneus
Talocrural joint
• Tibia, fibula, talus
• Mortise & tenon
configuration
• Talus is wedgeshaped
• Lateral malleolus
extends more
distally than medial
malleolus
Arches of the foot
• Support body weight
• Absorb forces from
the ground
• Provide space for
blood vessels,
tendons, & muscles
Arches of the foot
• Metatarsal Arch – across metatarsal
heads
• Transverse Arch – across metatarsal
bases & cuneiforms
• Medial Longitudinal Arch – along the
medial aspect
• Lateral Longitudinal Arch – along the
lateral aspect
Arches of the foot
Plantar fascia
• Broad, thick tissue
covering the bottom
of the foot
– Extends from the
calcaneus to the
base of each
metatarsal
– Supports the foot
against downward
forces
Muscles & tendons
• Intrinsic muscles of
the foot:
– Toe extensor
– Toe flexors (3)
– Great toe & 5th toe
abductors
– Great toe adductor
Muscles & tendons
• Extrinsic muscles of the foot:
– Divided by compartments
•
•
•
•
Anterior
Lateral
Superficial posterior
Deep posterior
Muscles & tendons
• Anterior
compartment
– Tibialis anterior
– Extensor hallucis
longus
– Extensor digitorum
longus
• Dorsiflex the foot
Muscles & tendons
• Lateral compartment
– Peroneus longus
– Peroneus brevis
• Evert the foot
Muscles & Tendons
• Superficial posterior
compartment
– Gastrocnemius
– Soleus
– Plantaris
• Plantarflex the foot
Muscles & tendons
• Deep posterior
compartment
– Tibialis posterior
– Flexor hallucis
longus
– Flexor digitorum
longus
• Plantarflex & invert
the foot
Neurological & Vascular
• Tibial nerve
– Posterior leg &
plantar aspect of foot
• Common peroneal
nerve
– Anterior leg & foot
• Blood supply
– Anterior tibial artery
 Dorsal pedal
artery
– Posterior tibial artery
Distal pulse
OA 11.12
If an athlete came to you complaining
of ankle pain, how would you address
them?
• What questions would you ask to
gather clues about what is going on?
• What are some relevant observations
to make regarding their body?
34
The Foot & Ankle
Evaluation
Objectives
Identify…
• Pertinent information to gather during a
foot & ankle evaluation
• Important observations to make during
a foot & ankle evaluation
The Secondary Survey
• After ruling out life-threatening injuries,
we begin the secondary survey
– Treat for major injuries with acute on-field
care
• Begins with an assessment of vital signs
• Musculoskeletal Assessment
DOCUMENT EVERYTHING!
HOPS TECHNIQUE
The Evaluation Process
H.O.P.S.
• History
• Observation
• Palpation
– Range of motion
• Special tests
H.I.P.S.
• History
• Inspection
• Palpation
– Range of Motion
• Special tests
History
• What happened?
– Gain information about the patient and the
injury
– Most critical part of the evaluation!
– Past medical history
– History of the present condition
History
• Start with generic history questions
– Chief complaint
– Age
– Occupation / sport / position etc.
– General health
condition
– Activity level
– Medications
History
• History of previous injuries
– What happened?
– Who did you see?
– What did they tell you?
– How long were you out?
– Has it fully resolved?
History
• Mechanism of injury
– How did it happen?
Tension = sprain; fracture; strain
Torsion = sprain; fracture
Compression = contusion; fracture
Shear = fracture; sprain
Bending = fracture
History
Ask these questions regarding PAIN
• P-rovocation – what causes it? what
makes it better?
• Q-uality – what does it feel like?
neurological symptoms?
• R-egion – where does it hurt? can you point
w/one finger?
• S-everity – how bad does it hurt? (1-10)
• T-iming – when does it hurt? how long?
History
Type of Pain
Structure
Cramping, dull, aching
Muscle
Dull, aching
Ligament, joint capsule
Sharp, bright, lightning-like, burning
Nerve
Deep, nagging, dull
Bone
Sharp, severe, intolerable
Fracture
Throbbing, diffuse
Vasculature
History
• Sounds & sensations
– Did you hear any sounds? Did you hear
any pops, crackles, snaps, clicks?
• What could this
indicate???
– Did you feel
anything unusual?
History
• Specific to the foot & ankle
– Previous history = chronic ankle instability
– Mechanism of injury = ROM (Inversion,
Eversion, Plantarflexion, Dorsiflexion)
– Location of pain – heel, foot, toes, arches,
lateral ankle, medial ankle, etc.
• Determines what is injured
– Changes in activity,
footwear, or training
surfaces
Observation
•
•
•
•
•
•
Athlete Moving?
Position of athlete?
Conscious?
Primary Survey
Inspect injury site
Secondary Survey
Observation
• When does this begin?
• Compare each side bilaterally
to identify what is normal for
that person
• We look for:
– Deformity, asymmetry,
edema, ecchymosis
Observation
We assess:
• Gait
• Gross motor function
• Posture/position
• Facial expression
• Guarding
Observation
• Gait – how a person walks
– Difficulty walking = antalgic gait
• Does the athlete favor one foot, limp, or
is unable to bear weight?
• Does the athlete carry their weight on
their toes or heel?
• Is the arch maintained while both
weight-bearing and non-weight bearing
Observation
• Can the athlete move the limb on their
own through normal function?
• Is the arch maintained while both
weight-bearing and non-weight bearing
Critical thinking…
An athlete limps in to the ATR complaining of
pain on the lateral aspect of his right ankle. He
said he stepped off the curb funny and heard a
pop in his foot. Now he is feeling sharp pain,
and points to the lateral aspect of his ankle, just
anterior to the lateral malleolus. You inspect the
ankle and find edema beginning to form around
the lateral malleolus.
Critical thinking…
An athlete limps in to the ATR complaining of
pain on the lateral aspect of his right ankle. He
said he stepped off the curb funny and heard a
pop in his foot. Now he is feeling sharp pain,
just anterior to the lateral malleolus. You inspect
the ankle and find edema beginning to form
around the lateral malleolus. He states the pain
is a 6/10 and he can’t put all his weight on the
ankle.
OA 11.13
• Identify 3 history questions to ask a
soccer player who complains of
discomfort in his dominant foot.
• List 5 anatomical areas you would
observe.
– What are you observing for?
56
Palpation
• Allows us to feel
what is going on
• Compares normal
to abnormal
• Utilizes touch to
gather information
Palpation
• Bony Structures
– Alignment
– Crepitus – crackling
sound with movement
– Joint alignment!
• Soft Tissues
– Swelling
– Painful areas
– Muscle/tendon deficit
Range of motion
• Definition:
– Range of motion refers to the distance
and direction a joint can move between
the flexed position and the extended
position
– In true clinical settings,
we use a goniometer
to measure ROM
Range of motion
• Types
– Active range of motion (AROM)
– Passive range of motion (PROM)
– Resistive range of motion (RROM)
Range of motion
• AROM
– The patient’s ability to move a joint under
their own strength
• PROM
– The joint’s ability to be moved through a
range of motion
• RROM
– Measurement of the muscle strength of a
joint through the ROM
Range of motion
• Performed bilaterally on the uninjured
side first
– Why??
Allows us to get a look at what
is normal for that athlete!
Range of motion
• For the foot…
– ROM occurs at
each joint
– Only the MTP &
IP joints of the
toes are
assessed
Range of motion
• For the ankle…
– ROM occurs at
the subtalar and
talocrural joints
– Both are
assessed as one
unit
Movements
• The foot & ankle act together
during movement
• The toes are assessed together
Movements
Ankle Movements
Toe Movements
• Dorsiflexion
• Plantar Flexion
• Flexion
• Extension
• Inversion
• Eversion
• Adduction
• Abduction
– Only for Great & 5th
toe
Ankle movements
• Dorsiflexion (DF) –
elevating the toes
above the ankle joint
• Aka: walking on your
heels
• Normal: 20o
Ankle movements
• Plantarflexion (PF) –
depressing the toes
below the ankle joint
• Aka: walking on your
toes, pushing a gas
pedal
• Normal: 50o
Ankle movements
• Inversion (INV) –
bringing the sole of the
foot medial
• Aka: walking on the
outside of the foot
• Normal: 20o
Ankle movements
• Eversion (EV) –
bringing the sole of the
foot lateral
• Aka: walking on the
arch/inside of the foot
• Normal: 5o
Toe movements
• Flexion (FLEX) –
decreasing the joint
angle by bringing the
bones together
• Aka: curling the toes
• Normal: 45-90o
Toe movements
• Extension (EXT) –
increasing joint angle
by separating the
bones
• Aka: straightening the
toes
• Normal: 70o at the
MTP joints
Toe Movements
• Abduction (ABD) &
Adduction (ADD)
(Great & 5th toe):
– Simply known as
splaying or squeezing
the toes
• Normal: ??
Assessing ROM
• When assessing, make note of:
– Differences in AROM
– Pain during PROM
– Decreased strength during RROM
Assessing AROM
• Have the patient move their ankle
through the 4 movements
– Toes up like walking on heels
– Point toes like pushing on gas pedal
– Bring big toe in and down
– Bring little toe out and up
Assessing AROM
• Have the patient flex & extend, ABD &
ADD the toes
– Curl your toes
– Straighten them
– Splay the toes
– Squeeze the toes
Assessing PROM
• The examiner will move the ankle
through the ROMs to the extreme end –
why??
– I am going to move your foot/ankle for you.
Just try to relax and let me know if you feel
discomfort, pain, or anything unusual.
Assessing RROM
• The athlete will move through each
ROM as the examiner places
resistance against the movement
– DF – pull the dorsal foot downward
– PF – resist the sole of the foot
– INV – push against the 1st MTP joint
– EV – push against the 5th MTP joint
Assessing RROM
• The athlete will move through each
ROM as the examiner places
resistance against the movement
– Toe FLEX – resist the curling of the toes
– Toe EXT – resist the straightening of the
toes
Resistive range of motion
• Each motion is caused by
certain muscles or muscle
groups
• DF: tibialis anterior
• PF: gastrocnemius &
soleus (calf muscles)
• INV: tibialis posterior
• EV: peroneal muscle
group
Grading ROM
• AROM & PROM are graded as within
normal limits (WNL) or
decreased/limited & why
– AROM: R = WNL, L = decreased DF due
to pn
Grading ROM
• RROM is graded on a 0-5 scale
0.
1.
2.
3.
4.
5.
Absent – no muscle contraction
Trace – contraction without movement
Poor – full ROM without gravity
Fair – full ROM against gravity
Good – 3 + some resistance
Normal – 3 + full resistance
Documenting ROM
• When documenting ROM, each movement
must be listed & assessed.
AROM: R = WNL, L = WNL
PROM: R = WNL, L = WNL with Pn
RROM: R = 5/5DF, 5/5PF, 5/5INV, 5/5EV;
L = 5/5DF, 3/5PF due to Pn,
3/5INV due to Pn, 2/5EV due to
Pn
So far…
• Gathered clues by taking a history
• Observed for signs of injury
• Palpated the structures for
abnormalities
• Tested ROM to find differences
Differential Diagnosis
• By now the choices of injury should be
narrowed down to a handful of
options…
• A list of possible injuries is known as a
Differential Diagnosis (DDx)
Rule Them Out
• In order to determine the injury, we
must rule out the DDx
• To do this we use special tests
Special Tests
•
•
•
•
Ligamentous
Joint play
Neurological
Vascular
OA 11.14
• What does HOPS stand for?
• Which part is most important?
• A list of possible injuries is known as
a…
88
SPECIAL TESTS FOR
FRACTURES
Long Bone Compression Test
• Patient: supine
• Examiner: standing in front of patient’s
feet
• Action: grasp one MT by the head and
apply an axial force down the length of
the bone.
Long bone compression test
Long Bone Compression Test
• Positive: pain along the MT shaft
• Pathology: MT fracture
Tap test
• Patient: supine
• Examiner: standing in front of patient’s
feet
• Action: tap on the end of the phalange
Tap test
• Positive: pain along the phalange
• Pathology: phalangeal fracture
Squeeze test
• Patient: supine
• Examiner: adjacent to injured leg, hands
cupped behind tibia/fibula
• Action: gently squeeze the tibia/fibula,
progress towards site of pain
Squeeze test
Squeeze test
• Positive: pain; crepitus
• Pathology: fibular fracture; syndesmosis
sprain
Bump test
• Patient: supine
• Examiner: standing in front of involved
heel
• Action: Dorsiflex the ankle and bump
the calcaneus
Bump test
Bump test
• Positive: pain
• Pathology: stress fracture of talus or leg
SPECIAL TESTS FOR SPRAINS
Anterior drawer test
• Patient: Sitting over edge of table with knee
flexed
• Examiner: Sitting in front of patient
– Hand 1 stabilizing leg above malleoli
– Hand 2 cups calcaneus with foot on forearm
• Action: Calcaneus and talus drawn forward
while stabilizing leg
Anterior drawer test
Anterior drawer test
• Positive: Increased translation of talus; lack
of end feel; pain
• Pathology: ATF ligament sprain
Talar tilt test (INVersion)
• Patient: Supine or Sitting over edge of table
with knee flexed
• Examiner: In front of patient
– Hand 1 grasps calcaneus
– Hand 2 stabilizes leg above malleoli
• Action: Hand 1 provides inversion stress
Talar tilt test (Inversion)
Talar tilt test (INVersion)
• Positive: Increased tilt of talus or gap; lack of
end feel; pain
• Pathology: CF ligament sprain & possible
ATF sprain
Talar tilt test (EVersion)
• Patient: Supine or Sitting over edge of
table with knee flexed
• Examiner: In front of patient
– Hand 1 grasps calcaneus
– Hand 2 stabilizes leg above malleoli
• Action: Hand 1 provides eversion stress
Talar tilt test (Eversion)
Talar tilt test (EVersion)
• Positive: Increased tilt of talus or gap;
pain
• Pathology: Deltoid ligament sprain
SPECIAL TESTS FOR
TENDON RUPTURES
Thompson’s test
• Patient: Prone with feet off edge of table
• Examiner: Side of patient
– Hand 1 over gastroc muscle
• Action: Squeeze gastroc while
observing plantar flexion of foot
Thompson’s test
Thompson’s test
• Positive: No plantar flexion
• Pathology: Achilles tendon rupture
INJURIES
objectives
• Identify pathologies that occur in
the foot & ankle, differentiating their
signs & symptoms
– Bony pathologies
– Ligamentous pathologies
– Musculotendinous pathologies
– Other structural/functional pathologies
Of the foot
STRUCTURAL DEFORMITIES
Foot malalignments
• Pes Planus (flat foot)
– Rigid or flexible
– Trauma/weakness to supporting structures
of the arch
• Pes Cavus (hollow foot)
– Congenital
– Less effective at absorbing ground forces
than pes planus
Pes planus and pes cavus
Foot malalignments
• Mallet toe –
DIP flexion
• Hammer toe –
PIP flexion
Of the foot
SKELETAL PATHOLOGIES
fractures
• Can occur to any bone in the foot/ankle
• Some are more typical than others
• All may have general Sx/Sy:
–
–
–
–
–
–
–
Deformity
Limited ROM
Crepitus
Localized pain
Radiating pain
Swelling
Inability to bear weight
Jones vs. base of
th
5
fracture
Jones Fx
Base of 5th Fx
• Proximal base of
• Attachment of
the 5th metatarsal –
peroneus brevis
1 cm from styloid
muscle
process
• Often avulsion fx
from countering
INV mechanism
Jones vs. base of
th
5
fracture
Metatarsal stress fracture
• Known as a
March Fx
• Stress fx of
metatarsal 2-4
(typically)
– Very localized pain
– Dull pain
– Worsens with activity
What is the diagnosis?
Lisfranc injury
• Acute injury
• Mechanism of Injury (MOI)
– Rotation of the TMT joints
– Forced hyper-plantarflexion
– Forced toe extension & DF
• Displacement of the metatarsals
• Severe pain & swelling; “pop” or
“tear”
• Most require surgery
Of the foot
SOFT TISSUE PATHOLOGIES
sprains
• Can occur to any ligament in the
foot/ankle
• General Sx/Sy
–
–
–
–
–
Limited ROM
Localized pain
Swelling - edema
Inability to bear weight
(+) special test for that ligament
Arch sprain
•
•
•
•
Caused by increased stress on arch
Flattening of the foot
Acute or chronic
Sx/Sy:
– Pain with weight bearing activities
– swelling
Plantar fasciitis
• MOI: acute or
insidious
• Sx/Sy:
– Pain at origin &
plantar fascia
after non-weight
bearing (NWB)
– Pain w/ DF &
toe extension
– Tight gastrocs, old age, ↓ ankle mobility
Hallux Valgus
• Great toe deformity
• Degeneration of 1st MTP joint
• Often leads to bunions
st
1
MTP Joint sprain
• “Turf toe”
• MOI: planted foot w/
DF ankle
–Hyperextension of the
MTP joint
–Pain with push-off,
joint ROM, quick stops
Retrocalcaneal bursitis
• “Pump bump”
• Inflammation of
the Achilles
bursa
Of the ankle
SKELETAL PATHOLOGIES
Tibial/fibular fracture
• MOI: Direct blow, or INV/EV
stress
• May have:
– gross deformity
– audible “pop”
– inability to bear weight
• Sx/Sy:
– Localized pain, radiating pain
– Crepitus & swelling
Talus fracture
•
•
•
•
MOI: forced dorsiflexion with inversion
May mimic an ankle sprain
Avascular necrosis may develop
Often missed in
x-rays – CT/MRI
to confirm
• Surgical fix
Stress fracture
• MOI: chronic microtraumatic forces
• Sx/Sy:
– Gradual onset
– Localized pain over shaft of bone
(“aching” pain)
– Pain ↑ w/ activity & ↓ w/ rest
– Often missed on x-rays
– May mimic MTSS
Stress fracture
Medial tibial stress syndrome
• AKA: “Shin splints”
• MOI: chronic pulling of the periosteum
surrounding the tibia by the posterior
tibialis muscle
Medial tibial stress syndrome
• Sx/Sy:
– Gradual onset from overuse, muscle
fatigue, biomechanics
– Pain during activity, relieved with rest
– Diffuse pain along the medial tibia
– Pain with palpation
– Pain during RROM for INV
Medial Tibial Stress Syndrome
• Medial Tibial Stress
Syndrome
Of the ankle
SOFT TISSUE PATHOLOGIES
Lateral ankle sprains
• Inversion with
plantarflexion
mechanism
• Most common injury to
the body
– Why?? – anatomically
– Stronger deltoid
ligament, lateral malleoli
extends further
Lateral ankle sprains
Lateral ankle sprains
• Area of pain = ligament
involved
• Anterior talofibular = sinus
tarsi
• Calcaneofibular = distal to
lateral malleolus
• Posterior fibular = posterior
to lateral malleolus
• Graded on a 1-3 scale
Lateral ankle sprains
Deltoid sprain
• Eversion or
rotation mechanism
• Rare injury (5%) –
most occur as
avulsion fracture
• Sx/Sy:
– General ligament
sprain sx/sy
Deltoid sprain
Syndesmosis sprain
• AKA “High ankle sprain”
• MOI: Forced DF and/or eversion; rotation
• Slow to heal
Syndesmosis sprain
• Sx/Sy:
– Pain around & above ankle mortise
– Inability to bear weight
– Decreased ROM
• Anterior tibiofibular ligament
• Interosseous membrane
Syndesmosis sprain
Achilles tendinitis
• Inflammation of the tendon due to
overuse
• Sx/Sy:
– Visibly enlarged Achilles tendon from
posterior aspect
– ↓ strength & ROM
– Altered gait or physical performance
– Localized pain (“burning”)
– Crepitus
Achilles tendinitis
Compartment syndrome
• Caused by direct blow or injury within
fascial compartment
– Typically anterior or deep posterior
compartments
Compartment syndrome
• Sx/Sy:
– Severe pain – “ache”, “dull”, “sharp”
– Muscle tightness, weakness, cramping; ↓
strength & ROM
– Feeling of numbness & tingling in area
– Sensation of hot/cold
• Medical emergency
Compartment syndrome
Compartment
Syndrome