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Kin191 A. Ch.5. Ankle. Lower Leg. Evaluation. Fall 2007
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Kin191 A. Ch.5. Ankle. Lower Leg. Evaluation. Fall 2007

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  • 1. KIN 191A Advanced Assessment of Lower Extremity Injuries ANKLE/LOWER LEG EVALUATION
  • 2. INTRODUCTION
    • HISTORY
    • INSPECTION
    • PALPATION
    • ROM TESTING
    • LIGAMENTOUS STABILITY TESTING
    • NEUROLOGIC TESTING
    • VASCULAR TESTING
  • 3.
    • Location of pain
      • May be referred site for compartment syndrome, tarsal tunnel syndrome, peroneal/tibial nerve injury, sciatic nerve or lumbar nerve root impingement
    • Nature/type of pain
      • Aggravating/alleviating activities
      • Effect of pain on activities
    HISTORY
  • 4.
    • Onset of pain
      • Acute: trauma (sprain, strain, fracture, etc.)
      • Gradual/insidious - overuse syndromes
    • Mechanism of injury
      • Macrotrauma - typically easy to identify tissues involved
      • Microtrauma - typically involves more in depth questioning to arrive at cause of problem
  • 5.
    • Activity changes
      • Duration, frequency, intensity, surface, shoes, orthotics, etc.
    • Prior history
      • Those with prior history of ankle injury may present with increased laxity and/or decreased proprioception vs. normal
  • 6. INSPECTION
    • General inspection
      • Weight bearing status
      • Gait pattern
      • Swelling
      • Obvious deformity
      • Discoloration
  • 7.
    • Inspection of the lateral structures
      • Peroneal muscle group
      • Distal one third of the fibula
      • Lateral malleolus
    • Inspection of the anterior structures
      • Appearance of the anterior lower leg
      • Contour of the malleoli
      • Talus
      • Sinus tarsi
        • Lateral aspect of the talus (anterior from the lateral malleolus)
  • 8.
    • Inspection of the medial structures
      • Medial malleolus
      • Medial longitudinal arch
    • Inspection of the posterior structures
      • Gastrocnemius-soleus complex
      • Achilles tendon
      • Bursae
        • Subtendinous (Retrocalcaneal) bursa
        • Subcutaneous calcaneal bursa
      • Calcaneus
  • 9. PALPATION (fibular structure)
    • 1. Common peroneal nerve
    • 2. Peroneus longus and brevis
    • 3. Fibular shaft
    • 4. Anterior and posterior
    • tibiofibular ligaments
    • 5. Interosseous
    • membrane
    • 6. Superior peroneal
    • retinaculum
  • 10. PALPATION (lateral ankle)
    • 1. Lateral malleolus
    • 2. Calcaneofibular ligament
    • 3. Anterior talofibular ligament
    • 4. Posterior talofibular ligament
    • 5. Peroneal retinaculum
    • 6. Peroneal tubercle
    • 7. Cuboid
    • 8. Base of the fifth metatarsal
    • 9. Peroneus tertius
  • 11. PALPATION (anterior structures)
    • 1. Anterior tibial shaft
    • 2. Tibialis anterior
    • 3. Extensor hallucis longus
    • 4. Extensor digitorum longus
    • 5. Dome of the talus
    • 6. Extensor retinacula
    • 7. Sinus tarsi
  • 12. PALPATION (medial structures)
    • 1. Medial malleolus
    • 2. Deltoid ligament
    • 3. Sustentaculum tali
    • 4. Spring ligament
    • 5. Navicular and
    • navicular tuberosity
    • 6. Tibialis posterior
    • 7 . Flexor digitorum longus
    • 8 . Flexor hallucis longus
  • 13. PALPATION (posterior structures)
    • 1. Gastroncnemius-soleus complex
    • 2. Achilles tendon
    • 3. Subcutaneous calcanel bursa
    • 4. Calcaneus
    • 5. Subtendinous calcaneal bursa
  • 14. Palpation of Pulses
    • Posterior tibial artery
      • Between the flexor digitorum longus and flexor hallucis longus tendons as they pass behind the medial malleolus
    • Dosalis pedis artery
      • Between the extensor digitorum longus and extensor hallucis longus tendons as they pass over the cuneiforms
  • 15. RANGE OF MOTION TESTING
    • The ROM can be affected by
      • Muscular tightness
      • Bony abnormalities
      • Soft tissue constraints
    • Active ROM
    • Passive ROM
    • Resistive ROM
  • 16. Active ROM
    • Plantar flexion/dorsiflexion at talocrural joint
    • Inversion/eversion at subtalar joint
    • PF – 50 degrees, DF – 15~20 degrees
      • Must have 10 degrees DF to walk with normal gait (15 degrees to run) – if absent, predisposes to biomechanical problems and overuse injuries
    • INV – 20 degrees, EV – 5~10 degrees
  • 17.  
  • 18. Passive ROM
    • Dorsiflexion
      • Measured with the knee extended to determine the overall influence of the triceps surae group
      • Measured with knee flexed to determine the influence of the soleus
      • Normal firm end-feel
    • Plantar flexion
      • Normal firm end-feel
      • Anterior joint capsule, deltoid ligament, and ATF ligament are stretched
  • 19.
    • Inversion
      • Should lie supine position
      • Normal firm end-feel (especially the CF ligament stretch) and peroneal muscles stretch
      • The tibia and fibular are stabilized to prevent hip or lower leg rotation
    • Eversion
      • A hard end-feel (because of the fibular’s striking the calcaneus)
  • 20. Goniometry
    • Plantar flexion/Dorsiflexion
      • Sitting or lying with the knee flexed to at least 30 degrees
      • Fulcrum
        • Centered over the lateral malleolus
      • Stationary arm
        • Aligned with the long axis of the fibula
      • Movement arm
        • Parallel with the long axis of the 5 th metatarsal
  • 21.  
  • 22. Goniometry
    • Inversion/Eversion
      • Sitting or lying with the knee flexed to at least 30 degrees
      • Fulcrum
        • Over the talocrural joint line, centered between the malleoli
      • Stationary arm
        • Centered over the long axis of the tibia
      • Movement arm
        • Over the 2 nd metatarsal
  • 23. Resistive ROM
  • 24.
    • Anterior talofibular ligament
      • Anterior drawer test
    • Calcaneofibular ligament
      • (Talar Tilt) Inversion stress test
    • Deltoid ligament
      • (Talar Tilt) Eversion stress test
      • Kleiger’s (External rotation) test
        • Place the ankle in neutral or slightly plantar flexed
    LIGAMENTOUS STABILITY TESTS
  • 25. Anterior Drawer Test Talar Tilt Inversion Stress Test
  • 26.
    • Distal tibiofibular ligaments/syndesmosis
      • Kleiger’s (External rotation) test
        • Place the ankle in dorsiflexion
      • Squeeze (Compression) test
    • Stress fractures of lower leg: tibia, fibular, talus, and/or calcaneus
      • Bump (Percussion) test
  • 27. Kleiger’s (External rotation) Test Squeeze (Compression) Test Bump (Percussion) Test
  • 28. Homan’s Test Thompson Test
    • For Achilles tendon rupture
    • For Deep Vein Thrombosis
  • 29. NEUROGIC TESTING
    • L4 – S2 dermatomes/myotomes/reflex
    • Tibial nerve
    • Deep peroneal nerve
    • Superficial peroneal nerve
  • 30. VASCULAR TESTING
    • Anterior compartment
    • Lateral compartment
    • Deep posterior compartment
    • Superficial posterior compartment

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