KIN 191A Advanced Assessment of  Lower Extremity Injuries ANKLE/LOWER LEG EVALUATION
INTRODUCTION <ul><li>HISTORY </li></ul><ul><li>INSPECTION </li></ul><ul><li>PALPATION </li></ul><ul><li>ROM TESTING </li><...
<ul><li>Location of pain </li></ul><ul><ul><li>May be referred site for compartment syndrome, tarsal tunnel syndrome, pero...
<ul><li>Onset of pain </li></ul><ul><ul><li>Acute: trauma (sprain, strain, fracture, etc.) </li></ul></ul><ul><ul><li>Grad...
<ul><li>Activity changes </li></ul><ul><ul><li>Duration, frequency, intensity, surface, shoes, orthotics, etc. </li></ul><...
INSPECTION <ul><li>General inspection </li></ul><ul><ul><li>Weight bearing status </li></ul></ul><ul><ul><li>Gait pattern ...
<ul><li>Inspection of the lateral structures </li></ul><ul><ul><li>Peroneal muscle group </li></ul></ul><ul><ul><li>Distal...
<ul><li>Inspection of the medial structures </li></ul><ul><ul><li>Medial malleolus </li></ul></ul><ul><ul><li>Medial longi...
PALPATION (fibular structure) <ul><li>1. Common peroneal nerve </li></ul><ul><li>2. Peroneus longus and brevis </li></ul><...
PALPATION (lateral ankle) <ul><li>1. Lateral malleolus </li></ul><ul><li>2. Calcaneofibular ligament </li></ul><ul><li>3. ...
PALPATION (anterior structures) <ul><li>1. Anterior tibial shaft </li></ul><ul><li>2. Tibialis anterior </li></ul><ul><li>...
PALPATION (medial structures) <ul><li>1. Medial malleolus </li></ul><ul><li>2. Deltoid ligament </li></ul><ul><li>3. Suste...
PALPATION (posterior structures) <ul><li>1. Gastroncnemius-soleus complex </li></ul><ul><li>2. Achilles tendon </li></ul><...
Palpation of Pulses <ul><li>Posterior tibial artery </li></ul><ul><ul><li>Between the flexor digitorum longus and flexor h...
RANGE OF MOTION TESTING <ul><li>The ROM can be affected by </li></ul><ul><ul><li>Muscular tightness </li></ul></ul><ul><ul...
Active ROM <ul><li>Plantar flexion/dorsiflexion at talocrural joint  </li></ul><ul><li>Inversion/eversion at subtalar join...
 
Passive ROM <ul><li>Dorsiflexion </li></ul><ul><ul><li>Measured with the knee extended to determine the overall influence ...
<ul><li>Inversion </li></ul><ul><ul><li>Should lie supine position </li></ul></ul><ul><ul><li>Normal firm end-feel (especi...
Goniometry <ul><li>Plantar flexion/Dorsiflexion </li></ul><ul><ul><li>Sitting or lying with the knee flexed to at least 30...
 
Goniometry <ul><li>Inversion/Eversion </li></ul><ul><ul><li>Sitting or lying with the knee flexed to at least 30 degrees <...
Resistive ROM
<ul><li>Anterior talofibular ligament </li></ul><ul><ul><li>Anterior drawer test </li></ul></ul><ul><li>Calcaneofibular li...
Anterior Drawer Test Talar Tilt Inversion Stress Test
<ul><li>Distal tibiofibular ligaments/syndesmosis </li></ul><ul><ul><li>Kleiger’s (External rotation) test </li></ul></ul>...
Kleiger’s (External rotation) Test Squeeze (Compression) Test Bump (Percussion) Test
Homan’s Test Thompson Test <ul><li>For Achilles tendon rupture </li></ul><ul><li>For Deep Vein Thrombosis </li></ul>
NEUROGIC TESTING <ul><li>L4 – S2 dermatomes/myotomes/reflex </li></ul><ul><li>Tibial nerve </li></ul><ul><li>Deep peroneal...
VASCULAR TESTING <ul><li>Anterior compartment </li></ul><ul><li>Lateral compartment </li></ul><ul><li>Deep posterior compa...
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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

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

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