Kin191 A. Ch.4. Foot. Toes. Evaluation. Fall 2007

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Kin191 A. Ch.4. Foot. Toes. Evaluation. Fall 2007

  1. 1. FOOT/TOES EVALUATION KIN 191A Advanced Assessment of Lower Extremity Injuries
  2. 2. INTRODUCTION <ul><li>EVALUATION </li></ul><ul><ul><li>HISTORY </li></ul></ul><ul><ul><li>INSPECTION/OBSERVATION </li></ul></ul><ul><ul><li>PALPATION </li></ul></ul><ul><ul><li>ROM TESTING </li></ul></ul><ul><ul><li>LIGAMENTOUS AND CAPSULAR TESTING </li></ul></ul><ul><ul><li>NEUROLOGIC EXAMINATION </li></ul></ul>
  3. 3. <ul><li>Location of pain </li></ul><ul><ul><li>Retrocalcaneal </li></ul></ul><ul><ul><ul><li>Retrocalcaneal bursitis </li></ul></ul></ul><ul><ul><ul><ul><li>Typically isolated to specific anatomic location </li></ul></ul></ul></ul><ul><ul><ul><li>Achilles tendinitis </li></ul></ul></ul><ul><ul><ul><ul><li>Tends to be more diffuse in nature </li></ul></ul></ul></ul><ul><ul><ul><li>Os trigonum syndrome </li></ul></ul></ul><ul><ul><ul><ul><li>Will discuss later </li></ul></ul></ul></ul>
  4. 4. <ul><li>Location of pain </li></ul><ul><ul><li>Heel </li></ul></ul><ul><ul><ul><li>Heel spur </li></ul></ul></ul><ul><ul><ul><ul><li>Bony projection typically from medial calcaneal tubercle </li></ul></ul></ul></ul><ul><ul><ul><li>Plantar fasciitis </li></ul></ul></ul><ul><ul><ul><ul><li>May or may not be associated with heel spur, they may occur simultaneously, but may be independent </li></ul></ul></ul></ul><ul><ul><ul><li>Fat pad contusion </li></ul></ul></ul>
  5. 5. <ul><li>Location of pain </li></ul><ul><ul><li>Medial arch </li></ul></ul><ul><ul><ul><li>Tarsal tunnel syndrome </li></ul></ul></ul><ul><ul><ul><ul><li>Neuro condition so presents with neuro sx. (radiating, paresthesia) </li></ul></ul></ul></ul><ul><ul><ul><li>Midfoot sprain </li></ul></ul></ul><ul><ul><ul><li>Plantar fasciitis </li></ul></ul></ul><ul><ul><ul><li>Navicular fracture </li></ul></ul></ul><ul><ul><ul><li>Pes planus/Pes cavus </li></ul></ul></ul><ul><ul><ul><li>Tibialis posterior tendinitis </li></ul></ul></ul>
  6. 6. Pes Planus Pes Cavus
  7. 7. <ul><li>Location of pain </li></ul><ul><ul><li>Lateral arch </li></ul></ul><ul><ul><ul><li>Fracture of 5 th Metatarsal </li></ul></ul></ul><ul><ul><ul><li>Peroneal tendinitis </li></ul></ul></ul><ul><ul><ul><li>Posterior tibial nerve compression </li></ul></ul></ul><ul><ul><ul><ul><li>Presents with neuro sx. </li></ul></ul></ul></ul>
  8. 8. <ul><li>Location of pain </li></ul><ul><ul><li>Metatarsal </li></ul></ul><ul><ul><ul><li>Fractures </li></ul></ul></ul><ul><ul><ul><li>Stress fractures </li></ul></ul></ul><ul><ul><ul><li>Metatarsalgia </li></ul></ul></ul><ul><ul><ul><li>Neuromas </li></ul></ul></ul>
  9. 9. <ul><li>Location of pain </li></ul><ul><ul><li>Great toe </li></ul></ul><ul><ul><ul><li>Hallux valgus </li></ul></ul></ul><ul><ul><ul><li>Hallux rigidus </li></ul></ul></ul><ul><ul><ul><li>Sesamoiditis </li></ul></ul></ul>
  10. 10. HISTORY <ul><li>Onset and MOI </li></ul><ul><ul><li>Acute onset </li></ul></ul><ul><ul><ul><li>Metatarsal/phalangeal fracture </li></ul></ul></ul><ul><ul><ul><li>Ligamentous/capsular sprain </li></ul></ul></ul><ul><ul><ul><li>Muscular strain </li></ul></ul></ul><ul><ul><li>Insidious onset </li></ul></ul><ul><ul><ul><li>Playing surface </li></ul></ul></ul><ul><ul><ul><li>Training changes: distance, duration, intensity </li></ul></ul></ul><ul><ul><ul><li>Footwear changes </li></ul></ul></ul>
  11. 11. INSPECTION/OBSERVATION <ul><li>Starts with initial presentation prior to formal evaluation commencement </li></ul><ul><ul><li>Ambulation </li></ul></ul><ul><ul><li>Gross deformity </li></ul></ul><ul><ul><li>Discoloration </li></ul></ul><ul><ul><li>Swelling </li></ul></ul><ul><ul><li>Weight bearing vs. non-weight bearing </li></ul></ul><ul><ul><li>Inspect footwear if possible </li></ul></ul>
  12. 12. <ul><li>Foot type </li></ul><ul><ul><li>Pronated </li></ul></ul><ul><ul><li>Neutral </li></ul></ul><ul><ul><li>Supinated </li></ul></ul><ul><li>Calluses/blisters/corns/warts </li></ul>General Inspection of the Foot
  13. 13. <ul><li>General toe alignment </li></ul><ul><ul><li>Morton’s toe </li></ul></ul><ul><ul><ul><li>Hypertrophy of the second MT </li></ul></ul></ul><ul><ul><li>Claw toes </li></ul></ul><ul><ul><ul><li>Hyperextension of the MTP joint and flexion of the PIP and DIP joints </li></ul></ul></ul><ul><ul><li>Hammer toes </li></ul></ul><ul><ul><ul><li>Hyperextension of the MTP and DIP joints and flexion of the PIP joints </li></ul></ul></ul><ul><ul><li>Mallet toes </li></ul></ul><ul><ul><ul><li>Flexion of the DIP joints </li></ul></ul></ul>Inspection of the Toes
  14. 15. <ul><ul><li>Hallux valgus </li></ul></ul><ul><ul><ul><li>The big toe begins to deviate away from the midline of the foot </li></ul></ul></ul><ul><ul><ul><li>Bunion </li></ul></ul></ul><ul><ul><ul><ul><li>A bunion is a painful swelling of the fluid-filled sac (bursa) at the base of the big toe. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>A smaller bunionette (tailor’s bunion) may form on the 5 th MTP joint </li></ul></ul></ul></ul>
  15. 16. <ul><ul><li>Ingrown toenail </li></ul></ul><ul><ul><li>Subungual hematoma </li></ul></ul><ul><ul><ul><li>The formation of a hematoma beneath the nail </li></ul></ul></ul>
  16. 17. <ul><li>Inspection of the medial structure </li></ul><ul><ul><li>Medial longitudinal arch </li></ul></ul><ul><li>Inspection of the lateral structure </li></ul><ul><ul><li>Fifth metatarsal (length and deviation) </li></ul></ul><ul><li>Inspection of the plantar surface </li></ul><ul><ul><li>Plantar warts </li></ul></ul><ul><li>Inspection of the posterior structures </li></ul><ul><ul><li>Achilles tendon </li></ul></ul><ul><ul><li>Calcaneus </li></ul></ul>
  17. 18. <ul><li>Non-weight bearing inspection of foot and calcaneal alignment </li></ul><ul><ul><li>Assessment of talar position </li></ul></ul><ul><ul><li>Mobility of the first ray </li></ul></ul><ul><li>Inspection of foot alignment </li></ul><ul><ul><li>Foot posture </li></ul></ul><ul><ul><ul><li>Forefoot varus and valgus </li></ul></ul></ul><ul><ul><ul><li>Rearfoot varus and valgus </li></ul></ul></ul><ul><ul><li>Plantarflexed 1 st ray </li></ul></ul>
  18. 19. Forefoot Varus Rearfoot Varus
  19. 20. Forefoot Valgus Rearfoot Valgus
  20. 21. Feiss’s Line for Navicular Drop
  21. 22. Feiss’ s Line for Navicular Drop <ul><li>PP: Sitting with the feet off the end of the table </li></ul><ul><li>EP: Positioned at the patient’s feet </li></ul><ul><li>EVP: </li></ul><ul><ul><li>With NWB, identifies and marks the apex of the medial malleolus and plantar aspect of the 1 st MTP joint </li></ul></ul><ul><ul><li>A line is drawn between two marks / Mark the navicular tubercle </li></ul></ul><ul><ul><li>Stands with the feet approximately 1 ft apart with evenly weighted </li></ul></ul><ul><ul><li>The new position of navicular is marked </li></ul></ul><ul><li>PT: A navicular drop 2/3 or greater the distance of the floor </li></ul><ul><li>IM: Hyperpronated foot </li></ul>
  22. 23. <ul><li>Medial Structures </li></ul><ul><ul><li>First MTP joint (1) </li></ul></ul><ul><ul><li>First metatarsal (2) </li></ul></ul><ul><ul><li>First cuneiform (3) </li></ul></ul><ul><ul><li>Navicular (4) </li></ul></ul><ul><ul><li>Navicular tuberosity (5) </li></ul></ul><ul><ul><li>Talar head (6) </li></ul></ul><ul><ul><li>Sustentaculum tali (7) </li></ul></ul><ul><ul><li>Spring ligament (8) </li></ul></ul><ul><ul><li>Medial talar tubercle (9) </li></ul></ul><ul><ul><li>Calcaneus (10) </li></ul></ul><ul><ul><li>Medial tendons (11) </li></ul></ul><ul><ul><ul><li>Flexor hallucis longus </li></ul></ul></ul><ul><ul><ul><li>Flexor digitorum longus </li></ul></ul></ul><ul><ul><ul><li>Tibialis posterior </li></ul></ul></ul>PALPATION
  23. 24. <ul><li>Lateral structures </li></ul><ul><ul><li>Fifth MTP joint (1) </li></ul></ul><ul><ul><li>Fifth metatarsals (2) </li></ul></ul><ul><ul><li>Styloid tuberosity (3) </li></ul></ul><ul><ul><li>Cuboid (4) </li></ul></ul><ul><ul><li>Peroneal tubercle (5) </li></ul></ul><ul><ul><li>Lateral border of the calcaneus (6) </li></ul></ul><ul><ul><li>Peroneal tendons (7) </li></ul></ul>
  24. 25. <ul><li>Dorsal Structures </li></ul><ul><ul><li>Rays (1) / Cuneiforms (2) / Navicular (3) </li></ul></ul><ul><ul><li>Dome of the talus (4) / Sinus tarsi (5) </li></ul></ul><ul><ul><li>Extensor digitorum brevis (6) </li></ul></ul><ul><ul><li>Inferior extensor retinaculum (7) / Tibialis anterior(8) </li></ul></ul><ul><ul><li>Extensor hallucis longus (9) / </li></ul></ul><ul><ul><li>Extensor digitorum longus (10) / Dorsalis pedis pulse (11) </li></ul></ul>
  25. 26. <ul><li>Plantar Structures </li></ul><ul><ul><li>Medial calcaneal tubercle (1) </li></ul></ul><ul><ul><li>Plantar fascia (2) </li></ul></ul><ul><ul><li>Intermetatarsal neuroma (3) </li></ul></ul><ul><ul><li>Metatarsal heads (4) </li></ul></ul><ul><ul><li>Sesamoid bones of the great toe (5) </li></ul></ul>
  26. 27. RANGE OF MOTION TESTING <ul><li>Active Range of Motion (AROM) </li></ul><ul><li>Passive Range of Motion (PROM) </li></ul><ul><ul><li>Normal form end-feel: flexion and extension </li></ul></ul><ul><li>Resisted Range of Motion (RROM) </li></ul>
  27. 29. Goniometry
  28. 30. LIGAMENTOUS AND CAPSULAR TESTING <ul><li>Metatarsophalangeal (MTP) and Interphalangeal (IP) joints </li></ul><ul><li>Intermetatarsal joints </li></ul><ul><li>Tarsometatarsal joints </li></ul><ul><li>Midtarsal joints </li></ul>
  29. 31. Valgus/Varus Test of MTP/IP Joints
  30. 32. Valgus/Varus Test of MTP/IP Joints <ul><li>PP: Supine w/ knee extended or sitting w/ knee flexed </li></ul><ul><li>EP: </li></ul><ul><ul><li>Standing or sitting </li></ul></ul><ul><ul><li>Proximal bone stabilized close to the joint to be tested </li></ul></ul><ul><ul><li>The bone distal to the joint being tested grasped near the middle of its shaft </li></ul></ul><ul><li>EVP: Valgus  the distal bone is moved laterally </li></ul><ul><li> Varus  the distal bone is moved medially </li></ul><ul><li>PT: Pain/Laxity </li></ul><ul><li>IM: </li></ul><ul><ul><li>Valgus test: MCL sprains </li></ul></ul><ul><ul><li>Varus test: LCL sprains </li></ul></ul>
  31. 33. Intermetatarsal Glide Test
  32. 34. Intermetatarsal Glide Test <ul><li>PP: Supine w/ knee extended or sitting w/ knee flexed </li></ul><ul><li>EP: </li></ul><ul><ul><li>Standing </li></ul></ul><ul><ul><li>One hand grasps the first MT head </li></ul></ul><ul><ul><li>Other hand grasps the second MT head </li></ul></ul><ul><li>EVP: The two MT heads are moved opposite directions </li></ul><ul><li>(plantarly and dorsally and vice versa) </li></ul><ul><li>PT: Pain/Laxity </li></ul><ul><li>IM: </li></ul><ul><ul><li>Transverse metatarsal ligament, interosseous ligament sprains </li></ul></ul><ul><ul><li>Pain w/ the presence of laxity: may indicate a neuroma </li></ul></ul>
  33. 35. Tarsometatarsal Joint Glide Test
  34. 36. Tarsometatarsal Joint Glide Test <ul><li>PP: Supine, knee flexed and the heel stabilized by the edge of </li></ul><ul><li> the table </li></ul><ul><li>EP: </li></ul><ul><ul><li>Standing or sitting </li></ul></ul><ul><ul><li>One hand grasps the distal tarsal row </li></ul></ul><ul><ul><li>Other hand grasps the metatarsal being glided </li></ul></ul><ul><li>EVP: The metatarsal is glided dorsally on the tarsal and then </li></ul><ul><li>glided plantarly on the tarsal </li></ul><ul><li>PT: Pain/ ↑ or ↓ glide </li></ul><ul><li>IM: </li></ul><ul><ul><li>Increased glide: ligamentous laxity </li></ul></ul><ul><ul><li>Decrease glide: joint adhesions </li></ul></ul>
  35. 37. Midtarsal Joint Glide Test
  36. 38. Intermetatarsal Glide Test <ul><li>PP: Supine or sitting , knee flexed and the heel stabilized by </li></ul><ul><li> the edge of the table </li></ul><ul><li>EP: </li></ul><ul><ul><li>Standing or sitting </li></ul></ul><ul><ul><li>One hand grasps the plantar and dorsal aspect of one tarsal </li></ul></ul><ul><ul><li>Other hand grasps the adjacent tarsal in a similar manner </li></ul></ul><ul><li>EVP: One tarsal is glided dorsally and plantarly on the </li></ul><ul><li> stabilized tarsal </li></ul><ul><li>PT: Pain/ ↑ or ↓ glide </li></ul><ul><li>IM: </li></ul><ul><ul><li>Increased glide: ligamentous laxity </li></ul></ul><ul><ul><li>Decrease glide: joint adhesions </li></ul></ul>
  37. 39. NEUROLOGIC EVALUATION <ul><li>Dermatomes (L4 – S2) </li></ul><ul><li>Myotomes (L4 – S2) </li></ul><ul><li>Reflexes (L4-S2) </li></ul><ul><li>Tinel’s sign (Tarsal Tunnel) </li></ul><ul><li>Specific nerve testing – sensory/motor </li></ul><ul><ul><li>Tibial nerve </li></ul></ul><ul><ul><li>Deep branch of peroneal nerve </li></ul></ul><ul><ul><li>Superficial branch of peroneal nerve </li></ul></ul>
  38. 41. Peripheral Neurological Symptoms
  39. 42. VASCULAR EVALUATION <ul><li>Dorsalis pedis artery (anterior tibial a.) </li></ul><ul><li>Posterior tibial artery (medial and lateral plantar branches) </li></ul><ul><li>Capillary refill (nailbeds/toe ends) </li></ul><ul><li>Skin temperature/color </li></ul>

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