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sajithankle-160130132535.pdf

  1. 1. CLINICAL EXAMINATION OF ANKLE&FOOT Dr.SAJITH KURIAN PG M.S Ortho, Department of orthopaedics COIMBATORE MEDICAL COLLEGE
  2. 2. TITLES  HISTORY  GENERAL EXAMINATION  LOCAL EXAMINATION 1)INSPECTION 2)PALPATION 3)RANGE OF MOTION 4)MEASUREMENTS
  3. 3. HISTORY  1)Age:CTEV present since birth,TEV secondry to polio,neural tube defects etc.appear later.CVT noticed at walking age around 1 year  2)SEX:CTEV common in boys  ASSOCIATED DISEASES :fever with myalgia and weakness of limbs in polio
  4. 4. PAIN  1)site,  2)radiation,  3)type,  4)character  5)aggravating factors  6)relieving factors  7)diurnal variation  8)postural variation
  5. 5. SWELLING  Duration  Onset  Progress  aggravating factors,relieving factors  effect of any treatment received  diurnal and postural variation  associated with deformity in other foot
  6. 6. LIMP  onset  Duration  painless or painful  progressive or not
  7. 7. INSTABILITY  duration  Onset  unilateral or bilateral  on even or uneven surfaces
  8. 8. DEFORMITY Onset(at birth (CTEV)OR appeared later (aquired clubfoot)appears at around 1 year in CVT,after an episode of fever and myalgia with weakness of limbs and muscles polio,progress ,any treatment received,response to any such treatment
  9. 9. GENERAL EXAMINATION Examine hip and spine for congenital hip dislocation,myelomeningocele spinal dysraphism, Arthrogryposis multiplex congenita
  10. 10. INSPECTION  Foot examination should always start with patients footwear  look for Shoe upper deformation & sole wear (it can tell about severity and chronicity of foot deformity or neuromuscular imbalance especially in assymetrical cases  It can tell about the expectations of the paients
  11. 11.  Inspection has three major aspects  1)standing inspection  2)gait assessment  3)sitting inspection
  12. 12. STANDING INSPECTION  Imp: some critical deformities wiil be appreciated only while standing  Digree of hallux valgus and pronation,  Lesser toe deformity in particular deviation between the 2nd and 3rd toes in comparison to asymptomatic side  Forefoot abductus and adducts  And arch height
  13. 13.  Ask the patient to turn to opposite side  Look for alignment of heel relative to leg  Look for abnormal visualisation of digits laterally(the “ TOO MANY TOES” sign seen in pes planus with forefoot adductus)
  14. 14. GAIT ASSESSMENT  Avoidance patterns associated with HALLUX RIGIDUS(no great toe extension after heel off)  Toe walking:plantar fascitis,heel pain syndrome or stress frscture (to avoid heel wt bearing)  External rotation gait:ankle arthodesis
  15. 15. SITTING INSPECTION  Patient must be sitting at the edge of the table with legs hanging freely  Entire lowerlimb should be examined  Neurological examination should be done as defecits produce different deformities of foot and toes
  16. 16. INSPECTION OF ANTERIOR ASPECT  1)alignment: great toe(hallux valgus/varus)other toes(claw,hammer,mallet) Relations of forefoot,midfoot,hindfoot w.r.t each other and lower leg  2)Condition of skin: any discolouration,ulcers,dialated veins
  17. 17. 3)TOES  notice transverse skin crease at I-P joint(lost in polio)  Thickened cornified skin over dorsum(heloma durum) seen in toe deformities  Toe nail deformities in fungal infections.  Paronychia ,ingrowing toe nail  Osteophytes medially over 1st MTP joint is BUNION and lateral aspect of 5th MTP joint is called BUNIONETTE
  18. 18. 5)TENDON tendons of EHL andEDL are visible over foot and anterior aspect of ankle by active contraction of muscles 6)Relation of medial and lateral malleoli:normally lateral is below and posterior to medial malleoli 7)Any swelling over malleoli:seen in trauma, tendinitis ,bursitis 8)Anterior crest of tibia and subcutaneous border may show swelling,deformities
  19. 19. INSPECTION OF LATERAL ASPECT Visualise lateral malleolus ,5th MT base ,tendo achilles and peroneus brevis tendon,look for any swelling
  20. 20. INSPECTION OF POSTERIOR ASPECT 1)Alignment : varus/valgus,too many toes sign 2)heel:size,pattern and position 3)Tell the patient to stand on tips of toes(windlass effect- inversion and incresed height of medial arch) 4)Plantar fat pad,calcaeneal tuberosity(abnormally increased prominenece of superior aspect is hagelund deformity or pump-bump)
  21. 21. 5)Retro-calcaneal bursa:bursitis 6)Achilles tendon :tendinitis,rapture,swelling at the level of malleoli is seen in tendinitis and over whole length is seen in rapture 7)Calf atrophy(compared to normal):Residum of CTEV,TA rupture or prolonged immobilisatiion
  22. 22. INSPECTION OF MEDIAL ASPECT  Medial longitudinal arch:cavus or planus or rocker bottom deformity(in diabetes or improperly treated CTEV  Bony prominences :medial malleolus,head of 1st MT,calcaneal tuberosity and navicular tuberosity(prominent accessory in accessory navicular)
  23. 23.  Tibialis posterior tendon made visible by active contraction .structures underneath flexor retinaculum of ankle-tibialis posterior,flexor digitorum longus,posterior tibial artery,posterior tibial nerve and flexor hallucis longus
  24. 24. INSPECTION OF PLANTAR ASPECT  Callosity suggests point of weight bearing.Normally seen over metatarsal heads and lateral margin of foot.painful calluses over MT heads are seen in claw toe and hammer toes  Corns are localised thickening of skin over pressure areas.Two types hard and soft  Ulcerations:Diabetes,abnormal bony prominences  Warts and fungal infections
  25. 25. PALPATION  PALPATION OF ANTERIOR ASPECT  1)Local rise of temperature  2)Tenderness :over the anterior tibial crest (in stress fracture ).  Over the talar dome: palpated anterolaterally with maximal passive plantar flexion at ankle (in OCD).Over talo-navicular joint in osteoarthritis  Also palpate cuneiforms,metatarsals (stress fractures,bunions,gout ,septic arthritis,frieberg infarction)
  26. 26.  Tenderness in interdigital spaces suggest Mortons neuroma  4)SWELLING:over stress fractures,osteophytes over joints.effusion of joints –cross fluctuation can be demonstrated between anterolateral and ateromedial swellings in full plantar flexion.Also seen between posterolateral and posteromedial swellings in full dorsiflexion
  27. 27.  5)tendons (tautness,tenderness,ump or any gap,diffuse swelling,crepitus)  Toes palpate for corns ,ingrowing toe nails  Tinels sign over deep peroneal nerve
  28. 28. PALPATION OF LATERAL ASPECT  1)lateral malleolus ,anterior talo-fibular ligament and calcaneo-fibular ligament for swelling and tenderness  2)Peroneal tendons  3)calcaeneum in severs diseas  4)over sinus tarsi in subtalar arthritis  5)over fibular shaft :stress fractures
  29. 29. INSPECTON OF POSTERIOR ASPECT  1)Over gastro soleus:In tendo achilles rupture tenderness gap and swelling at 2-6 cm above TA insertion  2) over posterior tuberosity of calcaneum:Tender swelling in retro calcaneal bursitis
  30. 30. INSPECTION OF MEDIAL ASPECT  Medial malleolus and subcutaneous border of tibia  Head of talus  Navicular tuberosity :tender swelling in accessory naviculum  4)tendons of FHL,FDL @TP  Tinel sign over posterior tibial nerve and medial and lateral plantar nerves
  31. 31. PALPATION OF PLANTAR ASPECT  Callosities tendor  Sesamoids for tenderness  Plantar fascia tenderness ,tenderness on hyper extending the toes,painfull nodues  Plantar fat pad tenderness
  32. 32. RANGE OF MOTION  Ankle : normal dorsi flexion and palntar flexion are 20 and 50 degrees each  Ankle tested with fore foot in inversion and hind foot in neutral with one hand gripped in such a way that any movements of the the subtalar and mid tarsal joints are excluded  Assess the dorsiflexion in both knee flexion and extension in cases of gastrocnemius contracture
  33. 33.  Subtalar joint :normal inversion-40 and eversion 20 degrees each  Examined in prone position  Hold dorsum of the foot with one hand such that head of talus is stabilised between thumb and index,hold calcaneum with thumb and index of other hand
  34. 34.  Forefoot :abduction and adduction(normal is jog)with calcaneum stabilized in neutral postion
  35. 35. Great toe :MCP extension -70 flexion -45 digrees IP-extension -0 and flexion-90 digrees lesser toes :MCP flexion and extension are 90 & 0 IP 40 each also test for adduction and abduction
  36. 36.  Muscles  1)grossly ankle and plantar flexors are tested by toe walking  2)ankle dorsiflexors by toe walking  3)evertors by walking on medial border  4)invertors on walking on lateral border
  37. 37. MEASUREMENTS  Longitudinal ;true and apparent limb length  Heel length :from tip of medial malleolus vertically down to point of heel  Foot length :medial(from back of heel to tip of great toe) and lateral(to tip of 5th toe)  Circumferential :at thigh,calf and foot
  38. 38. DISTAL NEUROVASCULAR DEFICITS  Look for ATA & PTA  Complete neurological examination of ankle
  39. 39. SPECIAL TESTS  All are done with leg hanging freely at the edge of table  1)ANTERIOR DRAWER TEST: tests for ant talo-fibular lig: grasp just above the ankle with one hand and hold heel with other.Gently pull heel forward with an internal rotatory movement to foot. Observe for ant translation and prominence of talar head anteriolaterally Difference of 3-5mm in laxity between two sides with a soft end point or skin tenting anteriolaterally by talar dome is significant
  40. 40.  INVERSION STRESS TEST(varus stress test):tests for calcaneo-fibular ligament  Maximally dorsiflex ankle and apply inversion stress test to calcaneum.abnormal inversion of talus at ankle is significant
  41. 41.  PERONEAL TENDON INSTABILITY TEST  Rotate ankle from maximal dorsiflexion to eversion to plantar plantar flexion to inversion  Palpate posterior to lat malleolus .if peroneal tendons subluxate or dilocate anterior to malleolus ,suggests instability
  42. 42.  THOMSON TEST
  43. 43.  FIRST METATARSAL RISE TEST  For tibialis posterior tendon  Patient is made to stand.from behind of the patient ,rotate leg into ext rotation.if 1st mt rises of the ground, it suggests instability  Opposite is Rose test
  44. 44.  Mortons test :compress 1st and 5th mt heads if neuroma present patient will complaint pain I same space  Homan test :pain in calf on passive dorsiflexion of ankle seen in DVT

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